What is the Best Treatment Approach for Patients With MM Ineligible for Transplant?

At the 2019 Lymphoma & Myeloma Congress, Vincent Rajkumar, MD, Mayo Clinic, Rochester, Minnesota, explained treatment approaches for patients with newly-diagnosed multiple myeloma who are not eligible for transplant.

Transcript

Hi, I'm Vincent Rajkumar, Professor of Medicine at the Mayo Clinic in Rochester, Minnesota.

I'm here at the Lymphoma & Myeloma meeting in New York. My talk is on the approach to treatment of patients with newly diagnosed myeloma who are not eligible for transplant.

There have been a number of randomized controlled trials done, and I'll make it simple by saying the one that really changed practice and standard of care was the SWOG study that compared bortezomib-len/dex to len/dex.

That study showed that bortezomib-len/dex prolonged progression-free survival and overall survival for patients with multiple myeloma. Bortezomib-len/dex, also called as VRD, has currently been the standard of care for a number of years in the United States and in the rest of the world.

We are never satisfied, and we want to improve on bortezomib-len/dex. The questions are, how can you do it? Can you change the proteasome inhibitor? People are testing carfilzomib-len/dex, ixazomib-len/dex? Or can we change the partner to lenalidomide?

Instead of bortezomib or another proteasome inhibitor, maybe we can try a monoclonal antibody. There are trials going on with daratumumab, with elotuzumab, and isatuximab.

Where are these studies right now? The one that is mature is the MAIA trial, which looked at daratumumab-len/dex versus lenalidomide dexamethasone. That study has been published in The New England Journal of Medicine and has shown a significant improvement in progression-free survival with a daratumumab-len/dex combination. Overall survival results are pending.

We have the 2 regimens, bortezomib-len/dex and dara-len/dex, that are reasonable options for patients with multiple myeloma who are not eligible for transplant. How we choose between one of them would depend upon availability, cost, patients' perceptions of inconvenience, tolerance to the therapy, and so on.

With bortezomib-len/dex, you just use the triplet for 9 months and then you're only on lenalidomide or lenalidomide-dex. Whereas with daratumumab-len/dex, it's more or less a triplet-until-progression-type regimen. That also factors into the choice. We'll be having to wait for more long-term follow-up to decide between the 2.

The other regimens are still in phase 3 trials. Until further results come, such as the ECOG trial, which compared bortezomib-len/dex head-to-head with carfilzomib-len/dex, it's just too early to say.

For certain high-risk patients, one could consider carfilzomib-len/dex, but this is not something we recommend for older patients who are not transplant-eligible. At this point, bortezomib-len/dex or dara-len/dex remains the main 2 options for patients in this category.

There are some patients who cannot tolerate a triplet because they're too frail or they cannot get to a center every week for infusional or subcutaneous therapy. In those patients, len/dex or perhaps in the future if the trial is promising, ixazomib-len/dex may be options.