Are There New Treatment Strategies for High-Risk Myeloma Patients?

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Topics include: Treatments and Understanding

What treatment approach is recommended for high-risk multiple myeloma? Can a different strategy improve patient outcomes and lower risk factors? Our panel of distinguished experts, including Dr. Sagar Lonial, Dr. Carol Ann Huff and Dr. Suzanne Lentzsch, explain what the treatment goal is and share the latest techniques to effectively treat high-risk myeloma patients. Watch now to find out more.

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Jenny Ahlstrom:         

Let’s talk about high-risk patients for a minute. What new strategies are you seeing that are working for high-risk patients? Maybe we want to start with you because you mentioned some of your patients, how you’re treating them upfront and aggressively.

Dr. Lonial:                  

Yeah, I think in the context of high-risk post-transplant or post-induction, combination maintenance approach is certainly our recommendation. The current recommendation from our group is bortezomib (Velcade) and lenolidomide (Revlimid) together for three years, unless patients have not had a good enough response upfront to that combination, in which case we then go to pomalidomide (Pomalyst) and carfilzomib (Kyprolis).

So I think the key for high-risk disease is trying to keep it under control for as long as you can and maximize that duration of first remission. What we know from old, old data sets from Dr. Barlogie’s previous practice is that if you can take a high-risk patient and keep them in remission for three years after a transplant, their outcomes don’t look like a high-risk patient anymore. They look more like a standard risk patient.

That’s a major part of our goal is to try and push that remission, that first one, out as long as we can. And I think the antibodies are gonna be incorporated into those and other new treatment approaches as well, so I think there’s a lot of exciting new ideas that are coming out for high-risk patients. 

Jenny Ahlstrom:         

And Dr. Huff, did you have any other ideas?

Dr. Huff:                    

Well, I think just to elaborate on that, I think that really the goal for high-risk patients is to keep them in the deepest possible remission that you can. I think as we understand more about genetics and genomics and things, we may be better able to select those drugs.

But until that time, really combinations are the standard for what we do as well too to try to keep those patients in remission – first remission as long as we can, but even all subsequent remissions for those patients.

Dr. Lentzsch:              

I completely agree. I think in high-risk patients it’s important to point out that the first remission should be the deepest and to maintain that remission, as Dr. Lonial pointed out, so I start to treat those patients relatively aggressively with KRD, this carfilzomib, Revlimid, and dexamethasone. Transplant, I recommend transplant consolidation with KRD. And again, I think the maintenance of a proteasome inhibitor is key here—Revlimid/ixazomib (Ninlaro), or Revlimid/Velcade. Absolutely, that is important. And I would be very generous to add daratumumab (Darzalex) very early on. I think in the future we might give quadruples to those patients; that means an IMiD proteasome inhibitor, a steroid, and daratumumab. 

Dr. Lonial:                  

One point that I think may be confusing for patients coming out of this meeting is the data from the Europeans that suggests that two transplants is more effective in patients with high-risk myeloma.

And I think that again gets into the when can you extrapolate from a European experience and when can’t you? So in those trials that they were reporting on, the induction therapy that they gave is what I would argue is an inadequate or insufficient induction therapy with Velcade, cyclophosphamide (Cytoxan), and dex (Decadron). And their maintenance therapy was what I would consider inadequate for a high-risk patient as well. If you have inadequate—inadequate is probably not the fair word. If you had suboptimal front and backend therapy, then what you do in the middle probably really does make a difference. So for those patients, in terms of access and other issues, a tandem transplant might make sense.

For us here, we did a randomized trial for standard risk and high-risk patients and did not show any benefit for tandem auto transplant. I think that’s because the frontend and the backend of therapy are very different here.

So I think, because this is coming up. I can see it already in referrals I’m getting from the community. Physicians or other transplanters are saying tandem transplant, this is what we should do, and I don’t think that that really again looks at the entirety of the data analysis. 

Dr. Lentzsch:              

I was surprised about those data actually, that the concept was, I would say, resuscitated—double transplant, especially given the fact that a transplant is not an easy treatment, and most patients who undergo a first transplant probably have more problems in the second transplant and really don’t enjoy the procedure.

Dr. Lonial:                  


Dr. Lentzsch:              

So I would be very careful in the interpretation of those data, and I agree with Dr. Lonial that probably the induction—the inferior induction is key here, and that in the U.S., where we really try to give a very potent induction and possibly go with a complete remission into the transplant, that those data really do not apply to our patients. 

Jenny Ahlstrom:         

But it looks like proteasome inhibitor for deletion 17 patients maybe has made a difference. So adding that in, like you’re saying, in the maintenance therapy, not just a single drug maintenance. 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on April 2, 2018