Review of Emerging Therapies Forecasts A ‘Bright’ Future in Multiple Myeloma

C. Ola Landgren, MD, PhD

University of Miami Sylvester Comprehensive Cancer Center

Miami, FL

At a recent Around the Practice^® program, a panel of experts discussed the most recent practice-changing developments in the treatment of newly diagnosed multiple myeloma, including the use of transplantation, transplant eligibility vs ineligibility, and new immunotherapies. C. Ola Landgren, MD, the moderator of the program, recapped the discussion in an interview with CancerNetwork^®.

Landgren is a professor of hematology, chief of the Myeloma Section, leader of the Experimental Therapeutics Program, and co-leader of the Tumor Biology Program at the University of Miami Sylvester Comprehensive Cancer Program. In addition to summarizing the discussion, Landgren also highlighted the lingering unmet needs in the space regarding insufficient biomarkers, inadequate discrimination between high-risk and lower-risk disease, and the increasing importance of multidisciplinary teams. He also discussed the utility of minimal residual disease (MRD) tracking.

Other panelists included Benjamin Diamond, MD, an assistant professor of medicine at the University of Miami; Dickran Kazandjian, MD, a professor of medicine at the University of Miami; and Dennis Verducci, APRN, a nurse practitioner at Memorial Sloan Kettering Cancer Center.

Q: Will any treatment options on the horizon impact the standard of care in multiple myeloma?

Landgren: It’s almost like a meteor rain; there are so many different [emerging treatment] options. A commonality is that [many of] the upcoming drugs that are coming are immunotherapy agents, [including] many of the antibodies. [There are] bispecifics, trispecifics in development, naked antibodies, and cell therapies. There are many other options as well. Additionally, the drugs that have recently arrived have already begun to change the standard of care quite a bit.

What is an unmet need in the space that you hope will be overcome within the next 5 years?

The unmet needs for myeloma have shifted over time. We used to have unlimited unmet needs because we lacked drugs. Nowadays, we have a lot of drugs [available], but still, unfortunately, there are patients who don’t do well in the upfront setting. We’ve referred to these patients as [having] high-risk disease; we lack better markers to identify true high-risk disease. [Current] cytogenetic markers are not good enough. [As such], many of the patients we label as having high-risk disease don’t [actually] have high-risk disease. Also, unfortunately, some patients who are not labeled as having high-risk disease still have poor outcomes. So, they [should have been labeled as] high-risk. We need better markers. We also need better drugs for patients with high-risk disease.

Overall, we [also] need curative treatments. Patients continue to relapse, but we have come a long way. Patients can [often] live for 10 or 20 more years [than they used to], but they still need therapy.

What is the importance of multidisciplinary practice in the treatment of multiple myeloma?

Multidisciplinary teams are increasingly important in the field of multiple myeloma because the therapies are increasingly complicated; more things can happen [during treatment]. The patient may experience infections, for example, and may need to have additional infusions to boost their immune function. [It is very important for] nurses to talk with the patients, to reach out and ensure they’re doing well, [and for] mid-level providers—physician assistants or nurse practitioners—to be in contact with patients, in addition to the physicians; pharmacist involvement [is also important].

On our team, we also have patient coordinators who are always available when patients contact the office. We have other health care professionals [available] as well, in addition to other types of services [provided by] social workers and so forth. It’s [standard in] modern medicine to have access to a whole team and not only a single person like the physician; that’s old-school to me.

What were the big takeaways from today’s discussion?

Today we discussed how the field is changing in the newly-diagnosed setting. We talked about the traditional nomenclature of [patients with] transplant-eligible and non–transplant-eligible [disease], and our discussion put everything on the spot. Do patients have to undergo transplantation? Is eligibility the right terminology, or should [we divide patients according to] those who don’t want to undergo transplantation vs those who may need a transplant? I tweaked the terminology here to be controversial, but the field is undergoing many shifts.

Transplantation is going to be less important in the future as a result of better drugs. We have better immunotherapy drugs, [including] both antibodies and CAR T-cell [therapies], coming to earlier lines [of therapy], including in newly diagnosed patients; that will change the field. It also brings together older patients and younger patients, as well as frail patients vs those that are in better shape; everyone has a great chance to access effective therapy.

We also talked about the relapsed/refractory setting. We had a patient case in which minimal residual disease [MRD] negativity [was achieved] after 3 or more prior lines of therapy [had failed]. That’s something that we never saw in the past. This [outcome] was, again, a result of access to immunotherapy.

The future looks bright, [however], we still need curative drugs, and we need access to established cures for patients with myeloma.

Is there anything else you wanted to highlight?

We covered many of the important trends in the field today, [but] one thing we didn’t talk much about is the utility of MRD tracking. As these technologies become [more] available, even [in the form of] blood-based tests, they will help the field [move] forward. We will [likely] see more individualized [disease] management; patients will have the intensity of their therapy increased or decreased based on MRD status. [For example], for a patient who is MRD-negative after a certain number of cycles, you could [consider] decreasing [therapy] and [switching] to maintenance. Conversely, if there is evidence of rising markers, the patient would convert back to MRD positivity, [which] in the future may trigger [the use of] some newer therapies. Basically, it will be a molecular relapse. That’s how I envision the field going forward.