Factors To Be Considered When Treating RRMM

Paul G. Richardson, MD:When we consider treatment for a patient with relapsed/refractory multiple myeloma, there are multiple factors to think about it. Importantly, is the time of progression from last therapy. That is absolutely critical. Also, understanding whether the patient was on continuous therapy at the time of relapse. For example, for a patient relapsing on maintenance after transplant, that maintenance regimen obviously is critical. Typically and characteristically, it’s lenalidomide. And when you see a lenalidomide failure in this setting, what do you then choose?

It’s a question of prior therapy, progression-free interval. It’s a question of number of lines of prior therapy. It’s a question, also, of the clinical characteristics of relapse. Are they underpinned by biochemical progression if the patient is entirely asymptomatic? Is there evidence of myeloma-related end organ injury? And by that I mean, is there evidence of worsening bone pain? Is there evidence of renal dysfunction? Is there evidence of fatigue and systemic symptoms that suggest the disease is much more active? And then when we think about that, we obviously fully reevaluate the patient. We do a bone marrow aspiration and biopsy to scrutinize the cytogenetics of the recurrent disease and assess the amount of plasmacytosis. We reimage with radiological imaging and additional imaging such as PET/CT [positron emission tomography/computed tomography] as clinically indicated, obviously taking into account those various factors.

One critical, outstanding factor is obviously the performance status of the patient. In the old days, things were very age dependent. In my opinion, that’s less valid now, because obviously our patients are older now and are much fitter. So we assess frailty as a broad concept, because there are obviously frail patients who are age 65 and fit patients who are age 75. And in that spirit, we also very carefully assess cardiovascular risk. We assess patients to see if they have vasculopathy. Are they at risk for those kinds of complications, versus are they otherwise experiencing preexisting peripheral neuropathy from previous proteasome inhibition? And in that context, how would you then make a best choice of therapy? So there are multiple factors we think about in selecting or assessing a patient with relapsed/refractory disease before we select a therapy.

Transcript edited for clarity.