Evolving Practice Patterns for Multiple Myeloma - Episode 1
Keith Stewart, MD, ChB, MBA; Sagar Lonial, MD, FACP; Cristina Gasparetto, MD; Joseph Mikhael, MD; and Nina Shah, MD, discuss the diagnostic work-up for a patient with newly diagnosed multiple myeloma and the impact of age and frailty scores on transplant eligibility.
Keith Stewart, MD, ChB, MBA: Hello. Welcome to this OncLive® Peer Exchange, “Evolving Practice Patterns for Multiple Myeloma.” I’m Dr Keith Stewart. Joining me today in this discussion are my colleagues who are all experts in the field of myeloma clinical research: Dr Sagar Lonial from the Winship Cancer Institute in Atlanta, Georgia; Dr Joseph Mikhael from the Translational Genomics Research Institute in Phoenix, Arizona; Dr Cristina Gasparetto from the Duke Cancer Institute in Durham, North Carolina; and Dr Nina Shah from UCSF Helen Diller Family Comprehensive Cancer Center in San Francisco, California. Today, we will be discussing modern management approaches to multiple myeloma, and we’ll reflect on the latest data from the recent ASH [American Society of Hematology] meeting and from ASCO [American Society of Clinical Oncology], which just finished its 2021 virtual meeting in June. Let’s get started on our first topic. I’m going to turn to Dr Shah to start us off. Dr Shah, or Nina, today, when you work up a patient with newly diagnosed multiple myeloma, what is your thinking with respect to whether that will influence what treatment you give? How is that relevant to younger and older patients?
Nina Shah, MD: Thank you for having me. I think this is a really important question because we want to be as specific as possible to treat our patients with myeloma, but sometimes we don’t have all the information we need. I think it’s important to get, of course, standard patient cytogenetics, and I would say that’s probably the most pertinent information, and also the most available information you’ll get. But I also like to get things like a PET [positron emission tomography] scan, etc, to understand the true burden of disease. This helps us to understand not only what’s going on with the patient physiologically, but we also have to think about what’s going on functionally with the patient, understanding frailty calculators, etc, so that we can decide where we may start their treatment, thinking about transplant eligibility vs not.
Keith Stewart, MD, ChB, MBA: There’s a lot packaged in what you just said. Let’s start with a frailty score. Do you use that in your assessment of your patients?
Nina Shah, MD: I probably should use it more than I do. It’s pretty helpful because it incorporates some of the morbidities that a lot of patients with multiple myeloma have. You can think about that with whether there’s going to be a transplant in the future or not. And if not, that will help you decide on the induction therapy. But I have to say that I would like to apply it more rigorously than I actually do.
Keith Stewart, MD, ChB, MBA: Cristina, what about you? Do you use frailty scores when you’re looking at patients?
Cristina Gasparetto, MD: No, not necessarily. When I encounter the patient, trying to figure out the different comorbidities, I don’t necessarily follow it rigorously, like Nina mentioned. Of course, you have your own idea at the end of the day if a patient is robust vs being incapable of tolerating the aggressiveness of treatment.
Keith Stewart, MD, ChB, MBA: Cristina, at your center, the Duke Cancer Institute, are you using an age cutoff for transplant eligibility? Or is it a frailty and comorbidity assessment?
Cristina Gasparetto, MD: We do some transplants for patients older than 70, 75, 76 years old, robust patients, as I mentioned, with a good performance status. But the younger patients, we tend to push toward transplant even if they don’t have the best performance status, and sometimes, I question that decision. But we don’t have a real age cutoff. I have to admit, 76 years old is probably my higher age.
Keith Stewart, MD, ChB, MBA: How about you, Joe? Dr…used to say you could transplant anyone, age was irrelevant. Are you an advocate of an upper age limit?
Joseph Mikhael, MD: I’m not an advocate of an exact limit. Even when we wrote the ASCO guidelines recently, we said that age shouldn’t be the only factor, but it is a factor. The way I look at it, Keith, is that we look for the benefit of transplant these days. I shudder to say this in the presence of individuals like Professor Shah, but for transplant, the best evidence we have is in people under 65. So when someone’s 65 to 75 years old, in my mind, it’s more of a gray area. That’s where I’m more rigorous in a frailty evaluation, especially now that we have long-term data from MAIA and other studies showing that we can do well with a transplant-less route. I have to say, I used to think 70 years old was the cutoff for sure. But now, for patients between 65 and 70 years old, I have to convince myself why to do a transplant, Keith.
Keith Stewart, MD, ChB, MBA: Sagar, do you do a PET scan for every patient?
Sagar Lonial, MD, FACP: I think we do PET scans on every patient at the time of diagnosis. I think skeletal surveys have fallen by the wayside. I want to add, if I can, to the last discussion because I think there have been multiple retrospective analyses that show that the benefit of transplant in patients over the age of 65 is the same magnitude as the benefit for younger patients. I think it does continue to offer significant benefit. When we get to the MRD [minimal residual disease] section, I’ll tell you why I think an age cutoff has taken us down the wrong path.
Keith Stewart, MD, ChB, MBA: Sagar, your center, the Winship Cancer Institute, published some phenomenal single-center results with triplet therapy, transplant, and more triplet therapy. The median survival was more than 10 years for standard-risk patients, which was very impressive. Do you change your therapy based on the FISH [fluorescence in situ hybridization testing]? If you’re giving everybody that treatment and you’re not changing anything, why bother doing it?
Sagar Lonial, MD, FACP: What we change is in the maintenance phase. The answer is, certainly in that series, our approach was to give everybody the same induction and change the maintenance phase. Our current guidelines are that the high-risk patients will receive KRd [carfilzomib, lenalidomide, dexamethasone] up front, whereas the standard-risk patients will get RVd-dara [lenalidomide, bortezomib, dexamethasone plus daratumumab]. Again, we can talk about that more as a group later.
Transcript Edited for Clarity