Andrew P. Dalovisio, MD: I’m going to lead that into the transplant discussion. When you refer your patients for transplant, what kind of discussion do you have with them? What do you tell them? Why are you going to see this guy? Let me start with Ernest.

Ernest C. Quintin, MD: Every time I talk to a patient about multiple myeloma [MM], it’s [interesting] because in the very beginning, as you said, when we went down this [road], historically, it was such a poor prognosis that it was a very difficult conversation to have. Nowadays, even during training, the number of drugs is going up and up, and it really is exploding. So now it’s as you said about quadruplet therapy, I think the general thinking is if we can get a deeper response faster, that’s really what buys you the most time down the road. And that’s how I talk to my patients about it. You went through all of this in the beginning so we could get you into a position where we can do even better with a transplant. And that’s really how I present it to them.

Andrew P. Dalovisio, MD: Sure.

Ryan P. Griffin, MD: In some ways transplant, in my experience, has been a tougher sell sometimes in the community setting. I think post pandemic, patients are very hesitant to sign up for a weeklong stay or longer in the hospital. So when I see a new patient with MM, I’m selling the disease as this is a very complicated, complex disease. I’m going to refer you to our MM experts at our main campus. There are lots of different therapies [and] they’ll discuss certain ones with you. I sort of let you all frame the first discussion about transplant. And then usually on the second or third visit, when patients are coming back with the questions, I’m trying to tease out a patient’s goals and preferences and trying to smooth the discussion. I think for a high-risk patient, I’m really pushing it. If there’s a standard-risk patient who is hesitant, I think that’s a patient [for whom] I would consider using MRD [minimal residual disease] testing to guide some of these decisions. Although I will say I’ve only done MRD testing in probably 4 to 5 patients, so I think it’s a little bit newer in the community setting,… MRD testing.

Kelly Pippin, MD: I’ll just jump off of what he said. I’m a visual person, so I tend to draw them a picture. I’ll draw a line down and say, “This is how far we can get with IV [intravenous] therapies.” And then I’ll draw a line way down and say, “This is what stem cell transplant can get you.” I think of it almost like a submarine drawing to kind of get the disease as minimally detected as possible. The big question and concern that people tend to have is maybe they’ve heard of somebody who has had an allotransplant and understanding the difference between an autotransplant and an allotransplant. Distinguishing that if they’ve heard of someone with leukemia, for example, is a big thing to tease out and let them know it’s quite different. Also, let them know that time is really important, and we shouldn’t wait a couple of years to decide this. Having an early transplant really does have a good benefit for them. Getting them to a transplant or even while we’re going through the induction process, because a lot of times they’ll say, “Well, I want a delay, or I want to wait till we get a little bit further down the road.” And I’ll say, “Oh, it’s really important we get you to a transplant physician early and this is why.”

Ernest C. Quintin, MD: I think you touched on that. If you open with, “Hey, this is part of what we have got to do.” I think it opens it up to a little bit of an easier conversation down the road when they say, “But I thought you said all my labs have gotten better. Why would I need to do even more chemotherapy?” When you tell them that depth of response is really what we’re going for, and you start with, “Yes, we’re going to do [daratumumab with lenalidomide, bortezomib, and dexamethasone], but by the way, right after that, when we get you well, when we get you better, we got even more things for you.”

Kelly Pippin, MD: That’s right.

Ernest C. Quintin, MD: And with that, it’s almost not like a surprise.

Thomas Atkinson, MD: I will mention transplant to anybody who I think is eligible as soon as we’ve confirmed the diagnosis. And I start teasing out what their preferences are. Historically, in my practice, I would send almost everybody for a referral right away. But as I’ve grown a little bit and realized that there really are certain patients who just really are ineligible or are just clearly unwilling, and it’s not going to be a good use of your time to try to convince them. I won’t necessarily send 100% of people, but I think it’s really important that a newly diagnosed myeloma patient be referred for transplant as soon as possible. And I put a really strong emphasis on that to my patients.

Andrew P. Dalovisio, MD: That’s good. I think that’s an important point. And a couple of things…the IFM [NCT01191060] and DETERMINATION [NCT01208662] trials weren’t transplant vs no transplant trials, they were early vs delayed because a lot of those patients could cross over and get a transplant later. So that’s probably why you don’t necessarily see the difference in the overall survival [OS]. The other thing is that we have 3 data sets now…from Mayo [Clinic], the MASTER trial [NCT03224507], and in GRIFFIN trial [NCT02874742], that after transplant more patients got to MRD negativity, if you believe it from transplant. So if you believe MRD negativity portends PFS [progression-free survival] and OS, I do think that in the quad and modern era certain patients do actually get a PFS and an OS benefit from transplant. Interestingly, the other thing… [CROSSTALK]

Thomas Atkinson, MD: [CROSSTALK] …It’s probably going to be a long time before we have an answer to [CROSSTALK] …a quad followed by.

Andrew P. Dalovisio, MD: A decade.

Thomas Atkinson, MD: [CROSSTALK] …So, in the meantime, is there some way that we can perhaps ease the burden of new stem cell consults if we have people who may not need it?

Andrew P. Dalovisio, MD: I think it’s always better to have them see the transplant doctor because there can be a lot of nuance, and sometimes there are questions of whether someone’s ineligible when they actually are and vice versa. And that’s something we’ll dive into briefly. One other thing I will often talk to patients about is that we have data sets going back 20 to 25 years now with chemotherapy, Velcade [bortezomib], Revlimid [lenalidomide], transplant, and maintenance. And it does look like there’s about a 10% to 20% signal for a cure, that patients never relapsed. I do tell people, this transplant may offer you the chance of being in a small group of [cured] people. But I think all of us take care of patients who we’ve adopted from a doctor, who they adopted from somebody else, who is 20 years post diagnosis.

Thomas Atkinson, MD: That leads to the question, is it fair to tell people that myeloma is considered curable now?

Andrew P. Dalovisio, MD: My take is it is a curable disease in a small group of patients now. I think we still need the long-term data from these quad trials, but I suspect that the cure rate is probably going to go up to about 20% to 30% of people. But I think that’s [comparable to some] later-stage solid tumor cancers, and people walk out being like, “Oh, I’ve got a curable cancer.” So I think it’s in a lot of the ways [CROSSTALK]…

Thomas Atkinson, MD: [CROSSTALK]…I think that shift in mindset to this being curable vs this being a permanent chronic illness is profoundly important in the broader oncology community…or in the medical community at large because as long as people continue to think of it as this terrible condition that can’t be treated or cured, that has a really negative impact on patients. I’m sure you’ve seen it.

Andrew P. Dalovisio, MD: All the time. Again, I don’t want to sugarcoat it, the majority of people will succumb, but you can offer them that hope. Not really in the advanced high-risk disease, but in standard-risk disease, which is fortunately a majority of patients, that they have a good, not unreasonable, chance of having remission periods beyond 10 or 15 years. For a lot of people, that would get them to the finish line, I mean, if they’re diagnosed when they’re 70. So, yeah, that concept of a functional cure.

Transcript edited for clarity.