Better Therapies Leading to Improved Outcomes for Transplant-Ineligible Patients With MM

At the virtual 2020 Great Debates & Updates in Hematologic Malignancies, Jonathan Kaufman, MD, Associate Professor, Winship Cancer Institute of Emory University, Atlanta, Georgia, discussed the standard front-line approach for treating patients with multiple myeloma who are ineligible for transplantation.

“After making the diagnosis of myeloma, the next question is to ask whether the patient is transplant-eligible or transplant-ineligible. And one of the most important things that we’ve learned over the years is that when making that determination, probably the least important thing is patient age,” he told attendees.

Instead, focus should be placed on patient performance status not related to acute active disease, low ejection fraction of <50%, pulmonary function tests <50% of normal, and those who have concomitant multi-organ amyloidosis (especially cardiac amyloidosis) who would not be good candidates for transplant.

According to Dr Kaufman, the 2 most common regimens administered to patients with MM today are an RvD-like regimen and the combination of daratumumab, lenalidomide, and dexamethasone.

However, there are some circumstances, particularly in the case of renal failure, where considering giving the patient bortezomib plus cyclophosphamide and dexamethasone is important.

The standard approach is to continue therapy until progression occurs. Citing a study led by the Italian group, Dr Kaufman told attendees about how, after 9 months of receiving lenalidomide and dexamethasone, patients were randomized to receive ongoing lenalidomide plus dexamethasone or lenalidomide alone, with outcomes ultimately found to be the same for both treatment arms.

“After about 9 months of dexamethasone, a patient can discontinue that therapy,” he explained.

Although lenalidomide and dexamethasone were not discontinued for patients in the study receiving daratumumab plus lenalidomide and dexamethasone, Dr Kaufman states that it is reasonable to stop administering dexamethasone after 9 months, or simply reduce the use of dexamethasone to as a pre-med to the daratumumab.

“The outcomes of our transplant-ineligible patients are improving, and they are improving in a large part because of our better therapies,” Dr Kaufman concluded.—Hina M. Porcelli