Individualized Treatment Needed for Relapsed, Refractory Multiple Myeloma

Patients with relapsed/refractory multiple myeloma should be given individualized treatment approaches guided by the biology of their disease, frailty of the patient and other comorbidities, said Natalie S. Callander, M.D., who presented on the topic at the NCCN 12th Annual Congress: Hematologic Malignancies in San Francisco, California.
BY WAYNE KUZNAR
PUBLISHED: OCTOBER 10, 2017
Patients with relapsed/refractory (R/R) multiple myeloma (MM) should be given individualized treatment approaches guided by the biology of their disease, frailty of the patient and other comorbidities, said Natalie S. Callander, M.D., who presented on the topic at the NCCN 12th Annual Congress: Hematologic Malignancies in San Francisco, California.

Immediate considerations in the treatment of the relapsed patient are whether the relapse is biochemical or symptomatic, whether relapse is occurring on maintenance or other treatments, whether the relapse is early (less than 12 months), and how extensive the relapse is, said Callander, a professor of medicine at the Division of Hematology/Oncology, University of Wisconsin Cancer Center, Madison.

“If you had a patient who had a symptomatic relapse, you would treat them much more vigorously than if it was biochemical, and it’s important to know [when looking at study results] what we mean by refractory; this is a patient who relapses on therapy, within 60 days of stopping therapy, or has never really reached more than stable disease,” she said. The better outcome with biochemical relapse versus symptomatic is likely a reflection of biology, she explained. One caveat for clinicians to look out for is the patient who develops light chain escape and appears to do worse as a result of clonal evolution.

For patients with early relapse, monoclonal antibodies and triplet combinations with Kyprolis (carfilzomib) and Pomalyst (pomalidomide) are attractive, Callander said.

Preferred regimens for patients with previously treated MM, per the NCCN guideline v2.2018, are:
  • Repeat primary induction therapy (if relapse occurs at six months)
  • Velcade (bortezomib)/ Revilmid (lenalidomide)/dexamethasone
  • Kyprolis /dexamethasone (category 1)
  • Kyprolis / Revilmid /dexamethasone (category 1)
  • Daratumumab/ Velcade /dexamethasone (category 1)
  • Daratumumab/ Revilmid /dexamethasone (category 1)
  • Empliciti (elotuzumab)/ Revilmid /dexamethasone (category 1)
  • Ninlaro (ixazomib)/ Revilmid /dexamethasone (category 1)
Several other regimens are recommended (with phase 2 data to support them) and others can be useful in certain circumstances.

Revilmid-based regimens for early (first) relapse have produced excellent response rates and progression-free survival (PFS) superior to dexamethasone in phase 3 clinical studies, similar to rates observed in newly diagnosed patients, said Callander. Velcade-based regimens for early (first) response are also associated with high response rates and superior PFS rates versus dexamethasone. These regimens “looked to be equally efficacious in patients with high-risk relapsed multiple myeloma, which is also something to keep in mind,” she said.

A second autologous transplant for R/R MM “is often a very good choice, particularly for patients who are looking to do something and try to get back on as little therapy as possible,” Callander said.



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