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Duration:33:41
Uploaded:2019-05-24
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Aaron is talking to Dr. Rafat Abonour about multiple myleoma. Multiple myeloma is a cancer that forms in white blood cells, and Dr. Abonour tells Aaron about how the disease affects patients, and the cutting edge of research into treatments. And we get a nice story about biking.

The Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.

IU School of Medicine is leading Indiana University's first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer and childhood sarcoma and prevent type 2 diabetes and Alzheimer’s disease.
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Aaron: Welcome back to the Healthcare Triage Podcast. This Healthcare Triage Podcast is sponsored by Indiana University School of Medicine, whose mission it is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research, and patient care. IU School of Medicine is leading Indiana University's first grand challenge: the precision health initiative with bold goals to cure multiple myeloma, triple negative breast cancer, and childhood sarcoma, and prevent type-2 diabetes, and alzheimer's disease.

And, that's perfect, because today we're going to be talking about multiple myeloma. Our guest this week is Rafat Abonour, who's the director of the myeloma program at Indiana University School of Medicine. We're going to be talking today about multiple myeloma and where the cutting edge research is. What people are doing, what people are thinking, where we might be going.

So, welcome. Thank you for joining us.

Rafat: Thank you for having me.

A: Could we start a little bit, we're always interested in hearing about the backgrounds of our guests. How did you get to this position, and how did you get interested in your research? How did you get here?

R: So I started wanting to become a transplant surgeon, but then I ended up doing just a hematology fellowship and bone marrow transplant. And, I did my research on plasma cells; these are the cells that cause multiple myeloma. And then, I started doing gene therapy, and gene therapy was an exciting and dangerous. I needed to focus on something. So, I knew plasma cells and I loved myeloma patients, so I decided to focus on that.

A: So, let's say, what are plasma cells?

R: So, plasma cells are the cells that make antibodies to help us fight infection. We need them; that's how we survive, you know, 100 years, 70 years, whatever. So, what happened is that one of these plasma cells become malignant and start reproducing itself and causing harm to the patient. 

A: So, so they're a type of white blood cell?

R: Yes, sir.

A: Ok. Where are they made?

R: Well, they actually start in the lymph nodes and then they migrate to the bone marrow where they reside. You know, so you get your first sort of encounter was, for example, let's say tetanus or, you know, pneumonia bacteria in the blood, and these cells, you know, mature, become plasma cells, produce memory antibodies to help us fight infections as, you know, when we get exposed again to the pneumonia.

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And they reside in the bone marrow. When we need them, you know, they get out, they make more new antibodies to help us fight infection.

A: So, can you talk a little bit more about how they work when they're working right? How exactly do they help us fight infection?

R: Well, they produce a specific antibody. So, we have a repertoire of plasma cells that are capable of recognizing different pathogens, you know, from the mumps to the measles to the influenza to the pneumonia. And, so, every time we get exposed to one of these pathogens, these plasma cells proliferate and produce more antibodies to fight the infection.

A: And, so what happens when they produce the antibodies? What happens next?

R: Well, the antibodies bind to the pathogens, and you just neutralize it or, you know, help other cells gobble it up.

A: Ok. So, what happens when things go wrong?

R: Well, when things goes wrong, is that one of these plasma cells start accumulating in the bone marrow. So, you initially have, for example, maybe 5% of abnormal plasma cells in the bone marrow. They don't cause any harm. We call that condition MGUS (monoclonal gammopathy) of undetermined significance. Just having a monoclonal protein doesn't cause harm to the patient. But, what happens next is that tons of these cells start, you know, accumulating in the bone marrow. So, you have like 10/20%, but it's still not causing harm. So, we call that condition smoldering myeloma. And then, eventually what will happen is that these plasma cells can affect the patients in different ways. One is that it can weaken the bone. So, about 70% of patients with myeloma will have either osteoporosis, holes in the bones, or they start breaking bones..

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So, they have, you know, they just try to lift a bag, you know, and then they break a bone in their back or something like that. So, myeloma can affect the bones, can cause anemia, can cause very high calcium level, because you're leeching calcium out of the bone. So, the patient become, yeah, uh, unable to think and may go into a coma, or they can actually get kidney damage. So, we call these sort of the CRAB criteria for diagnosing myeloma. The "C" is for high calcium, the "R" renal or kidney failure, "A" anemia, or bone disease. So, you have a lot of these abnormal cells in the bone marrow and you have one of these criteria, then we, you know, that patient has multiple myeloma. 

A: What makes the plasma cells go bad? What goes wrong?

R: So we actually, a lot of research going on in terms of environmental exposures, and just this week got, uh, big settlement against Roundup, because they, when, patients develop multiple myeloma from using that. So, we think there's toxic exposures; farming communities, there's increased risk of multiple myeloma, near factories and near mining communities. For example, I have patients in, near a mine in southwest Indiana where multiple people who work in that mine's developed multiple myeloma, you know, and the question is what did they dump into the water, I mean, these people are drinking well water. And so, I think, we think chemical exposure plays a role in making these plasma cells sort of, um, become malignant and multiply and, you know, cause harm and cause disease.

A: Ok, so once somebody is-- Once, we have a concern, they've met the CRAB criteria, what happens next to help make the diagnosis?

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R: So, we do several things, and number one, obviously we need to do a blood test to see if they are anemic, they have high calcium, or they have kidney failure. The second thing is that we look for this abnormal protein, because myeloma starts from one plasma cell. The protein they produce is unique, we call it monoclonal protein. So, we do a specific blood test to check for that monoclonal protein, and find it. We have to find a monoclonal protein or we find an abnormal part of that protein race, we call it a free light chain. So, we check that.

The second thing, we have to look and see what they have in the bone marrow. So, we do a bone marrow biopsy to see the number of these abnormal cells and what type of cells. We do genetic analysis on those cells to see what they do, because myeloma patients, some of them do very well, some of them do ok, and some of them do poorly. And, the genetic makeup of the myeloma can help you distinguish these three groups.

A: So, that was actually going to be my next question. Are, is sort of all or all cases of multiple myeloma the same? Or, are they all very different? Or, do they fall into a bunch of categories?

R: Yeah, I mean, I think the term multiple may not be really because of multiple lesions was in the patients. I think it's multiple presentation of the disease.

A: Ok. 

R: So, I have patients who do very well. They get one kind of treatment, and they go on and stay in remission forever. And then, we have patients who within a year or two, they relapse and they actually don't do well. And then, so that's about 20% for each group. And then the rest, the 60%, those patients, you know, have multiple relapses but you can control the disease and they can live a long life.

A: So, what is the treatment for the most part?

R: So, the treatment has evolved. It use to be more chemotherapy or traditional drugs that cause hair loss or blood counts abnormalities, but now we have these, we call them sort of novel drugs. They work on things that influence the proliferation of the cells, or their interaction with the neighborhood where they live.

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