Patients with relapsed or refractory multiple myeloma should be given individualized treatment based on numerous factors, including biology of the disease and type of relapse, according to a presentation at the 12th Annual National Comprehensive Cancer Network (NCCN) Congress: Hematologic Malignancies (October 6-7, 2017; San Francisco, CA).
Natalie S Callander, MD, professor of medicine, University of Wisconsin Cancer Center, also explained that frailty of the patient and other comorbidities are important factors to consider when individualizing treatment.
Among initial considerations for relapsed patients, Dr Callander explained, is whether the relapse is biochemical or symptomatic, whether relapse occurred on maintenance or other treatments, whether it occurred in less than 12 months from treatment initiation, and the extent of the relapse.
“If you had a patient who had a symptomatic relapse, you would treat them much more vigorously than if it was biochemical,” said Dr Callander.
Referencing NCCN guideline recommended regimens for patients with previously treated multiple myeloma, Dr Callander explained that lenalidomide-based and bortezomib-based regimens have produced superior response rates and progression-free survival rates in patients with early relapse. These regimens also are efficacious in patients with high-risk relapsed disease.
Additionally, Dr Callander mentioned that a second autologous transplant for relapsed or refractory disease “is often a very good choice, particularly for patients who are looking to do something and try to get back on as little therapy as possible.”
Patients who classify as “frail” often have worse outcomes than fit patients, and are twice as likely to discontinue therapy. Dr Callander suggests oral agents for “frail” patients, with less of an emphasis on steroids. Biweekly or monthly dosing after a confirmed response is a safe and effective dosing schedule in this population.
For patients aged 65 years or older, pomalidomide-dexamethasone and ixazomib-cyclophosphamide-dexamethasone are reasonable regimens to consider.
Journal of Clinical Pathways interviewed Dr Callander extensively about the challenges of treatment resistance and relapse, evidence-based treatment decision-making, and the economic burden of multiple myeloma.—Zachary Bessette