Transplant-Eligible NDMM: Selecting Induction Therapy Based on Risk Status

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In the setting of transplant-eligible newly diagnosed multiple myeloma, expert panelists consider how risk status may affect the selection of induction therapy.

Transcript:

Andrew P. Dalovisio, MD: One other question I would ask is about your transplant-eligible patients: When you treat them, do you think of treating them differently if they’re-high risk vs standard risk?

Kelly Pippin, MD: Absolutely. I’ll jump in there. I just my finished fellowship less than a year ago. The practice was doing transplants and at standard risk tended to want to go with the 3-drug regimen at the time. With the more high-risk patients, they incorporated the daratumumab. I think some of the studies you’ve mentioned have been more practice-changing, and we should move into a…quad regimen for all standard and high-risk [disease]. I think a couple of years ago it was a triplet regimen for a standard-risk [patient] and then a quad regimen for a high-risk [patient]. But I think that aspect of treatment is changing.

Andrew P. Dalovisio, MD: Yes. And I think the VRd [lenalidomide, bortezomib, and dexamethasone regimen] has stayed in NCCN [the National Comprehensive Cancer Network guidelines]; it’s stayed in mSMART [Mayo Stratification of Myeloma and Risk-Adapted Therapy guidelines] for standard-risk disease. I think one thought behind that was cost. [Some] regimens can be $40,000 or $50,000 a month, so it kept costs down. Also, as I said, with the GRIFFIN trial [NCT02874742], there hasn’t been a proven overall survival advantage yet. So I think you can still make a rational argument, if you want to be a data purist, about staying with triplets.I think we need to wait for that data to play out another 5 years. My suspicion is quads are going to go out, and that’s why I generally tend to give them to everyone.

Thomas Atkinson, MD: I’d like to ask a question. One of the arguments I hear about not using quad therapy up front is that it will be available to you at relapse. I think that argument is somewhat wrongheaded, but I would like to hear your thoughts on that.

Andrew P. Dalovisio, MD: We’ll dive a little bit into that during the relapse portion of the talk. But I definitely think, when I’m talking to my fellows about this, the concept of saving therapies for later in myeloma is not really one…that’s good. If you look at myeloma, you’re going to get 2, maybe 3 shots to make a meaningful progression-free period. And, really, that first shot is the big one. I’m a big fan of giving the best drugs in combination up front and not saving drugs for later. That’s a principle that I really believe in. I think the exciting thing about quads, too, and one of the questions I’ll ask for patients who are…MRD [minimal residual disease] negative after quad therapy [is], do they need a transplant? Right now we don’t know that. Right now we still think that they do. There’s a trial going on called the PERSEUS trial [NCT03710603] that takes transplant-ineligible patients but gives them 4 drugs and no transplant. It’s going to be interesting to watch that data play out because I think there’s [probably] a subset of patients who don’t need a transplant or don’t necessarily benefit from it.

Transcript edited for clarity.

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