Overview of Treatment Options for Relapsed/Refractory Multiple Myeloma
Key opinion leaders share comprehensive insight to the treatment armamentarium for patients with relapsed/refractory multiple myeloma.
Transcript:
Thomas G. Martin, MD: Teclistamab is approved in patients who have had 4 or more prior lines of therapy. As you know, the treatment of relapsed/refractory [multiple] myeloma is an individual patient decision and a practice decision. Practices do it in a bit of a different way. Jeremy, forpatients with relapsed/refractory myeloma, how are you treating them when they come to you after first-, second-, and third-line [treatments]? What is your strategy?
Jeremy Larsen, MD: Thanks, Dr Martin. This is where the nuance and the art of being a myeloma doctor come in. Obviously, the distinction between relapsed and refractory—at this point many patients are both—but exposure to prior lines [of therapy]. The big 3 columns of therapy that we’ve had historically include IMiDs [immunomodulator imide drugs] and the various iterations: lenalidomide, pomalidomide primarily in the United States, and proteasome inhibitors [PIs]. Usually patients have cycled through bortezomib, ixazomib, or carfilzomib and the anti-C238 monoclonal antibodies.
Once we’ve entered into this refractory space, patients have not only been exposed but are actively progressing. Triplet therapies are very common at this point. It’s been clear that this concept of triple-class refractoryhas scooched out. I think back to my training patients, who were double refractory to IMiDs and PIs. Shaji Kumarhad a seminal paper multiple years ago showing that that was a significant hazard for long-term survival once you developed PI and IMiD resistance. Now we’ve scooted the bar further to the right, but patients are still at risk of death at this point beyond triple-class exposure and especially refractoriness.
In terms of how we choose, the multitude of options coming starts to drive the question of sequencing. We have BCMA-targeted therapy, which in my mind is our first next stop. Then the question is, what’s the modality? Are we thinking about bispecifics, as we’ll highlight today? Is this patient eligible for CAR [chimeric antigen receptor] T cells or antibody-drug conjugates? Many trials in the therapeutic space are happening with various iterations of this as well. At this point, a BCMA therapy would usually be considered. Fortunately, in my mindmost patients who are eligible for a bispecific are also eligible for a CAR T. [We also calculate the patient’s]fitness into it. Does this patient have access to a treatment center? Do they have a caregiver who can help get them through CAR T management up front? For the non-BCMA-targeted therapies, we’re thinking about nutritional status. Is this drug going to come with a lot of GI [gastrointestinal] toxicity or cachexia? These are the personalization factors when you’re sitting in front of the patient, trying to put it all [together]. There isn’t 1specific right-size approach at this point.
Transcript edited for clarity.
