Selecting Appropriate Treatment for Patients With Heavily Pretreated Multiple Myeloma

Natalie Callander, MD: One of the wonderful things that’s happened in the myeloma treatment world is we’re seeing more people live longer with myeloma, and that means there’s a growing population of patients who need treatment after they’ve had more than 3 lines of therapy. Some of the principles that we look at in that particular situation are what the patient has had previously and what the patient has had most recently. If the patient is progressing on a CD38 antibody, perhaps an IMiD [immunomodulatory imide drug] or a proteasome inhibitor, and that’s the regimen they’re on at that time, it’s probably safe to say that using those agents again or switching one of them may not produce the response that you want. Many experts would recommend trying to come up with a strategy that combines different drugs.

If a patient had excellent responses to certain agents in the past and isn’t receiving those agents, you can try to circle back. But in terms of available strategies for more than 3 lines or triple-class refractory, there are a couple of options. Belantamab is certainly an excellent option. As we’ve been discussing, it’s something that has excellent responses in patients who respond, which is about a third of patients. Other options include bringing in the drug selinexor, which is an exportin-1 inhibitor. As a single agent, selinexor has about a 25% response rate when combined with dexamethasone, but some of the publications are showing some very nice responses of selinexor combined with both IMiDs and proteasome inhibitors.

If a patient has never had a stem cell transplant, we’d certainly want them to consider that. Then there’s the option of considering a CAR [chimeric antigen receptor] T-cell transplant for such patients. Some of the problems with that strategy can be that those patients have to be stable enough for a leukapheresis to occur to collect cells for the engineering process. It requires a certain level of fitness in those patients. Then there’s the manufacturing time that elapses. You have to have a strategy to help that patient stay stable before those CAR T cells are ready.

Transcript edited for clarity.