NDMM: Identifying Patient and Disease Factors to Select Appropriate Therapy

Transcript:

Joshua Richter, MD: Along those lines of alkylators, I'll throw this one back to you. So, a patient comes into your clinic and obviously it's a complex dynamic, who gets transplant, who doesn't, patient may have biases for or against it. But is there a specific phenotype of patient from your standpoint who is eligible by criteria but should absolutely get it or should absolutely not get a transplant?

Susan Bal, MD: Of course, this is a nuanced decision and discussion with the patient, taking into account what they value deeply, however, from my perspective, the patients who I certainly will try to discuss transplant and keep that on the table, would be the patients with ultra­–high risk multiple myeloma. Those patients who have 2 or more high-risk cytogenetic features. We've seen for theme after theme from all the quadruplet studies that those are the patients who are an unmet need, still. And those are the patients who we've seen derive the greatest magnitude of benefit from autologous stem cell transplant. And I often even discuss a tandem, although that's not something routinely done in our country, but I have discussed that data, so that they're aware and at least know that that's something that the field studied and could be a recommendation.

Joshua Richter, MD: That's the CTN 0702 STaMINA is still showed in that subgroup, the intention to treat the benefit there. So, for me, those patients who I give one of our standard modern-day regimens and they don't do so great, and transplant gets it, there still is a role for some people to get tandem. So, I agree.

Alfred L. Garfall, MD: But we need to be a little careful about undertreating our standard-risk patients. Because everybody has high-risk myeloma, some people take longer than others to get there, right? We all have these patients who look like they had very calm myeloma and then 10 years later, they have very angry myeloma. And you have to ask yourself, if you held back on therapy early on, could you have maybe expedited the emergence of that high-risk phenotype. And the patients with standard risk disease, if you take them through that evidence-based first line of therapy that includes transplant and maintenance therapy, maybe these are the patients who are going to have decades of survival, or maybe they're never going to relapse after first-line therapy. And so, I agree there's some room for risk adapted approaches, but remember that there has never been a randomized trial that looked just in the standard-risk or just in the high-risk and asked transplant vs no transplant. Overall, it does seem like the benefit of transplant does cut across these subgroups.

Natalie S. Callander, MD: And I would imagine, every single person here has patients in their clinic that are 10 years plus out now that used to be a rarity. And now we see them all the time. I would say without an exception that all of those patients have had a transplant somewhere along the line. And you could say, well, that's because that's what's around, but at the same time, I guess, I'm convinced that, that has added something to their care over the years. And many of those patients, I'm sure you've seen them 5, 6 years, post auto transplant doing fine.

Elizabeth O’Donnell, MD: But I want to echo your point. It's important that just because someone has standard disease upfront does not mean you should hold back on optimal therapy. You should always go with your best, most aggressive regimen upfront to give people the opportunity to have that durable progression for…

Natalie S. Callander, MD: Well, and I would highlight a trial that doesn't get a lot of publicity right now. ECOG is doing EAA181 (NCT04566328), which is an interesting trial, standard-risk deferred transplant. Everybody gets 9 months of DRD, so daratumumab, lenalidomide, dexamethasone, but then, at 9 months, people are randomized to add in Velcade (bortezomib) for an additional 9 months. And what they're trying to figure out is whether stepping up the therapy is going to make a difference or not, or whether you need to do that, which is an interesting question.

Susan Bal, MD: And the theme that we've often seen is that any therapy that helps high-risk helps standard-risk more. We are all trying to say the same thing is that anything that we do that helps high-risk is certainly something that's going to go a long way in helping our standard-risk patients. So, I completely agree, we shouldn't take the breaks off on those patients.

Transcript edited for clarity.