Unmet Needs and Advice for Community Oncologists Treating Patients With NDMM
Natalie Callander, MD, offers advice for community oncologists and discusses unmet needs in treating transplant-preferred patients with newly diagnosed MM.
Case: A 61-Year-Old Woman with Transplant-Preferred Newly Diagnosed Multiple Myeloma (NDMM)
- Patient ML is a 61 y/o woman.
- PMH: Hypertension (well controlled on medication)
- SMH: Does not smoke; drinks occasional glass of wine in social setting; Walks with friends 2-3 times weekly.
Clinical Presentation:
- In October 2022, ML visited her PCP for her annual checkup. She reported having persistent pain in her shoulders.
Clinical Workup and Diagnosis:
- Calcium 13.2 mg/dL
- LDH 600 U/L (> ULN)
- CrCl, 45 mL/min
- Hgb, 7.0 g/dL
- Beta-2-microglobulin, 6 mg/dL
- Bone marrow biopsy showed 24% monoclonal plasma cells.
- Serum monoclonal protein, 5 g/dL
- Serum kappa FLC, 200 mg/dL
- Del(17p) cytogenetic abnormalities were detected by FISH.
- PET-CT showed osteolytic lesions in the shoulders; no EMD.
- ECOG PS 1
- ML was diagnosed with ISS stage II/R-ISS stage III IgG-kappa myeloma; determined to be transplant-preferred.
Current Treatment:
- After discussions with her family and clinical team, ML was initiated on Daratumumab/bortezomib/lenalidomide/dexamethasone induction therapy (D-RVd).
- Post-induction therapy, ML achieve very good partial response (VGPR).
- Patient underwent stem cell mobilization and 3 months later underwent ASCT.
- Post-ASCT response: VGPR
Transcript:
Natalie Callander, MD: We all agree that there are 2 very important issues. One need is in patients with high-risk myeloma. We all see them. Depending on how you define high risk—and that’s a moving target—around 15% or as high as 20% of patients meet that definition. The issue is, how are we going to do better for them? We feel pretty comfortable that quadruplet induction is a good first step. But besides transplant, they’re going to need an addition to their therapy, maybe that’s in a maintenance phase. Likely it will include the introduction of novel agents.
The second need—and there are important studies investigating this—is whether we can de-escalate patients who have standard-risk myeloma and maybe need less treatment. In the United States, many of the studies are put together with indefinite maintenance, which ends up being a treatment burden, an adverse effect burden, and financial burden on patients. If we can prove through a couple of important studies, like SWOG-S1803, that we can cut back on therapy effectively—particularly in lower-risk patients—that’s going to be great for everybody, certainly for our patients.
At my center [University of Wisconsin Carbone Cancer Center], our definition of who’s transplant eligible gets down to fitness. Fitness not just at presentation of their diagnosis but as time goes on, because many of patients with myeloma get better. The case we started with is a patient who’s having a lot of pain initially. Often in a few cycles, patients feel much better. You might think there’s no way that a patient could tolerate transplant, but then they end up being a good transplant candidate. Keep that in mind.
Because we know that quadruplet regimens influence the ability to collect stem cells, we’d like to see those patients sooner rather than later. If you started a patient on a quadruplet regimen, you’d want to get in touch with a transplant center by the second cycle to say, “We have this patient, and we’d love for you to see them.” That’s a good strategy. Of course, because these treatments are so effective—we mentioned the German study [GMMG-HD7]—you’re MRD [minimal residual disease] negative in 18 weeks. You can collect people and send them back to complete their treatment. They shouldn’t need to think they have to complete an entire package or 4 months of treatment, or something like that, before they’re sending a patient for stem cell collection.
I’d also like to emphasize that we increasingly think it’s critical to complete all the staging. Even though these tests seem like a laundry list of things to do, about 75% of patients with myeloma are getting FISH [fluorescence in situ hybridization] and cytogenetic analysis. FISH is the important part. We’d love it to be 100% because that helps us define risk. Another study that is not done but is part of our risk stratification is lactate dehydrogenase. It’s important to get those at baseline to help us categorize patients appropriately.
Transcript edited for clarity.
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