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Treating Myeloma: Newly Diagnosed Transplant-Eligible Patients

Panelists: Sagar Lonial, MD, FACP, Winship Cancer Institute of Emory University; Amrita Y. Krishnan, MD, City of Hope Comprehensive Cancer Center; Thomas G. Martin, MD, UCSF Helen Diller Family Comprehensive Cancer Center; Krina K. Patel, MD, MSc, University of Texas MD Anderson Cancer Center; Saad Z. Usmani, MD, FACP, Levine Cancer Institute
Published: Wednesday, Jul 03, 2019



Transcript: 

Sagar Lonial, MD, FACP: Let’s move on to newly diagnosed myeloma in the transplant-eligible patient population. Tom, why don’t you get us started on how you choose among commonly currently used approaches—VRd [bortezomib, lenalidomide, dexamethasone], KRd [carfilzomib, lenalidomide, dexamethasone]. Just get the ball rolling.

Thomas G. Martin, MD: This is 1 thing that I really like about being a myeloma physician. Before I walk into the patient’s room, I really don’t know what I’m going to give them for therapy, because I do think we provide personalized therapy.

Sagar Lonial, MD, FACP: Many might not find that reassuring.

Thomas G. Martin, MD: Now, in fact, the choices are getting smaller and smaller, especially for transplant-eligible, newly diagnosed patients. I think we have 2 options: lenalidomide-bortezomib and dexamethasone, or RVd, and carfilzomib-lenalidomide-dexamethasone, or KRd. For the transplant-eligible patients, we’re not adding the antibody just yet. But in terms of those, I would say that the majority of my patients, I treat with RVd [lenalidomide-bortezomib-dexamethasone]. It provides an excellent overall response rate of greater than 95%. We get CRs [complete responses] in the 30%-to-40% range, and MRD [minimal residual disease] negativity 10-5 in upward of 40% to 50% of patients. It’s a very good regimen. I would say that our bias, or my bias in general, has been if I have a really young patient or if I have a patient who has a high-risk cytogenetic profile—and that, for me, does include 4;14s, 14;16s, 17p deleted patients or multiple cytogenetic abnormalities—I then do give them carfilzomib-lenalidomide-dexamethasone or KRd. So, for me, it’s RVd [lenalidomide-bortezomib-dexamethasone] versus KRd [carfilzomib, lenalidomide, dexamethasone], with KRd [carfilzomib, lenalidomide, dexamethasone] winning in the young and really strong and also the patients who have high-risk disease.

Sagar Lonial, MD, FACP: Krina, I know that you take a slightly different tact at The University of Texas MD Anderson Cancer Center in Houston, Texas. You want to talk to us about the generic patient who walks in?

Krina K. Patel, MD, MSc: Sure. So you have to prove yourself not worthy of KRd [carfilzomib, lenalidomide, dexamethasone]. You have to have cardiomyopathy or something that tells me, “Hey, carfilzomib is probably not going to be the right drug for you.” Of course for all our high-risk patients, and sometimes even our frail patients who are high risk, we are able to do carfilzomib-rev-dex [lenalidomide-dexamethasone]. The biggest reason, I think, is the neuropathy. We do see a lot of neuropathy with Velcade, and with carfilzomib it’s a lot less. I think I’ve had 1 or 2 patients out of all patients we treat.

And I think of how quickly the carfilzomib works. I do have a lot of patients with high-risk but also bulky disease who just didn’t know they had myeloma until something bad happened, and they have a lot of disease. Pain, bone pain, it seems to get it down really quickly. I’m usually able to decrease the amount of cycles I need prior to transplant, so the majority of our patients get KRd [carfilzomib, lenalidomide, dexamethasone].

Sagar Lonial, MD, FACP: Other comments on other state-of-the-art approaches before we walked into ASCO [the American Society of Clinical Oncology Annual Meeting]?

Amrita Y. Krishnan, MD: I think the antibody is interestingly on its way into the frontline, and I would imagine many of us do add it on, maybe not routinely. But if we’re unhappy with the response with RVd [lenalidomide-bortezomib-dexamethasone], I certainly very quickly either switch to KRd [carfilzomib, lenalidomide, dexamethasone] or—based on the Griffin study—I add daratumumab because you again see deep, quick responses and the tolerability is quite excellent. I guess the other point I would make is that I did, before coming into ASCO, in fact have a discussion about the FORTE data and the role of stem cell transplantation up front. There was a lot of hand-wringing now that the response rates look similar in the KRd-12 [12 cycles of carfilzomib, lenalidomide, dexamethasone] versus the KRd [carfilzomib, lenalidomide, dexamethasone] plus transplant. But I left the session this morning actually quite reassured about the role of stem cell transplantation, given the high rates of MRD negative in the transplant arm.

Transcript Edited for Clarity

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Transcript: 

Sagar Lonial, MD, FACP: Let’s move on to newly diagnosed myeloma in the transplant-eligible patient population. Tom, why don’t you get us started on how you choose among commonly currently used approaches—VRd [bortezomib, lenalidomide, dexamethasone], KRd [carfilzomib, lenalidomide, dexamethasone]. Just get the ball rolling.

Thomas G. Martin, MD: This is 1 thing that I really like about being a myeloma physician. Before I walk into the patient’s room, I really don’t know what I’m going to give them for therapy, because I do think we provide personalized therapy.

Sagar Lonial, MD, FACP: Many might not find that reassuring.

Thomas G. Martin, MD: Now, in fact, the choices are getting smaller and smaller, especially for transplant-eligible, newly diagnosed patients. I think we have 2 options: lenalidomide-bortezomib and dexamethasone, or RVd, and carfilzomib-lenalidomide-dexamethasone, or KRd. For the transplant-eligible patients, we’re not adding the antibody just yet. But in terms of those, I would say that the majority of my patients, I treat with RVd [lenalidomide-bortezomib-dexamethasone]. It provides an excellent overall response rate of greater than 95%. We get CRs [complete responses] in the 30%-to-40% range, and MRD [minimal residual disease] negativity 10-5 in upward of 40% to 50% of patients. It’s a very good regimen. I would say that our bias, or my bias in general, has been if I have a really young patient or if I have a patient who has a high-risk cytogenetic profile—and that, for me, does include 4;14s, 14;16s, 17p deleted patients or multiple cytogenetic abnormalities—I then do give them carfilzomib-lenalidomide-dexamethasone or KRd. So, for me, it’s RVd [lenalidomide-bortezomib-dexamethasone] versus KRd [carfilzomib, lenalidomide, dexamethasone], with KRd [carfilzomib, lenalidomide, dexamethasone] winning in the young and really strong and also the patients who have high-risk disease.

Sagar Lonial, MD, FACP: Krina, I know that you take a slightly different tact at The University of Texas MD Anderson Cancer Center in Houston, Texas. You want to talk to us about the generic patient who walks in?

Krina K. Patel, MD, MSc: Sure. So you have to prove yourself not worthy of KRd [carfilzomib, lenalidomide, dexamethasone]. You have to have cardiomyopathy or something that tells me, “Hey, carfilzomib is probably not going to be the right drug for you.” Of course for all our high-risk patients, and sometimes even our frail patients who are high risk, we are able to do carfilzomib-rev-dex [lenalidomide-dexamethasone]. The biggest reason, I think, is the neuropathy. We do see a lot of neuropathy with Velcade, and with carfilzomib it’s a lot less. I think I’ve had 1 or 2 patients out of all patients we treat.

And I think of how quickly the carfilzomib works. I do have a lot of patients with high-risk but also bulky disease who just didn’t know they had myeloma until something bad happened, and they have a lot of disease. Pain, bone pain, it seems to get it down really quickly. I’m usually able to decrease the amount of cycles I need prior to transplant, so the majority of our patients get KRd [carfilzomib, lenalidomide, dexamethasone].

Sagar Lonial, MD, FACP: Other comments on other state-of-the-art approaches before we walked into ASCO [the American Society of Clinical Oncology Annual Meeting]?

Amrita Y. Krishnan, MD: I think the antibody is interestingly on its way into the frontline, and I would imagine many of us do add it on, maybe not routinely. But if we’re unhappy with the response with RVd [lenalidomide-bortezomib-dexamethasone], I certainly very quickly either switch to KRd [carfilzomib, lenalidomide, dexamethasone] or—based on the Griffin study—I add daratumumab because you again see deep, quick responses and the tolerability is quite excellent. I guess the other point I would make is that I did, before coming into ASCO, in fact have a discussion about the FORTE data and the role of stem cell transplantation up front. There was a lot of hand-wringing now that the response rates look similar in the KRd-12 [12 cycles of carfilzomib, lenalidomide, dexamethasone] versus the KRd [carfilzomib, lenalidomide, dexamethasone] plus transplant. But I left the session this morning actually quite reassured about the role of stem cell transplantation, given the high rates of MRD negative in the transplant arm.

Transcript Edited for Clarity
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