Initiation of Second-Line Treatment in Multiple Myeloma

Robert A. Vescio, MD:The patient decided, as mentioned, to continue on lenalidomide and dexamethasone without the proteasome inhibitor. She was followed and felt well. A few years later, her markers for her disease started to increase. Her monoclonal protein went from 0.5 g/dL to 0.7 g/dL to 0.9 g/dL. She felt well. She really didn’t have any complaints, but it was clear that her disease was growing, and so a decision had to be made regarding treatment.

Historically, patients were not always treated when their disease was growing, as determined by tests, if they felt well. We didn’t have drugs that would be well tolerated, and chemotherapy drugs have a bit of a limited life span. They can cause harm when you give them for a long period of time. I personally believe, and I think most data back this up, that if a patient’s disease is growing, even if they feel well, they should be started on treatment to get their cancer back under control.

When you’re deciding whether to start somebody on treatment, particularly when they’re feeling well, I think it is important to be certain that the cancer is growing. A lot of the ways that we follow this disease are through lab tests. There are errors in the testing. Certainly, mistakes can happen in the lab, so in studies and certainly in practice, one should be certain that the markers are getting worse. Usually, in studies, you have to have confirmatory testing to prove that the cancer’s growing back.

Once the monoclonal protein spike has doubled or whatever light chain that their myeloma is making has significantly increased, that’s enough information to embark on treatment.

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