Treatment Approach for a 57-Year-Old Man With Triple-Class Refractory MM

Sagar Lonial, MD, FACP: Hello, and welcome to this OncLive® My Treatment Approach program titled “BCMA-Targeting Agents in the Treatment of Multiple Myeloma: Translating Evidence to Clinical Practice.” I’m Sagar Lonial, a professor and the chair of the department of hematology and medical oncology and the chief medical officer of Winship Cancer Institute of Emory University in Atlanta, Georgia. I’m joined by 2 experts who see patients with multiple myeloma. The first is Dr Karen Klugo, a comprehensive ophthalmologist and cataract surgeon at Cincinnati Eye Institute in Cincinnati, Ohio; and Dr Natalie Callander, who is a professor in the department of medicine and the director of the myeloma program at Carbone Cancer Center at the University of Wisconsin in Madison, Wisconsin. Welcome, and thank you both for joining us.

We’re going to discuss recent updates on the role of BCMA-targeting agents in the treatment of multiple myeloma that were presented at key recent conferences. We’ll discuss the data in the context of guidelines, the treatment landscape, and its impact on clinical practice.

Let’s get started with a case. We start with a 57-year-old previously healthy man who’s found to have symptomatic IgG kappa R-ISS [Revised International Staging System] and ISS [International Staging System] stage II multiple myeloma. Laboratory studies demonstrate hypercalcemia and anemia with a normal LDH [lactate dehydrogenase], but on FISH [fluorescence in situ hybridization] analysis the presence of deletion of 17p. PET [positron emission tomography]–CT scan showed diffuse lytic disease throughout the axial skeleton, and the past medical history was unremarkable. The patient was initially treated with daratumumab plus VRd [bortezomib, lenalidomide, dexamethasone] induction followed by high-dose melphalan and autologous stem cell transplant, and then lenalidomide maintenance.

Unfortunately, about 2 years after that, he had evidence of serologic progression as well as new lytic bone disease and was switched over to a pomalidomide-plus-daratumumab–based salvage therapy. However, the response to that was less than 6 months, and he was subsequently switched to carfilzomib as given in the ENDEAVOR trial at 56 mg/m2 twice a week with dexamethasone and a bit of oral cyclophosphamide. The patient tolerated that treatment well, but its response lasted only 3 or 4 months, and this patient basically had triple-class refractory multiple myeloma.

Given that the patient had received 3 prior lines of therapy, including an IMiD [immunomodulatory imide drug], a PI [proteasome inhibitor], and anti-CD38 antibody, his physician recommended starting him on belantamab mafodotin. The patient underwent evaluation by an ophthalmologist prior to initiating belamaf [belantamab mafodotin] and was found to have good eye health. Fourteen months into treatment with belantamab [mafodotin], the patient is tolerating the treatment well and is quite active.

When we begin thinking about how to treat patients with relapsed and refractory multiple myeloma, the first things we look at are what they received at induction, what their genetics are, and how long their remission lasted. We also begin to evaluate patients who received lenalidomide-based induction therapy or PI-based induction therapy and non-CD38–based induction regimens.

This patient unfortunately had received lenalidomide, PI, and CD38-based induction regimens, which are rapidly evolving into a standard of care. However, they’d also received additional lines of therapy that got them into triple-class refractory myeloma, meaning that it’s resistant to PIs, resistant to IMiDs, and resistant to anti-CD38 antibodies. This opens the door to using treatments that aren’t in what we’d consider our big 5 or 6 as induction or salvage therapy approaches. These include agents with new mechanisms of action, specifically potentially targeting things like BCMA. That’s where belantamab mafodotin comes in.

Transcript edited for clarity.