Selecting Appropriate Therapy for Transplant-Eligible NDMM


Panelists briefly review factors they use to select induction therapy for patients with transplant-eligible, newly diagnosed multiple myeloma.


Noopur Raje, MD: I’m going to open this up to all of you, but I’m going to start with you, Jacob. We’ve jumped onto the 4-drug bandwagon, but is there a patient you would treat with 3 drugs now in your practice, and do you do that usually, in a transplant-eligible patient?

Jacob Laubach, MD, MPP: Yes, that’s an important and pressing question for our field because this evolution from 2 drugs to 3 drugs, and now 3 to 4 drugs, historically speaking, has happened fast. We don’t want to get ahead of ourselves and where the data are. As Andrew said, further data from phase 3 trials will be critical in terms of our thinking about how and when to implement 4-drug induction therapy for transplant-eligible patients. Should it be given across the board, or should we reserve it for patients with higher risk as we wait for more data? There are 2 schools of thought at this time, and I think both are reasonable. On the one hand, we haven’t seen major safety concerns with the 4-drug regimens; the depth of response is outstanding, and the initial data we have on PFS [progression-free survival] is impressive. You could make an argument to utilize 4-drug regimens for basically any patient with newly diagnosed myeloma who’s transplant eligible. On the other hand, the data for RVd [lenalidomide, bortezomib, dexamethasone] followed by transplant is impressive. The other school of thought is, let’s continue to use RVd as a standard induction approach with transplant, followed by lenalidomide maintenance, and wait for additional data on the quadruplets, recognizing that for high-risk patients, the addition of daratumumab makes sense.

Noopur Raje, MD: Your patient had high-risk disease based on the FISH [fluorescence in situ hybridization] data that you presented, Jacob. One question is, besides the fact that, yes, you would use a quadruplet, would you use daratumumab-RVd like you did in this case, and now we have the option of the MASTER data, or would you consider daratumumab-KRd [carfilzomib, lenalidomide, dexamethasone]? Do you pick based on genetics, Omar, one vs the other, bortezomib vs carfilzomib?

Omar Nadeem, MD: There have been head-to-head studies with bortezomib- and carfilzomib-containing induction regimens, and the take-home message for me is that they have different toxicities. They’re both active proteasome inhibitors, and they both work well in these combinations. There are some deeper responses seen with the carfilzomib-containing regimens, but then there are some toxicity concerns, particularly related to cardiovascular risk, that come into play when you’re choosing the optimal induction regimen. Currently, I don’t think I am choosing one over the other simply because of risk of disease. It’s mostly determined by patient-related factors.

Transcript edited for clarity.

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