Changing Patterns of Care in Multiple Myeloma

Looking at the current state of multiple myeloma management, experts discuss interest in novel therapies and MRD assessment to guide treatment.

Transcript

Bruce Feinberg, DO: Hello, and welcome to this AJMC® webcast titled “Changing Patterns of Care in Multiple Myeloma.” I’m Dr Bruce Feinberg from Cardinal Health Specialty Solutions. Joining me today in this virtual discussion are my colleagues Dr Sagar Lonial of Winship Cancer Institute of Emory University, Stacey McCullough of Tennessee Oncology, and Ray Bailey of Florida Cancer Specialists.

Our panel of experts will review therapeutic options for multiple myeloma, understand challenges and best practices in dispensing multiple myeloma medications, and discuss the impact of COVID-19 [coronavirus disease 2019] on treatment patterns and dispensing.

The way we’re going to handle today’s discussion is in 4 segments. In the first, we’ll discuss the patient journey in multiple myeloma. In the second, therapeutic options for multiple myeloma patients. In the third, dispensing multiple myeloma oral medications. And in the fourth and final segment, we’ll discuss the impact of COVID-19 on treatment patterns and dispensing.

With that, let’s begin. I said we’re going to deal with the patient journey in this first segment. We’re very fortunate today because we have someone who has been following patients’ journeys for what could be 20-plus years. I’m being on the conservative side. I’ve known him. We’re both Atlanta based, so we’ve had a chance to work together in the past. It’s a remarkable opportunity to have Dr Sagar Lonial here with us to discuss this.

More importantly, very specific to this topic, is that incorporation of oral therapeutics for multiple myeloma was championed by him. He was 1 of the early adopters of RVd [lenalidomide, bortezomib, dexamethasone], which is 1 of the early triplet regimens and 1 that contains an oral drug.

I want to get into this conversation about induction therapy—where it was, where it is now, how it’s changing—as well as this discussion about transplant and the continued role of transplant, eligibility and ineligibility, and the variables that comprise that. We’re going to get into it. It’ll be fairly rapid-fire to get started, but it’ll help everyone listening and following along to level set on the current state of myeloma but also where that came from.

Sagar, let’s start with the beginning of modern care, which is, I think, RVd [lenalidomide, bortezomib, dexamethasone].

Sagar Lonial, MD, FACP: You’re absolutely right, and I appreciate the opportunity to be here and talk through some of this. Myeloma is a field that’s changing incredibly fast. Just in the span of my career, we’ve gone from what you could argue was roughly palliative care, with melphalan and prednisone, to high-intensity triplets and now even quadruplet-based approaches that get patients into MRD [minimal residual disease] negativity and can have a significant impact on their duration of remission and overall survival.

Bruce Feinberg, DO: All right. Sagar, my first interruption…

Sagar Lonial, MD, FACP: Yeah.

Bruce Feinberg, DO: MRD. For audience members who may not be as familiar with some of the terms, it would be good to explain what that represents and why it is the next step in the process.

Sagar Lonial, MD, FACP: In the old days, when we talked about response by the old criteria, a 75% reduction in the M protein was considered a complete remission. When you take that even further, with the response criteria we have had available more recently, elimination of the protein was considered a complete remission [CR]. But we know that patients, even those who achieve CR, or complete remission by the current criteria, still have residual disease. That’s where MRD testing comes in.

It’s a way to test minimal residual disease, or MRD, at a level of sensitivity much lower than we see with routine immunofixation or serum protein electrophoresis or even free light chains. And MRD negativity at 10-6, meaning 1 in 1 million or fewer, is a really high bar that we’re able to achieve with our current therapies.

Bruce Feinberg, DO: But that doesn’t equate to cure.

Sagar Lonial, MD, FACP: Correct. You’re absolutely right. Although I might argue that there are some patients who are potentially cured—we’ve got patients treated with RVd [lenalidomide, bortezomib, dexamethasone], as you mentioned earlier, with a single transplant on lenalidomide maintenance who are 10, 12, 15, 18 years out. But you’re right. MRD at 10-6 doesn’t equate with cure. That’s a correct statement.

Bruce Feinberg, DO: I want to pause there because I want to bring in our other panelists. Stacey and Ray, you both represent very large progressive practices that do their own transplants, that have the wherewithal of what would almost be the equivalent of a small institution setting, like an academic center, to some degree, doing research and other things.

Are you still seeing that RVd [lenalidomide, bortezomib, dexamethasone], transplant, and maintenance is the standard of care within practice? Are the academic institutions and practices aligned right now in that standard of care in myeloma management? Ray, you go first.

Ray Bailey, BPharm, RPh: Yes, absolutely. In our practice, that is the case. Obviously, every patient is different. But yes, that is the standard of care within our practice for sure.

Bruce Feinberg, DO: All right. Stacey?

Stacey McCullough, PharmD: Absolutely. I agree.