Risk Assessments Can Improve Tailored Treatment for Multiple Myeloma

Shaji Kumar, MD, a hematologist at the Mayo Clinic and chair of the Plasma Cell Disorders Scientific Committee at the American Society of Hematology, discusses how risk assessments and new drug combinations could influence treatment of patients with newly diagnosed multiple myeloma.

According to Kumar, the current standard of care for early-stage multiple myeloma is a proteasome inhibitor in combination with immunomodulatory drugs or monoclonal antibodies. Multiple regimens may be used depending on if patients are eligible for stem cell transplant. Eligible patients receive induction therapy with dexamethasone prior to a single transplant. After the transplant, patients can receive lenalidomide maintenance (Revlimid). High-risk patients may be given daratumumab (Darzalex) plus a combination of bortezomib, lenalidomide, and dexamethasone (VRd).

Patients who are transplant-ineligible may receive daratumumab until disease progression. For high-risk disease, modified lenalidomide, bortezomib, and dexamethasone (VRd-Lite) may be given with a proteasome inhibitor or other immunomodulatory drug.

Kumar suggests that targeted treatment could be improved with new drug combinations in frontline treatment. Combinations with better response and lower toxicity can allow patients to stay on treatment for a longer period. He also points to improvements in treatment based on risk assessments such as the Revised International Staging System (R-ISS) risk factors and minimum residual disease (MRD) testing to assess the efficacy of treatment. MRD measures the number of remaining myeloma cells in the bone marrow while a patient is in remission, which can predict disease progression and relapse.

TRANSCRIPTION:

0:08 | A couple of areas that we focused on were looking at the concept of risks of rapid therapy, how can we change the treatments based on some of the commonly used risk factors like the R-ISS staging system? Also, [we are] talking about the concept of a dynamic risk assessment because patients' outcomes can vary based on how what kind of response they get, how deep a response, how long will MRD negativity last, and so forth. So, I think that's one aspect of how we will tailor therapy in the up-front setting, and maybe even in the setting of relapsed disease.

I think the other concept is one of using multidrug combinations to provide us with a limited-duration therapy so that patients can stay on treatment for a very, very long time. But it can help with both toxicity related to therapy as well as the cost of care. So, how can we use some tools like MRD testing to guide us towards more scientifically defining the ideal duration of therapy for individual patients?