Looking to the Future of Treatment Options for Patients With Multiple Myeloma

In a panel discussion at the 2023 Great Debates & Updates in Hematologic Malignancies conference in New York, New York, Melissa Alsina, MD, Moffitt Cancer Center, Tampa, Florida, discussed treatment options for patients with multiple myeloma (MM), with careful consideration of the overall survival, MRD-negativity, and quality of life of these patients. 

Transcript:

My name is Melissa Alsina. I am the head of the myeloma section within the Bone Marrow Transplant and Cellular Immunotherapy Department at Moffitt Cancer Center in Tampa. This weekend we had a panel discussion talking about the future of myeloma.

A very important question was posed and that is, "Where do you see myeloma in 5 years? What would you like to happen in 5 years?" There were 3 main things. Number 1, [chimeric antigen receptor] (CAR) T-cell therapy and other immunotherapies like T-cell engagers have changed dramatically in the past few years. The treatment of relapsed myeloma giving patients with very refractory disease, triple refractory, and even penta-refractory, an opportunity to have a very significant response in many patients' [complete response] (CR) and quality of life and also impacting overall survival for patients that otherwise have a very limited survival. 

Obviously, in the future we want to see these cell therapies moving upfront, hoping that they're going to work better for patients with high-risk myeloma, but for other patients as well. There are multiple clinical trials ongoing right now looking at that question, both for newly diagnosed or patients that have a clinical high-risk disease for first relapse or even consolidation after transplant. I think these studies will shed some light as to whether these therapies will improve the progression-free survival for these patients and whether we can move these therapies like CAR T in the newly diagnosed setting. Similar questions are being asked with bi-specifics, also in the newly diagnosed setting.

I think the first breakthrough that is probably coming sooner is using CAR T for a second line or third line as opposed to the fourth line, which is the current FDA approval. I think that's coming soon. The KarMMa-3 trial that randomized patients that have failed 1 to 3 prior lines of therapy to standard of care versus CAR T results are out. There's definitely a benefit in terms of progression-free survival for patients that receive CAR T. That might lead to moving CAR T early on, even though not necessarily to newly diagnosed. The CAR T 4 data, which was a trial with a similar design, results are coming out during ASCO of this year. We're hoping that those are going to be positive and that also can lead to a change of CAR T to be offered early on in the course of the disease. That's one very important change. 

The other thing that we discussed is the use of [minimal residual disease] (MRD). As you know, there have been many trials showing that MRD is important, [and] that patients that achieve MRD-negativity have better progression-free survival and overall survival, whether that is reached as part of frontline therapy or at relapse. It is also a very important goal of therapy. We're still learning how to use it, but I hope that in 5 years we'll have enough information that would help us decide [on] therapy [and] when to continue or stop therapy based on MRD results. That would be excellent because it would help us treat the patients according to what they need as opposed to a 1 size fits all approach.

[For] those patients that achieved MRD in negativity and sustain MRD negativity, which is even more important, perhaps we can withdraw therapy. Whereas [for] those patients that are still MRD-positive, we can make adjustments to try to get them there. The third important thing that we discussed is using more genetics stratification to classify myeloma. As long with the clinical picture and try to direct therapy, especially more in precursor stage. Just a smoldering. That is a challenging goal because the techniques used to look at genome sequencing are not easy, are not well established, but that should be a goal for the future.

Source: 

Alsina, M. Special panel discussion-Future of myeloma. Presented at Great Debates & Updates in Hematologic Malignancies Conference; April 13-15, 2023; New York, NY.