Patient Case Introduction: A 76-year-old Female Diagnosed with Transplant-ineligible NDMM
Jonathan Kaufman, MD describes a second patient case featuring a 76-year-old female diagnosed with transplant-ineligible NDMM.
Dr. Sagar Lonial: Let's move on to case two. Dr. Kaufman.
Dr. Jonathan L. Kauffman: This is my patient, 76 year old woman who was found to have an elevated total protein on routine evaluation in March, 2019. Evaluation of the elevated protein revealed the monoclonal gammopathy with an M spike of four grams per deciliter. It was an IgG kappa. We did a bone marrow biopsy, showed 25 to 30% positive cells, clonal by flow and hyper deployed seen on FISH testing. PET showed lytic bone disease, a compression fracture, and she did not have any evidence of extramedullary disease. She had newly diagnosed standard risk myeloma. She was 76 years old. Her performance status at the time was limited because of the compression fractures and back pain. And we chose to treat her with a combination of daratumumab, lenalidomide, dexamethasone like the MAIA study. And she had a really dramatic response. PR after one cycle, VGPR after three cycles, and a stringent CR after six cycles. We discontinued dexamethasone after a year and she's right around four years initiation of therapy and she continues in stringent CR on daratumumab and lenalidomide.
Dr. Sagar Lonial: So, Jonathan, can you set the stage because for the next few minutes, we're going to be talking about the older frailer patient population. I prefer that to the transplant ineligible patient definition. Talk to us about what the landscape looks like in 2023 for those patients.
Dr. Jonathan L. Kauffman: For the patient that we deemed is not going to be transplant eligible. I think in, at least in the United States, there's two regimens that have clearly been shown to have benefit over the combination of lenalidomide and dexamethasone, and that's daratumumab, lenalidomide and dexamethasone per the MAIA study similar to how we treated our patient. And the other one is bortezomib lenalidomide dexamethasone, or RVD-light. RVD was compared against RD in a randomized study, showed greater response rate, greater PFS and an absolute 10% overall survival difference. So clearly, three drug better than two drug in this patient population. A very small study showed RVD Light showed similar outcomes. We developed our own RVD-light type treatment for these patients. And for many years, RVD-light was our standard of therapy for all patients. And I think based on a variety of reasons. But particularly, the ease of administration, especially post six months after therapy of giving dara-len versus RVD-light. And in a large part for my standard risk patients, that's where I've gone. But I think the right answer for this patient population is one of those two regimens.
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