The Blood Cancer Twice
As Likely
To Affect African
Americans:
Multiple Myeloma
11th Annual National Leadership Summit on Health Disparities
Innovation Towards Reducing Disparities
Congressional Black Caucus Health Braintrust
April 28-29, 2014
Ritz-Carlton Hotel • Washington, DC
Craig Emmitt Cole, M.D.
Department of Internal Medicine
Division of Hematology
University of Michigan Comprehensive Cancer Center
Ann Arbor, Michigan
OBJECTIVES/ OVERVIEW
•
•
•
•
•
Definitions: “What is a cancer of the blood?”
Anatomy and Biology of the Bone Marrow
Common Cancers of the Blood and Bone Marrow
Myeloma
• What is Multiple Myeloma?
• Incidence in African Americans
• Treatment and Improved Survival
• Ethnic Disparities in Myeloma Treatments
• Testing for Multiple Myeloma
• Community Education of Myeloma
Conclusions
Disclosures: Craig Cole, MD is a consultant for Onyx
Pharmaceuticals government affairs office and has no relevant
financial interests to disclose
Definitions: what is a hematologic
(Blood) cancer?
• Is it “bone cancer”?
– NO
– Bone cancer is a very rare cancer
of the bone called Sarcoma.
• Is it “cancer that has gone to
the bones?”
NO
 Other cancers that have gone
to the bone are called
“Metastatic cancer to the
bone”.

• Is it “cancer of the blood cells
produced by the marrow
inside the bone”?
Anatomy and Biology (just a little….)
Red Blood
Cells
Bone Marrow
Stem Cell
White
Blood
Cells
Bone Marrow
Blood Factory
Platelet
Cells
Lymph
Cells
Lymph
Glands
Antibody
Proteins
Plasma
Cells
Red Blood
Cells
Bone Marrow
LEUKEMIA
Stem Cell
White
Blood
Cells
Bone Marrow
Blood Factory
Platelet
Cells
Lymph
LYMPHOMA
Cells
Lymph
Glands
Antibody
Proteins
Plasma
MULTIPLE
MYELOMA
Cells
What is Multiple Myeloma?
• Multiple myeloma is a
cancer of the plasma cell.
‒ When plasma cells become
cancer they make excessive
amounts of antibody (M) protein.
• Manifestations
M-protein
– 90% of people with myeloma have
multiple sites of disease involved
at the time of diagnosis.
– Low blood counts – fatigue.
– Kidney damage from M proteins
which are toxic to the kidneys
– Bone tumors and fractures- pain
• Diagnosis
MULTIPLE
MYELOMA
– Blood tests, urine tests, X-rays,
and bone marrow biopsy.
Race and Incidence of Multiple Myeloma
All Black
11.6 /100,000
All Races
5.8/100,000
All Hispanic
5.29/100,000
• 22,350 new cases of multiple
myeloma were diagnosed in
2013.
• African Americans have more
than twice the myeloma
incidence rate of whites.
o 12 vs. 5 per 100,000
population.
• African Americans have the
highest risk of myeloma of any
Am Indian
race/ ethnic group in the world.
4.59/100,000
• Incidence in older black males
All Asian
and females was 126% greater
3.2/100,000
than the incidence in similar age
white males and females in
2010.
NCI Surveillance, Epidemiology,and End Results (SEER) Program report, www.seer.cancer.gov Leukemia(2012)26:609–614
All White
5.26/100,000
Race and Incidence of Multiple Myeloma
• From 2006 to 2010,
myeloma was the 8th
most common cancer
among African
Americans males.
• 7th most common
cancer among African
Americans females.
• Incidence of myeloma
increased with age.
– Median age at diagnosis
for AA is 66 years.
• The highest incidence
rates are found in
African American males
older than 85 years of
age.
NCI Surveillance, Epidemiology, and End Results (SEER) Program report, www.seer.cancer.gov ; BLOOD, 16 DEC 2010 Vol 116, No25
Why do African- Americans
have a High Risk for Myeloma?
• No conclusive evidence for multiple myeloma being
hereditary.
• Exposure to ionizing radiation and several
manufacturing occupations and industries are
associated with myeloma.
• The racial difference in incidence cannot be explained
by…
o Obesity
o Tobacco or Alcohol use
o Dietary preferences
o Vitamin intake
o Family history of myeloma
o Socioeconomic Status
Am J Public Health.(2000)90(8):1277–1281. Leukemia(2012)26:609–614. Blood. Prepublished online February 2013; oi:10.1182/blood-2012-07-443606
Advancements in Multiple
Myeloma Biology
• Until 1997, therapy for multiple
myeloma was limited to
chemotherapy.
– Only 30% of people responded.
– Average survival was 2 years.
• Research into the science of
how multiple myeloma grows has
resulted in targeted treatments
which selectively destroy the
cancer cells.
‒ Immunmodulatory therapy
• Thalidomide, Lenalidomide,
Pomalidomide
‒ Proteasome inhibitors
• Bortezomib, Carfilzomib
N Engl J Med 2011; 364:1046-1060
Advancements in Survival
from Multiple Myeloma
• With new biology based
medications response
rates are now 91 to 98%.
• Survival has more than
doubled in myeloma
patients to over 6.1 years!
• When novel therapies are
used at diagnosis, survival
is improved dramatically.

74,814
19,851
More People
Have
Survived
54,963
2004
2011
From 3.8 years to 7.3 years!
Myeloma is not curable.
But is survivable!
People in the United States living with,
or in a remission from Multiple Myeloma
Blood (ASH Annual Meeting Abstracts) 2011 118: Abstract 5070; Blood (ASH Annual Meeting Abstracts) 2011 118: Abstract 2948
Ethnic Disparities in Myeloma
treatment
Clinical trials = New treatments
New treatments = Better survival
Who is receiving
Clinical Trials?
Better Survival?
• New therapies and
clinical trials have
improved the survival
for Caucasians with
myeloma from
1993–97 to 2003–07.
• Smaller
improvements have
occurred for other
racial/ethnic groups.
• The mortality rate for
myeloma from 2006 to
2010 for black males
was nearly double the
rate for white males.
Years of life gained with new therapies
for multiple myeloma
Ethnic Disparities in Myeloma Treatment;
Impact of Novel Therapies
2
1.5
1.3
1
0.8
0.7
0.5
0.5
White
Black
Hispanic
Asian
Br J Haem 2012; 158: 91-98; Blood 2011 118: Abstract 4213; Am.Ca.Soc.2013.CaFact&Fig AA 2013-2014. Atlanta, GA
Ethnic Disparities in Myeloma Treatment;
Impact of Novel Therapies
Multiple Myeloma Five-year relative survival by
race for all age groups
Percent 5 year Survival
50%
44.9%
40%
30%
43.5%
35.4%
34.2%
% Difference in
survival from
1998 to 2009
+10.7
39.5%
39.6%
+8.1
Non- White
White
20%
1998-2001
2002-2005
2006-2009 All values p<0.0001
Survival Period
Pulte D, et al. Leukemia & Lymphoma, 2013; Early Online: 1–7
Do Myeloma Patients of Ethnicity
Receive the Novel Therapies?
• Patients with newly diagnosed
myeloma in 1999, 2003, and 2007
were examined by using the
National Cancer Institute's
Patterns of Care Studies.
• From 1999 to 2007, use of
chemotherapy for the initial
treatment of myeloma dropped.
– From 32.0% to 4.1% for Melphalan
– From 18.2% to 0.4% for other
chemotherapies
• The percentage of patients
receiving any novel agent rose
from 3.9% in 1999 to 75.5% in
2007.
Myeloma patients of ethnicity were
less likely to receive novel
therapies.
J Clin Oncol2013 Jun 1;31(16):1984-9. doi: 10.1200/JCO.2012.h
Ethnic Disparities in Myeloma Treatment;
Clinical Trials
Lenalidomide
plus
high-dose
Lenalidomide,
bortezomib,
and
Bortezomib plus
Melphalan
and
versus
low-dose
dexamethasone
dexamethasone
combination
Prednisone for Initial
Treatment ofas
initial
therapy
for newly
diagnosed
therapy
in
patients
with newly
Multiple
Myeloma
multiple
myeloma
diagnosed
multiple
N Engl J Med.
2008 Augmyeloma
28;359(9):906-17
Race
Race
White
White
White
Asian
NonBlack
Black
White
Other
Other
Missing
Lancet 2010
Oncol.
2010
Blood
Aug.
VolJan;
16611(1);29-37
(5)
Pomalidomide
plus
low-dose
dexamethasone
versus
high-dose
Bortezomib,
melphalan,
and prednisone
versus
Lenalidomide
after
Stem-Cell
dexamethasone
alone for patients
with
relapsed
bortezomib,
thalidomide,
and
prednisone
as
Transplantation
formyeloma
Multiple(MM-003):
Myeloma
and
refractory multiple
induction
therapy
followed
maintenance
New
England
Journal
a
randomised,
open-label,
phase by
3 trial.
treatment
Vol. 366,
No. 19,
1770-1781).
Lancet
Oncol.
2013
Oct;14(11):1055-66.
Race Not
Reported
Lancet Oncol. 2010 Oct;11(10):934-41
NCCN Guidelines Version 2,2014. www.nccn.org. www.cancer.gov/clinicaltrials/results/type/multiple-myeloma
Ethnic Disparities in Myeloma
Treatment; Barriers
Strategies for the prevention or screening multiple myeloma:
NONE
What are the barriers to more
timely diagnosis, treatment, and
survival with the new medications
for multiple myeloma?
•
•
•
•
•
•
Lack of awareness about research
Lack of access to clinical trials
Fear
Distrust
Cultural beliefs
Lack of access to facilities that are
performing research
Cancer 2008 112(3):447–454
Community Education of Multiple
Myeloma; Jacksonville, FL
• In 2010 Mayo Clinic-Jacksonville partnered
with African American churches to provide
educational programs focused on myeloma
awareness, cancer research and healthy
behaviors.
• Despite 88% having a primary care provider…
– 67% of participants had never received information
on multiple myeloma.
– 57% never received clinical research study
information.
– Most participants would enroll in clinical trials if
asked.
• At the 2013 African American Sankofa Health
and Wellness Forum in Milwaukee,WI 88% of
participants were unaware of multiple
myeloma.
J Canc Educ (2012) 27:294–298
Community Education of Multiple
Myeloma; Southeastern Wisconsin
• The Jane Cremer Foundation is a
not-for-profit in Southeastern
Wisconsin with its mission to…
• Educate and Empower women to
be proactive in the prevention,
diagnosis and treatment of cancer.
• With two African American church
based educational events, nearly
400 people were informed of:
– Increased incidence of multiple
myeloma in their community.
– How to empower themselves to seek
out the newest treatments and clinical
trials.
– Healthy life style activities.
Could I have Myeloma?
Think B.A.C.K
B - Bone pain from the
effects of myeloma cells
on the marrow.
A- Anemia
red blood)
Ask(lowfor
the Myeloma Blood
and Urine testing
C- high blood calcium or
confusion
K-
Kidney function is poor
The Keys to Myeloma Education and
Empowerment in the Ethnic Community
Breakdown the Barriers
• Bring the education to the
•
“duatonal
quanistic
“Mergæxli
” facts”
community.
Begin with the basics.
•
Do not use terms to challenge
anyone’s Health Care Literacy.
• Stress purpose of any
myeloma education in the
community is not “medical”
or “scientific” but is
“educational”.
J Canc Educ (2012) 27:294–298. John Cremer personal communication, April 5, 2013
The Keys to Myeloma Education and
Empowerment in the Ethnic Community
Empower Your Audience!
• Educate patient empowerment.
– To teach about multiple myeloma is not
enough.
– People need to be given “permission” to…
• Ask their doctor questions.
• To question their doctor.
– Educating communities on the importance of
cancer research as an empowerment tool.
– Deliver information necessary for racial and
ethnic groups to “break-through” the social
/economic barriers.
• Resources in the community.
• Overcome “health care illiteracy”.
• Educate the community providers (RNs,
MDs, PAs, etc…)
J Canc Educ (2012) 27:294–298. John Cremer personal communication, April 5, 2013
Conclusion
• The multiple myeloma is common hematologic (blood)
cancer of the plasma cell in the bone marrow.
• It is twice as common in African Americans that all other
racial and ethnic groups.
• The best method of detection is KNOWLEDGE of
multiple myeloma.
• Awareness of the signs and symptoms.
• With any suspicion, see your primary care doctor for
evaluation!
• Advances in science through clinical trials have improved
the detection, diagnosis, and treatment of multiple
myeloma.
• Resulting in longer and better lives for all myeloma patients.
Learn More and Educate Others
– The Leukemia & Lymphoma Society:
www.lls.org
– Multiple Myeloma Research Foundation:
www.themmrf.org
– International Myeloma Foundation:
www.myeloma.org
– National Cancer Institute:
www.cancer.gov
Thank You!
For Your Time and Attention
Email: [email protected]