Main Considerations When Choosing Therapy in Relapsed Multiple Myeloma

Krina K. Patel, MD, MSc, discusses how she chooses treatment for her patients with early or late relapsed/refractory multiple myeloma.

Krina K. Patel, MD, MSc, associate professor, Department of Lymphoma/Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, discusses how she chooses treatment for her patients with early or late relapsed/refractory multiple myeloma.

There are currently numerous options in the relapsed/refractory space for these patients, and picking the best therapy depends on many factors, including their previous treatments and comorbidities. Patel feels that above all, these patients should go on clinical trials unless they are unable due to their physical condition or the trials eligibility criteria.


0:08 | It's getting harder and harder to know what to do now since we have so many options, but I think the biggest thing is, is this an early relapse versus later line. So usually if they're second to fourth line, versus 4 lines and above is the way most of our drug approvals are coming out right now and that's how we've been able to use it.

First and foremost, any patient that I can get on a clinical trial, I will do that, because we want to do better than what we have already. However, we can't get everybody on a clinical trial, or some patients might be too frail or not eligible. Usually earlier lines of therapy, I'm still using triplets. It depends on what that patient got first line. It's rare for me to ever use the same regimen again. If someone's really frail and I think their comorbidities—they just can't get anything else, they did well with that first regimen, and it's been a long time, then maybe—but 99% of our patients are going to get something different. It totally depends on if they're refractory to, let's say, lenalidomide [Revlimid] because they were on maintenance the whole time before they relapsed. If they're not refractory then I feel like I have a little bit more choice but usually in the second, third, or fourth line, for patients have not gotten daratumumab [Darzalex] already, I'm using daratumumab/pomalidomide [Pomalyst]/dexamethasone [and] isatuximab [Sarclisa]/carfilzomib [Kyprolis]/dexamethasone.

1:24 | If they're high-risk patients, I'll use more of the CD38 proteasome inhibitor, like carfilzomib versus my standard-risk patients, I'm probably using a little bit more polmalidomide or Velcade [bortezomib] with daratumumab, or even elotuzumab [Empliciti]/polmalidomide/dexamethasone, so my patients who have really slow biochemically progressing disease, and I have time for elotuzumab to work, then I use that too. That tells me, if someone's high risk, they have a lot of disease going in, or it's just a biochemical progression, and their comorbidities—that's really how I pick these regimens. Patients who have never had a transplant, I might throw some cytoxan in there, now they need an alkylator and this might actually help them.

Then you have your later line, so 4 lines and beyond. So I'm in a little bit of a migration where I try not to use alkylators as much because now that CAR [chimeric antigen receptor] T bispecifics, [and] all these immune therapies are coming, I do think that alkylator therapy, especially right before any of those, probably weakens your immune system and makes it harder for you to have a better response. So at least the therapy before I try to have an alkylator-free therapy for that. But otherwise, I really am going for the BCMA-directed therapies because now it's a new antigen. So Blenrep [belantamab mafodotin], I've used a lot, especially [in] my frail patients who I know aren't going to be able to do bispecifics or CAR T. But if I have trials for CAR T bispecifics, that's really what I'm going for. We're seeing these amazing responses and these progression-free survival [data]. We don't have as much for bispecifics yet but for CAR T, a chemotherapy-free period where these patients are not on chemotherapy anymore for a year or even longer sometimes. The issue is slots and so in the end, we're still far away from it being ideal, but I'm hoping in the next year we'll be able to use it a little bit more aggressively.