Case 4: Relapsed-Refractory Myeloma

EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Ola Landgren, MD, PhD:Let’s switch to the last case. Ajai, I want you to present a patient who is relapsed-refractory.

Ajai Chari, MD:Sure. This is a 65-year-old [woman] diagnosed 4 years ago with stage II myeloma. She did have t(14;16). She had a great CR [complete response] after an RVd [lenalidomide, bortezomib, dexamethasone] induction followed by transplant. She did not go on lenalidomide maintenance. And then, on routine follow-up, she now has fatigue but is working full time. She has grade 1 neuropathy, her M-spike [monoclonal protein] is now 1.4 g/dL, and light chain levels are rising. She’s anemic, with a hemoglobin [level] of 10.3 g/dL, and she has a creatinine [level] of 1.3 mg/dL.

Ola Landgren, MD, PhD:When do you start therapy for this relapsed disease?

Ajai Chari, MD:This is a really interesting question, because clinical trials are probably way overrepresented with biochemical progressors, [so] you get these great numbers. What I’ve seen in real-world data is that on the 1 hand, duration of therapy is much shorter, but the time to next therapy is much longer. I think what’s happening in the community is that people aren’t treating that M-spike of 0.5 g/dL, for which we can put somebody on study. And so I think it depends on the patient. Obviously, if it’s a rapid rate of rise, even if it’s low I might start early. If it’s a high-risk patient, I might start early. If it’s somebody who has had bone disease, I might start early because I don’t want to risk that. Conversely, if it’s a low rise, biochemical [progression on a patient] with no history of bone disease, and is a low-risk patient, I might wait a little longer.

Ola Landgren, MD, PhD:Would you do it differently, Nina?

Nina Shah, MD:Definitely, if they had a history of renal insufficiency in the past because of their myeloma burden, I would do it on a biochemical progression. I just feel as if those guys get in trouble early, and definitely a little earlier I’ve seen, especially with the relapsed disease. That’s 1 case for which I would be more prone to use the numbers.

The reason I like to use numbers is because it gives me a hard point. I think, “OK, this clinical trial was done with a progressive disease history, and this person meets progressive disease, so I’m going to have the same result as this clinical trial did.” I think that in my head, obviously knowing that we don’t do the same in clinical trials.

But it’s a fine line, because what do we usually do? We say, “Oh, let’s repeat your labs when you come back. And if that’s still going up—I think 0.5, 0.7, 0.9 g/dL—that’s a time to change. But if there’s an absolute value difference of 1.0 g/dL in the M-protein or 200 mg/L on serum free light chain, that absolute value for sure is beyond progression now. I would treat that.

Ola Landgren, MD, PhD:Would you do it differently, Alfred?

Alfred Garfall, MD:No, I agree with all the considerations. I think you need to consider the pace of rise, the prior complications that the patient had, where they are, and if their numbers are relative to where they were when they were symptomatic. But if somebody was in a CR, and we watched the M-spike go up to 1.4 g/dL, I would treat this patient.

Ola Landgren, MD, PhD:I agree with that.

Transcript edited for clarity.