The session this morning focussed on precision medicine. There is a lot of information out to what extent can we target certain mutations in patients to really tackle the abnormality in the cell. We had a very interesting discussion with Dr Ravi and myself. So I was discussing the topic whether precision medicine right now in 2017 is more hype than reality. That means are we ready to use precision medicine? Patients are very excited about that topic and it sounds fascinating but today I did a reality check to analyse where do we stand, what is the reality, can we use precision medicine?

I brought up several problems we have with precision medicine, for instance very often it’s difficult to identify the right mutation. In case you have the right mutation it’s very often not expressed in all the cancer cells, all the myeloma cells. So, for instance, you have a mutation only in 20% of the myeloma cells, you treat the mutation with the right drug, that means you eradicate only 20% of the myeloma cells. So those are problems and right now we don’t really know how to approach those problems.

The next problem is that to identify a mutation we need next generation sequencing. This is nothing we do in our daily practice so this is not standard of care, that’s an additional and very expensive tool and insurances very often don’t cover this. So what is the access of our patients to next generation sequencing?

Number three is once we identify, for instance, a mutation with next generation sequencing do we have a drug for this? I addressed that topic also today to say only 25% of the mutations have drugs that can really treat the mutation. So there are a lot of open questions and today I contributed a little bit to say what is the reality check. What I also did is I did a survey before I prepared the talk and the survey went out to the leading myeloma centres in the world; I did that with the help of the International Myeloma Foundation. 27 centres answered the survey and opened the box and told me what they are doing in terms of precision medicine. Among those centres were pretty large centres that treat 1,900 myeloma patients per year and it turned out that only a minority, 4 out of 27 centres, are using next generation sequencing for the treatment of multiple myeloma and they only treat it in 10% of their cases. So right now we are treating a minority with precision medicine.

We are about to understand what precision medicine means in multiple myeloma. In the last twenty years we focussed very much on the microenvironment. We found out that the environment of the myeloma cells is very important for the growth and survival of myeloma cells, for instance, cytokines, growth factors that are secreted from the microenvironment, the growth of vessels, the immune system, T-cells and K-cells. We learned that the myeloma cell itself cannot survive without the microenvironment. Now we are focussing on the mutation in the myeloma cell itself. So the precision medicine can only be performed in combination with the microenvironment, that means that we have drugs that target the microenvironment and the mutation.

At the moment we are at a stage where we collect a lot of data. So we collect data and then we compare what is the outcome with certain mutations, how do certain patients with mutations really respond to treatment? Once we complete that collection phase of data we are ready to launch larger clinical trials in order to really pinpoint druggable mutations.