Frontline Treatment with RVd for Multiple Myeloma

Robert A. Vescio, MD:In this country, the typical standard is to use RVd—lenalidomide, bortezomib, dexamethasone—as treatment for multiple myeloma. In my mind, there’s really just 1 other potential option for somebody like this—carfilzomib, lenalidomide, and dexamethasone. That regimen has shown good results in a phase II trial. It’s not been compared head-to-head, but there’s potential, and I think it’s certainly possible that it will work better than RVd. It’s not always approved for use, however, by insurance companies.

If the patient had favorable cytogenetics, I still would have recommended the same regimen. I typically use a triplet regimen—a proteasome inhibitor, an immune-modulating drug, and a corticosteroid—for the majority of patients with multiple myeloma, because I think using all 3 weapons tends to work better and has been shown, in a randomized trial, to improve progression-free survival and overall survival. So, I think it’s really the standard. I will occasionally use an all-oral regimen and not give bortezomib, purely for convenience for patients who seem to have a very slow-growing disease and those in whom I’m not very worried about the pace of their malignancy, and they really have a hard time coming to get treatment. But I don’t think it’s preferable for most patients.

The patient had a very good partial response to treatment. I know patients typically hope for a complete response, and that’s always better. For pretty much any malignancy, it’s better to be in a complete remission over a less than complete remission. The reality is that one has to decide what to do with a patient who has not achieved a complete remission.

For her, I think a very good partial response was fine. I’ve had patients for more than 15 years who’ve never relapsed once and have never achieved a complete remission, so it doesn’t preclude good outcomes. You certainly don’t need to be in a complete remission before doing something like a stem cell transplant. Often, the transplant is the only way of achieving a remission.

One thing to remember for multiple myeloma patients is that you have to not only kill the cancer cells but you also have to prevent some of the complications that multiple myeloma can cause. One of the important complications is damaging of the bones. Patients should get some type of bone-protective agent. Nowadays, there are really 2 choices—zoledronic acid or denosumab. Both have been shown to be effective. There are some advantages for using one over the other, but patients should definitely receive some type of bone-protective drug, even if they don’t have bone lesions, which is not always apparent.

Patients with multiple myeloma frequently die from complications of therapy or infections. And so, patients need to be made aware that they need to call in if they get sick so that they can be treated quickly to try to minimize the risk of dying from some terrible infection.

Transcript edited for clarity.

A 55-year-old African-American Woman With Relapsed Multiple Myeloma

August 2015

• A 55-year-old African-American woman presented to her PCP complaining of worsening fatigue, back pain, and bone pain
• PMH: hypertension managed on a beta blocker, mild renal impairment
• Laboratory results:
  • Hb, 11.0 g/dL;
  • Ca²⁺, 10.1 mg/dL;
  • Creatinine, 1.2 mg/dL;
  • M-protein, 0.9 g/dL
  • Β2M, 5.0 mg/L
  • Albumin, 2.9 g/dL
• MRI showed multiple small lytic lesions in the T1/T2 vertebrae
• Bone marrow biopsy confirmed the diagnosis of multiple myeloma; R-ISS stage II; t(4;14)
• She was treated with lenalidomide/bortezomib/dexamethasone (RVd) for 6 months and achieved a VGPR
• The patient was recommended for autologous transplant, however, she instead opted to continue on a de-escalated treatment regimen of Rd after stating that she struggled to maintain her treatment schedule

May 2018

• M-protein, May 1.5 g/dL

June 2018

• M-protein, 1.7 g/dL

July 2018

• MRI, no new lytic skeletal lesions
• Laboratory results:
  • Hb, 11.5 g/dL;
  • Ca²⁺, 9.8 mg/dL;
  • Creatinine, 1.1 mg/dL;
  • M-protein, 1.9 g/dL
  • Β2M, 4.2 mg/L
• ECOG PS: 0