Jan. 08, 2021
In a sea of new multiple myeloma treatment options, Shaji Kumar, M.D., hematologist at Mayo Clinic in Rochester, Minnesota, recommends taking the long view: Both initial and subsequent treatments should be selected bearing in mind what may be coming in the future for the patient's disease. In presentations at the National Comprehensive Cancer Network 2020 Virtual Congress: Hematologic Malignancies, he proposed overall principles for assessment and treatment goals as well as selection of therapeutic options, and looked toward the future of multiple myeloma disease management.
Patient assessment and treatment goals
Dr. Kumar indicates that the Mayo Clinic multiple myeloma group's overall assessment of a patient's case includes a careful analysis of not only traditional staging and prognostication but also risk — factors such as comorbidities and age. This combination provides optimal direction for the hematologist to treat a patient's multiple myeloma, particularly for patients at high risk.
Some level of risk is ever present for any patient diagnosed with multiple myeloma, as the disease is not curable, nor does it have the 5-year mark with no recurrence that often signals freedom from disease in other cancers. "Multiple myeloma can relapse in 10 years," says Dr. Kumar. "The risk never goes away."
The chronic nature of multiple myeloma begs the question of appropriate treatment goals for patients given that cure is off the table, at least in a consistent and predictable manner with current therapies. Dr. Kumar offers a response: "The goal is to institute a treatment that is reasonably well tolerated and effective, so that patients can go back to their previous level of functioning."
Relapse should be expected with multiple myeloma, with each treatment regimen administered offering the patient roughly two to three years of disease control. Optimal treatment for patients allows for new options to explore at each relapse, as returning to a previous treatment often proves far less successful than its initial use.
Dr. Kumar recommends that hematologists move away from black-and-white thinking about treatment approach, and instead consider it an art as much as a science. "There's not a good or bad way to treat multiple myeloma or an optimal sequence, but you want to pick wisely early in treatment and each time the patient relapses," he says.
Dr. Kumar notes that he recommends an induction, consolidation and maintenance sequence for patients eligible for stem cell transplant, and induction followed by continuous therapy for ineligible patients; each relapse would then be treated in either scenario.
Broad treatment principles for relapsed multiple myeloma followed by Mayo Clinic hematologists specializing in multiple myeloma include:
- Noting the duration of initial response, which defines biology and provides important clues to the physician for a patient's risk stratification
- Preferring triplet or two active drug classes plus dexamethasone over doublet, including at least one drug from a nonrefractory class for the patient
- Considering performance status, age and comorbidities when selecting drugs and doses so that uptitration to maximum response can occur slowly if the patient displays poor performance status or frailty
- Taking into account prior or residual toxicities
- Treating to maximum response and maintaining on one drug until progression or signs and symptoms of diminished tolerability, such as low blood count or neuropathy
While grateful for the many options now available to treat patients with multiple myeloma, Dr. Kumar acknowledges that this variety presents a dilemma for treating physicians in terms of what direction to pursue at each decision point for a given patient's therapy. He suggests considering the following factors:
- Prior drug exposure and refractory status
- High risk versus standard risk
- Age, frailty and comorbidity
- Toxicity with prior drugs
- Stem cell transplant eligibility or prior transplant
- Patient preference and goals of care
- Logistics of drug administration
Key points for multiple myeloma management
In summary, while multiple myeloma remains a chronic disease with multiple potential recurrences for any given patient, a long-term strategy is essential. This plan should include a risk-stratified approach while selecting the most ideal combinations and sequencing the hematologist can determine for the given patient's disease.
Both available treatment options and prognosis for patients with multiple myeloma have radically and fundamentally improved, says Dr. Kumar. Whereas 10 to 15 years ago, median survival was only three years, it's now seven to eight years. He anticipates continued advances in the field and that therapeutic individualization will only expand in the coming years as additional drugs come onto the market.
For more information
Kumar S. New treatment regimens used to provide maximum benefit in multiple myeloma. National Comprehensive Cancer Network 2020 Virtual Congress: Hematologic Malignancies. 2020.
Tucker N. Optimal strategies for treatment of multiple myeloma in newly diagnosed patients. National Comprehensive Cancer Network 2020 Virtual Congress: Hematologic Malignancies. 2020.