A 75-Year-Old Man With Multiple Myeloma - Episode 6

Unmet Needs and the Future of Multiple Myeloma

Jonathan L. Kaufman, MD, discusses current challenges and unmet needs in the treatment landscape and provides insight into potential improvements in the future of multiple myeloma.

Jonathan L. Kaufman, MD: While we have significant improvement in outcomes of patients including deep responses and improvement in overall survival, we still have unmet needs. We still need to improve outcomes for our high-risk patients. On our highest-risk patients who have both deletion 17 and 1q abnormalities or deletion 17p and 14-16, we really need improved therapies and improved therapy approaches to these very high-risk patients. This is when we think about doing clinical trials; could we use aggressive immune therapy earlier in their course? Things like bispecific T-cell engagers and bispecific antibodies; could CAR [chimeric antigen receptor] T cells be used in this space? These are the questions we're asking. The other really important place where we have an unmet need is in the multiple refractory myeloma patient. While we have significantly improved outcomes with patients living many years, we still need new therapies for when they have multiple relapse. In [multiple] myeloma, we've been lucky enough to have approvals of several new drugs over the past several years. We really need to find those therapies that can be associated with deep and long remissions while maintaining patient quality-of-life.

In the future for myeloma therapy, with all the drugs that we have available now and the drugs that are coming that are currently in development, we can really think about changing the paradigm of myeloma and consider deep and long-lasting responses for the vast majority of patients. I believe that there are current studies being designed for that in the future.

The advice I would have for community oncologists in the context of the multiple regimens available in myeloma and the multiple new treatments that are available, is not necessarily to solely rely on NCCN [National Comprehensive Cancer Network] guidelines. The NCCN guidelines gives a list of options. It’s important for every community oncologist to have their go-to myeloma specialists, whether they communicate with them personally or they follow their advice in the papers written and the talks given, and really stick with one trusted myeloma colleague. Every myeloma physician I talk to across the country has a group of referring physicians that they connect with on a regular basis. We are all happy to help the community oncologists, because that's ultimately helping the myeloma patients.

Transcript edited for clarity.


Case: A 75-Year-Old Man with Multiple Myeloma

Initial Presentation

  • A 75-year-old man presents with worsening fatigue on exertion, pallor, and hip pain
  • PMH: osteoarthritis
  • PE: tired appearing male, poor hand-grip strength, mild tenderness on palpation of the left hip
  • ECOG 2


Clinical workup

  • Hb 9.8 g/dL, corrected calcium 11.9mg/dL, LDH 295U/L, creatinine 1.4mg/dL, albumin 3.7g/dL, CrCl 50mL/min
  • Peripheral blood smear showed rouleaux formation
  • Beta-2 microgloblulin 5.1 mcg/mL, M-protein 2.2 g/dL
  • Lambda free light chains: 0.6 mg/dL, kappa free light chains: 14.3 mg/dL, ratio: 29 (k/l)
  • FISH: hyperdiploid
  • UPEP: M-spike of 400 mg of lambda light chains in 24 hours
  • PET/CT revealed lytic bone lesions in the left hip
  • Bone marrow biopsy shows 58% plasma cells IgG k
  • Diagnosis: ISS and R-ISS, standard risk, stage II MM

Treatment

  • Patient is ineligible for ASCT due to comorbidities
  • Initiated treatment with daratumumab + bortezomib + melphalan + prednisone