Transcript
Hi there, I am Keith Stewart. I'm a hematologist at the Mayo Clinic. I'm here in Los Angeles today at the Great Debates and Updates in Hematologic Malignancies meeting, where I presented this morning on the treatment of newly diagnosed myeloma patients who are not eligible for transplantation.
We started the discussion by talking about the theory of less is more and we showed a clinical study where patients who are elderly and intermediately fit were randomized to receive lenalidomide and dexamethasone at full doses versus moving quite quickly to lenalidomide maintenance after 9 months of treatment.
Interestingly, those patients who reduced the dose of lenalidomide did better overall with less discontinuations and better tolerability without sacrificing outcomes such as progression free survival.
We started there and began to build on that by talking about using 3 drugs, particularly the combination of bortezomib with lenalidomide dexamethasone.
In the elderly spoke to the fact that you can reduce doses and use a regimen we call RVD light in which we use smaller doses of dexamethasone, lenalidomide, and bortezomib with good tolerability while maintaining good efficacy in an elderly population of patients.
We went on to then discuss other potential triplet combinations in the newly diagnosed group of patients, including although not yet approved by the FDA the use of ixazomib, lenalidomide, dexamethasone, but then perhaps a more impactful in our practice the introduction of daratumumab in the front-line setting.
In that case we talked about the 3-drug regimen of daratumumab, lenalidomide, and dexamethasone, which when compared to lenalidomide, dexamethasone alone had substantial benefits across the board by all metrics that could be measured.
We closed the discussion by asking the question, if three drugs are good, are 4 better? We presented the results of bortezomib, melphalan, prednisone versus the same regimen with daratumumab and showed that with 4 drugs, again, even in an elderly population there are quite dramatic improvements in progression-free survival over our response rate and depth of response.
We talked about alternatives to the use of melphalan, including cyclophosphamide, a regimen such as CyborD and daratumumab or perhaps other 4-drug cocktails could be employed perhaps using ixazomib as an example.
We summarized that by saying RVD light, daratumumab, lenalidomide, dexamethasone today are probably the gold standard regimens to turn to even in an elderly patient. For the very frail, lenalidomide, dexamethasone alone is fine. For perhaps your more elderly but more fit patient 4-drug cocktails are beginning to become part of our therapeutic program.
