The Use of Clinical Pathways in the Treatment of Patients With Multiple Myeloma

Nisha Joseph, MD, Winship Cancer Institute, Emory University, discusses her presentation at the 2022 Oncology Clinical Pathways Congress on antibodies in myeloma and the use of clinical pathways in the treatment of patients with multiple myeloma, touching on new, “ever-evolving” therapeutics and recent drug approvals in the multiple myeloma space.

Transcript

Hi, my name is Nisha Joseph, and I'm an Assistant Professor at the Winship Cancer Institute at Emory University in Atlanta, Georgia. And I was very happy to be invited to speak at OCPC this past year in Boston. And the topic of my presentation was specifically about antibodies in myeloma, but really I think the broader topic was the use of clinical pathways in the treatment of patients with multiple myeloma, which I think in general can be a challenge. We have a lot of new therapeutics in the myeloma space that are ever-evolving. We just had a recent approval a few weeks ago, and so it can be a challenge in the national and certainly international community to have standardized guidelines and pathways of how we treat myeloma patients. And so what I tried to talk about was the role of pathways, which I think is very important to standardize care in order to bring the best therapies we can to our patients and to all patients, regardless of their access, or where they are located, near an academic center or around the community.

I think guidelines like that would be very helpful for those that don't see myeloma on an everyday basis, because there are so many options and different ways to approach myeloma. And so what I tried to do throughout the talk is talk about each stage of myeloma treatment, so predominantly induction therapy, the role of stem cell transplant, maintenance therapy, and then therapeutic options in relapse, which I think gets trickier in terms of pathways. But in general, I talked about how we approach myeloma care and the induction space, which is generally using RVD or dara-RVD really preferably now. So the use of daratumumab, which is the anti-CD38 monoclonal antibody, in conjunction with what I think is standard of care, certainly in the past, which we published about using RVD with transplant and risk-adaptive maintenance, showing a median progression-free survival of 80 months at our most recent update and median overall survival that was not reached to 10 years for our standard risk patients.

So improving upon that RVD standard with the addition of daratumumab for our standard-risk patients and consideration of the use of carfilzomib in patients with high-risk disease, also defining how we classify high-risk vs standard-risk disease based on cytogenetics and FISH of the myeloma, as well as other clinical features. And then I moved into talking about the role of transplant, why we transplant, who we transplant, really highlighting that I think it can be challenging to always identify who's really a transplant-eligible candidate. So encouraging at least referral of these patients to a transplant center, because I think there's such a significant benefit with transplant still, which I think was recently confirmed with the DETERMINATION study, which was presented at ASCO last year. And then I talked about risk-adapted maintenance strategy, so continuous maintenance, potentially the use of triplet combinations in patients with high-risk disease.

And then we talked about relapse, and that again, is a more challenging space. But I tried to talk to the data that we have, particularly at early relapse. So for first relapse, I think there's reasonable data for daratumumab in combination with pomalidomide and dexamethasone, and that would be in patients with standard risk disease or good response to transplant, and then the consideration and potentially carfilzomib-based regimen at first relapse in high-risk patients or patients who did not have the response that we would expect, citing some of the data that we've mined here at Emory.

And then I talked about some of the newer agents we have, antibody-drug conjugates, the bispecific, natalizumab approval, and other bispecific T-cell engagers in the pipeline as well as two CAR T-cell products, Abecma and Carvykti, and how I try, at least in my clinical practice, to sequence these therapies based on disease-related as well as patient-related factors. And so hopefully that gave some kind of background for those who don't treat myeloma on a daily basis of how we kind of approach such a complex and really vast therapeutic landscape, and try to sequence these therapies in order to get the best overall survival and progression-free survival outcomes for our patients.