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Elderly Patients With Myeloma

Panelists: Keith Stewart, MB, CHB, Mayo Clinic; Sagar Lonial, MD, Winship Cancer Institute; Paul Richardson, MD, Dana-Farber Cancer Institute; Amrita Krishnan, MD, City of Hope Comprehensive Cancer Center; Saad Usmani, MD, Levine Cancer Institute
Published Online: Wednesday, Feb 08, 2017



Transcript:

Keith Stewart, MB, CHB:
Let’s summarize what we have discussed: triplet therapy; transplant still has a role; everybody is getting lenalidomide maintenance; many people are adding bortezomib; and some of the newer drugs are being explored in clinical trials in the maintenance setting. In elderly patients, we haven’t really dug into what we’re doing there. Sagar, what are you doing in an elderly patient today?

Sagar Lonial, MD: I think the first thing to say, in terms of elderly patients, is I define those patients more by frailty than I do by age. Patients that are not able to tolerate a standard RVD (Revlimid/Velcade/dexamethasone)-based induction or a transplant are the patients that I consider frail. And so, for those patients, my standard, currently, is probably lenalidomide and dexamethasone. But, there certainly is emerging data suggesting the antibodies may change that equation a little bit.

Keith Stewart, MB, CHB: The antibodies being elotuzumab and daratumumab?

Sagar Lonial, MD: I think the goals of therapy are probably the same for the elderly, but the pace at which you get there is probably going to be different.

Keith Stewart, MB, CHB: Are you doing anything different in your elderly patients?

Amrita Krishnan, MD: I think there are 2 points to make. Number one, I think, is that we’re still not very good at assessing our elderly patient. We need to do a better job of defining frailty. For example, the British have a trial that is trying to codify that and figure out response-adapted therapy. Do you give everyone “one-size-fits-all,” and then adjust for toxicity? Or do you modify early on— (some of it based on frailty scoring and indexes)? So, we need to make our assessment of frailty better, but also easier to do, so that we’ll actually do it.

Keith Stewart, MB, CHB: What do you do? That’s what I asked you?

Amrita Krishnan, MD: I think we do the “look” test still.

Keith Stewart, MB, CHB: I don’t mean for frailty. If an 82-year-old lady comes in, how do you treat her?

Amrita Krishnan, MD: We do a geriatric assessment, and for those who truly are frail, we will do Len-Dex (lenalidomide plus dexamethasone).

Keith Stewart, MB, CHB: I was quite taken with the RVD light protocol that Noopur Raje developed at Massachusetts General Hospital. I’ve been using that a lot. Paul, what do you do?

Paul Richardson, MD: I want to acknowledge Jacob Laubach (my partner), who is actually a partner with Elizabeth (Betsy) O’Donnell, MD, on that study. And RVD light was developed in a partnership with Noopur with exactly the goal of what we could do to minimize toxicity. It’s basically a 3 week on, 1 week off schedule of 15 mg of lenalidomide. Then the bortezomib is given weekly, subcutaneously. And Jacob and Betsy have demonstrated this very high response rate—85% objective response rate, overall, and has excellent tolerability in patients over the age of 75.

Keith Stewart, MB, CHB: Saad, what about the other proteasome inhibitors in the elderly—ixazomib and carfilzomib? Is there any role for those in newly diagnosed, elderly patients?

Saad Usmani, MD: I think the data are limited, but ixazomib could easily be used in place of bortezomib. So it could be a ixazomib/lenalidomide/dexamethasone dose-attenuated regimen for elderly patients where you would want to use the proteasome inhibitor and immunomodulatory drug backbone.

Paul Richardson, MD: Yes.

Keith Stewart, MB, CHB: We, with Shaji Kumar, ran a trial of ixazomib/lenalidomide/dexamethasone, and I was impressed with the tolerability. It takes a little bit longer to get to where you want to be, but you do get there in the end, I think. Is that other people’s experience as well?

Sagar Lonial, MD: Yes.

Transcript Edited for Clarity

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Transcript:

Keith Stewart, MB, CHB:
Let’s summarize what we have discussed: triplet therapy; transplant still has a role; everybody is getting lenalidomide maintenance; many people are adding bortezomib; and some of the newer drugs are being explored in clinical trials in the maintenance setting. In elderly patients, we haven’t really dug into what we’re doing there. Sagar, what are you doing in an elderly patient today?

Sagar Lonial, MD: I think the first thing to say, in terms of elderly patients, is I define those patients more by frailty than I do by age. Patients that are not able to tolerate a standard RVD (Revlimid/Velcade/dexamethasone)-based induction or a transplant are the patients that I consider frail. And so, for those patients, my standard, currently, is probably lenalidomide and dexamethasone. But, there certainly is emerging data suggesting the antibodies may change that equation a little bit.

Keith Stewart, MB, CHB: The antibodies being elotuzumab and daratumumab?

Sagar Lonial, MD: I think the goals of therapy are probably the same for the elderly, but the pace at which you get there is probably going to be different.

Keith Stewart, MB, CHB: Are you doing anything different in your elderly patients?

Amrita Krishnan, MD: I think there are 2 points to make. Number one, I think, is that we’re still not very good at assessing our elderly patient. We need to do a better job of defining frailty. For example, the British have a trial that is trying to codify that and figure out response-adapted therapy. Do you give everyone “one-size-fits-all,” and then adjust for toxicity? Or do you modify early on— (some of it based on frailty scoring and indexes)? So, we need to make our assessment of frailty better, but also easier to do, so that we’ll actually do it.

Keith Stewart, MB, CHB: What do you do? That’s what I asked you?

Amrita Krishnan, MD: I think we do the “look” test still.

Keith Stewart, MB, CHB: I don’t mean for frailty. If an 82-year-old lady comes in, how do you treat her?

Amrita Krishnan, MD: We do a geriatric assessment, and for those who truly are frail, we will do Len-Dex (lenalidomide plus dexamethasone).

Keith Stewart, MB, CHB: I was quite taken with the RVD light protocol that Noopur Raje developed at Massachusetts General Hospital. I’ve been using that a lot. Paul, what do you do?

Paul Richardson, MD: I want to acknowledge Jacob Laubach (my partner), who is actually a partner with Elizabeth (Betsy) O’Donnell, MD, on that study. And RVD light was developed in a partnership with Noopur with exactly the goal of what we could do to minimize toxicity. It’s basically a 3 week on, 1 week off schedule of 15 mg of lenalidomide. Then the bortezomib is given weekly, subcutaneously. And Jacob and Betsy have demonstrated this very high response rate—85% objective response rate, overall, and has excellent tolerability in patients over the age of 75.

Keith Stewart, MB, CHB: Saad, what about the other proteasome inhibitors in the elderly—ixazomib and carfilzomib? Is there any role for those in newly diagnosed, elderly patients?

Saad Usmani, MD: I think the data are limited, but ixazomib could easily be used in place of bortezomib. So it could be a ixazomib/lenalidomide/dexamethasone dose-attenuated regimen for elderly patients where you would want to use the proteasome inhibitor and immunomodulatory drug backbone.

Paul Richardson, MD: Yes.

Keith Stewart, MB, CHB: We, with Shaji Kumar, ran a trial of ixazomib/lenalidomide/dexamethasone, and I was impressed with the tolerability. It takes a little bit longer to get to where you want to be, but you do get there in the end, I think. Is that other people’s experience as well?

Sagar Lonial, MD: Yes.

Transcript Edited for Clarity
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