Patient Profile 2: A 74-Year-Old with Transplant-Ineligible NDMM


Myeloma experts present the case of a 74-year-old with transplant-ineligible newly diagnosed MM and offer their initial impressions.


Ola Landgren, MD, PhD: Let’s move on and talk about another case. This is very similar to our first case. The difference here is that it’s a 74-year-old male who presents with lytic lesions. The patient has underlying comorbidities in terms of well-controlled diabetes and mild hypertension. The bone marrow work-up shows around 40% plasma cells. The cytogenetics in this particular case show hyperdiploid disease, and there is an elevation of the markers in the blood. After a few cycles of therapy, 4 to 5 cycles, based on the information we have, the patient is worked up and has quite a good response. But by convention, this would be deemed to be a partial response because the markers have gone down more than 50%, but not down the 90% that we would require for a very good partial response. So what would be available treatment options for this 74-year-old male, Ben?

Benjamin Diamond, MD: What’s funny is here we don’t see a lot of difference. This patient, to the best of our knowledge, looks like they’re fit. So this patient should be given every opportunity to have the best therapy available to them at this point. I think for this patient, I would still recommend using our GRIFFIN [trial] combination of dara-VRd [daratumumab plus bortezomib, lenalidomide, dexamethasone].

Ola Landgren, MD, PhD: That’s absolutely an option, but there are multiple schools of thought. Dickran, what could be another option if you don’t want to give a 4-drug combination?

Dickran Kazandjian, MD: Very similar to what Ben was saying, we could use the data from the MAIA study and use a regimen of daratumumab with lenalidomide and dexamethasone [DRd]. I agree, there’s nothing to say we can’t give the best therapies up front, but the daratumumab-VRd was never compared with DRd, and DRd is pretty good at getting deep and durable responses. So if there were any question about, for example, diabetes and maybe some peripheral neuropathy or some other issues, I would favor the DRd regimen.

Ola Landgren, MD, PhD: Dennis, for a long time people have used the bortezomib combination, bortezomib, lenalidomide, and dexamethasone [VRd], and this was initially published in the Blood journal in 2010. It’s almost like 100,000 years ago. The field has moved forward so quickly, and there have also been different types and versions of the VRd regimen. People have talked about VRd-lite, which is given once a week, and you could even think about reducing the dose of bortezomib, and many times lenalidomide could go from 25 to 15 mg. Would VRd-lite be an option for this patient? Dickran was saying if the patient has neuropathy, it’s not a good idea, but let’s say the patient doesn’t have neuropathy.

Dennis Verducci, APRN: If the patient didn’t have any neuropathy, I think it’s a reasonable option. However, I would favor what Dickran said about giving DRd. I worry a bit about the patient having diabetes. Even if they have no peripheral neuropathy at this time, that may be exacerbated by the use of Velcade [bortezomib]. In that case, I would use that with caution.

Ola Landgren, MD, PhD: Ben, I pass the ball to you because you are the one who brought up the 4-drug combination that contains bortezomib. Would you still do that? Let’s say the patient doesn’t have neuropathy. Would you give the 4 drugs? Would you do all the cycles? Would you start with that and then go down to 3 drugs? How would you manage that?

Benjamin Diamond, MD: Yes, I think there is a bit of room here. So, if you have any question that the patient may not be fit, then certainly using the MAIA regimen is very appropriate. It’s a great regimen. If you think the patient is looking for a bit of a deeper response and can handle the 4-drug regimen, then absolutely, I would consider at least starting them on that. And there’s nothing set in stone. If you need to de-escalate, if the patient develops neuropathy, you can always drop the bortezomib.

Transcript edited for clarity.

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