News
Discussants: Matt Kalaycio, MD1; Sagar Lonial, MD2
From Cleveland Clinic, Cleveland, OH1; Emory University, Atlanta, GA2
Address for correspondence: Matt Kalaycio, MD, Cleveland Clinic Main Campus, Mail Code R32, 9500 Euclid Avenue, Cleveland, OH 44195
E-mail: kalaycm@ccf.org
Biographical sketch:
Matt Kalaycio, MD, FACP, is Chairman of the Department of Hematologic Oncology and Blood Disorders at Cleveland Clinic Taussig Cancer Institute. Dr. Kalaycio holds a joint appointment in Cleveland Clinic's Transplant Center and is a Professor in the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Board-certified in hematology and medical oncology, Dr. Kalaycio's clinical interests are in leukemia and stem cell transplantation.
Dr. Kalaycio has been published in numerous scientific publications including Bone Marrow Transplantation, Journal of Clinical Oncology, and Leukemia. He also is the editor of a book on leukemia and co-editor of a book on clinical malignant hematology. His research interests focus on testing new treatments for leukemia.
Dr. Kalaycio received his degree from West Virginia University School of Medicine in Morgantown. He completed his residency in internal medicine at Mercy Hospital of Pittsburgh and fellowships in hematology and medical oncology and bone marrow transplantation at Cleveland Clinic.
Sagar Lonial, MD, FACP, is internationally recognized as a leading authority in multiple myeloma treatment and research. As a medical oncologist at the Winship Cancer Institute, Dr. Lonial treats patients with multiple myeloma and is a lead member of the bone marrow transplantation team and clinical trials team. He is board certified in hematology, oncology and internal medicine.
Dr. Lonial is involved in numerous professional organizations including the American Society of Clinical Oncology, American Society of Hematology, and the American Society for Blood and Marrow Transplantation. He serves as Vice Chair of the Myeloma Committee in the Eastern Cooperative Oncology Group and as Chair of the Steering Committee for the Multiple Myeloma Research Consortium. Additionally, he is on the board of directors for the International Myeloma Society, and on the scientific Advisory Board for the International Myeloma Foundation.
Practice Guidelines
Dr. Kalaycio: I'm trying to avoid some of the controversy surrounding what treatment we should start with, or continue with. I think that literature is difficult to digest in a small soundbite. I’m more interested for this particular conversation in discussing some of the practicalities of managing patients with a newly diagnosed myeloma—regarding some of the things that a large center might take for granted, whereas a clinician in a smaller practice might not have as much experience, and might not know exactly how to handle. I think that literature is difficult to digest in a small soundbite. I’m more interested for this particular conversation in discussing some of the practicalities of managing patients with a newly diagnosed myeloma—regarding some of the things that a large center might take for granted, whereas a clinician in a smaller practice might not have as much experience, and might not know exactly how to handle. For example, current recommendations for bisphosphonates can be confusing. Although we use them, it's often an interesting discussion about which one we should use. Do you have a preference in your practice, and do you use criteria one way or another to pick one over the other?
Dr. Lonial: Yes, I think you're absolutely correct that the guidelines are a little confusing on how to do this. I'll tell you just from a convenience perspective for patients, we tend to use zoledronic acid as our go-to bisphosphonate, predominately because it's a shorter duration. We usually give it over 30 minutes. Patients prefer that sort of shorter infusion time. For patients that have any level of renal dysfunction—what I'm usually thinking about is creatinine levels over 2 mg/dL—we may use pamidronate as our preferential bisphosphonate. We'll even dose bisphosphonates. One of the things I think often gets lost in the bisphosphonate literature is that pharmacies will not release the drug because the patient's creatinine is 2.5 mg/dL or 3 mg/dL. What they don't realize is that no one gets renal failure from a single dose of bisphosphonate—it's really a cumulative effect over a long period of time.
For patients who have bone disease, I think the use of bisphosphonates is really important in terms of reducing the risk of skeletal events and fractures, which we see much less frequently now. Figuring out how to optimally do that—even in patients with renal dysfunction, I think—is really important. We disagree with the American Society of Clinical Oncology (ASCO) guidelines, in terms of how to approach giving bisphosphonates. Our approach is that any patient with myeloma (if you look hard enough) has some level of bone disease.
