Improving Outcomes in Newly Diagnosed Multiple Myeloma - Episode 5

Consolidation Therapy Post-Transplant in Multiple Myeloma

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The current rationale for managing a patient with newly diagnosed multiple myeloma with consolidation therapy post-transplant.

Saad Z. Usmani, MD: Last question before we move on is about the role of consolidation. The GRIFFIN trial from 2009 looked at consolidation, but in our practice, who do we consolidate for transplant? Let’s get some quick, short answers. Do you consolidate anyone?

Neha Korde, MD: I don’t necessarily. I know there’s data to support certain patients that have, for instance, a response after transplant and haven’t hit the deepest of responses. At that point, you can consider giving consolidation. Quite frankly, I find my conversations post-transplant, and this is one of those things where it’s more of a psychological thing. You have a patient that just came back to you after transplant and they feel as if they’ve gone through this whole thing. For me to say, “I’m going to give you the same cycles I gave to you at induction,” it can be a very jarring conversation. So, for me, I try to look forward. Sometimes, what I’ll do in high-risk patients, for instance, if I’m debating on having a conversation about a doublet with a PI-IMiD [proteasome inhibitor-immunomodulatory drugs], I will frame it as not necessarily consolidation, but it’s maintenance. I’ll do a maintenance type of regimen with the PI [proteasome inhibitor] on board where it’s frequency is reduced. Again, I think a lot of that has to do with psychological well-being of the person sitting in front of me, a patient, but if I do give consolidation, I do it for short periods of time—2 to 4 more cycles after that—and then hit my maintenance.

Saad Z. Usmani, MD: Would you agree with that as well?

Urvi Shah, MD: Very good.

Saad Z. Usmani, MD: The only patients that I’m picking consolidation for, and I try to introduce this idea before transplant, is the high-risk patients. If they’re not getting better than a VGPR [90% decrease in the serum monoclonal component level] post-transplant, I would negotiate with them to have a couple of post-consolidation cycles or post-transplant cycles with consolidation before going into a maintenance phase.

Urvi Shah, MD: Do you consider doing different triplets after consolidation or do you just continue what they’ve been on before?

Saad Z. Usmani, MD: I would continue with what they’ve been on.

Urvi Shah, MD: Provided they’re having a drop in their response.

Saad Z. Usmani, MD: They’re having a drop in the response. Exactly.

Sham Mailankody, MD: I also found it helpful that in these patients with high-risk or less than, if they, or you, decide not to do maintenance, then following them a little more closely to pick up biochemical relapse and starting treatments at that point is a very reasonable strategy. Instead of seeing them every 3 months, maybe you see them every 4 to 6 weeks until you know what the tempo of the disease is. If they’re going to have high-risk, unfortunately, they’re going to declare this in a few months if that is the case.

Urvi Shah, MD: Yeah.

Sham Mailankody, MD: What you don’t want is for those patients to have bad clinical outcomes from having relapse, and by following closely, I think many times you can avoid that.

Transcript edited for clarity.