Treatment Options in Early Relapse Multiple Myeloma

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Transcript:

Joseph Mikhael, MD: The NCCN [National Comprehensive Cancer Network] guidelines have almost turned into a laundry list. It's hard to be a guideline when you give 30 options, but here we do have preferred options and noticed this one. If a relapse is greater than 6 months, the regimen used for the primary therapy may be repeated. But I must say that very few of us really follow that. We have several options that are listed here. I would note that in those category 1 designations, we have, carfilzomib/daratumumab and dexamethasone [KdD], as well as isatuximab/carfilzomib and dexamethasone [IsaKd], which both fit with our audience. We do have some other ones, including daratumumab/pomalidomide and dexamethasone [DPd] and isatuximab/pomalidomide and dexamethasone [IsaPd], typically after 1 therapy that includes lenalidomide for DPd and 2 therapies that include lenalidomide and a PI [proteasome inhibitor] as well for IsaPd.

Now we also have those who are true lenalidomide refractory. And I think, in this case, this slide is perhaps the most relevant because we have a patient here who is in lenalidomide refractory within a year of transplant. And I'm going to ask our experts here does that influence you if, let's say you are going to choose a CD30 [TNF receptor superfamily member 8] antibody, be it DARA [daratumumab] or Isa [isatuximab], are you leaning more toward carfilzomib, like the audience seems to be because this person only relapsed within a year of being on lenalidomide maintenance? As opposed to, let's say, this is happening 4 or 5 years later, while on lenalidomide maintenance. Elisabet, let me ask you first. Does that fit a little bit more with your thinking? Are you wanting to class switch here because the person is progressing within a year of being on lenalidomide maintenance?

Elisabet Manasanch, MD: I think we compare bortezomib to carfilzomib, but you have to choose either one or the other. Carfilzomib usually tends to give higher responses early on so this patient needs a very fast-acting regimen. And she also has this abnormality in chromosome 1. And so, we have the IKEMA study that shows that isatuximab, carfilzomib, and dexamethasone give a very good and long progression-free survival. Being free of disease doesn’t happen to everyone, but it's a good start and it is well-tolerated.

So, I think in this patient, an option that includes carfilzomib with dexamethasone is very good because this is a very fast-acting medication that reduces myeloma very quickly. And maybe the addition of isatuximab because of the chromosomal abnormalities and the data from this study on the patients that have chromosome 1 abnormalities. And so, I think that that's what I would probably do for this patient. But I think the options presented were all very good and I agree with the audience in the choosing of the preferred regimens for this patient.

Joseph Mikhael, MD: That's really helpful. And just to round out the NCCN guidelines, I'll show that there were other treatment options here. And this is where we have to tailor it to the individual. I think we all feel that this person is a little bit more aggressive in their relapse and we probably want to use that but there are other options as well. I'll just quickly give Sikander and Keith a quick vote. Assuming all availability of those options, Sikander what would have been your selection for this patient?

Sikander Ailawadhi, MD: Joe, I think I would also go with IsaKd. In addition to the timing of the progression, I think for me, this being a clinical progression rather than just a slow biochemical change is another reason that I would go for the class switch.

Joseph Mikhael, MD: And Keith?

Keith Stewart, MD: I think one thing we haven't mentioned is geography. Carfilzomib requires coming into the clinic once a week, but if you live far away, Pomalyst [pomalidomide] would be a good alternative. Having said that, like the others, I would go with an anti-CD38 [cluster of differentiation 38] in carfilzomib. I would probably lean toward daratumumab because of the convenience of subcutaneous injection.

Transcript edited for clarity.