Practice Changers in Myeloma From ASCO 2017
Dr. Haffizulla: Welcome to this PracticeUpdate. I’m Dr. Farzanna Haffizulla. Joining me today is Dr. Rafael Fonseca. Dr. Fonseca is Chair of the Department of Internal Medicine at the Mayo Clinic. What a pleasure to have you here today.
Dr. Fonseca: The pleasure is mine. Thank you for having me here.
Dr. Haffizulla: Of course. So I know that we’re here at ASCO in Chicago and a number of studies this year report the use of novel combinations up front for the treatment of myeloma. How close are we to a new standard of care for front-line therapy?
Dr. Fonseca: That’s a great way to phrase that question. It goes without saying that we’re getting better and better at achieving very deep responses, very durable responses as well too in the front-line setting. And the questions right now are what are the best agents, how should they be combined, and of course, the second part of the question is should we be adding monoclonal antibodies? Actually, this morning we saw two presentations, one where they added elotuzumab, one where daratumumab was added, and it’s a little bit early to say whether any of those actually changed the standard of care at this point, but we’ve learned that the combinations of carfilzomib with lenalidomide and dexamethasone are very, very active and I think that’s probably the most pressing question, you know at what point should that become the standard front-line therapy and the second question of course is the daratumumab question. Everyone is very interested.
Dr. Haffizulla: Yes.
Dr. Fonseca: Dr. Jakubowiak presented a study in that regard and an impressive result, but the reason I say it’s harder because there’s so many options and we just want to get really smart about how we go about combining these agents. During the session, I was thinking about this and they were presenting so many clinical trial results. The one thing that struck me the most is the importance of achieving MRD, which really is becoming the central point for the development of new combinations and so much so that I was on social media and I was tweeting there, and I thought, I think the new response criteria for myeloma should be MRD-negative, any response, or progressive disease.
Dr. Haffizulla: Excellent.
Dr. Fonseca: And we’re getting to that point and some of those things really have to be sorted out in phase 3 clinical trials.
Dr. Haffizulla: Of course.
Dr. Fonseca: You know, fortunately, several of them were presented as well.
Dr. Haffizulla: Well, wonderful. So still some information that can be applied to clinical practice.
Dr. Fonseca: Yes, yes.
Dr. Haffizulla: Excellent.
Dr. Fonseca: I think it’s important for people to realize and this is probably even more important for patients that if one is diagnosed with myeloma and there is some unique situations where it can be challenging, there is no room to be nihilistic. I mean, the opportunities for successful treatment for the disease up front continue to get better.
Dr. Haffizulla: Excellent. Excellent. So just stay tuned, essentially, until the data refines itself.
Dr. Fonseca: Of course. Of course.
Dr. Haffizulla: But remain flexible in your treatment options.
Dr. Fonseca: Exactly. Exactly.
Dr. Haffizulla: Wonderful. Now I know data regarding the performance of two lenalidomide-based triplets, RAD versus BRD, prior to autologous stem cell transplant have been released this year at ASCO and comparable efficacy between the two groups, would you say?
Dr. Fonseca: That is correct, and I’m not sure that’s going to change practice in the United States because I think the appetite for the use of some of the standard chemotherapy or older chemotherapy is probably not going to be as high. And people seem to really like what we already have for those combinations, but those are key questions at the international level, at the global level.
Dr. Haffizulla: Okay.
Dr. Fonseca: Other studies looked at cyclophosphamide, for instance, combinations as well, which again are pertinent, but I think the more we go and then some of those differences are subtle, but the more we go along it’s probably the PI/IMiD plus dexamethasone as a new standard.
Dr. Haffizulla: Got it. But does the data validate the use of RAD as an alternative to BRD for induction? And which patients do you think might benefit?
Dr. Fonseca: In my opinion, I would not use the regimen right now…I think I would stick with BRD. Now, if a person lives in a country where there’s a difficulty in obtaining B up front, I think that would be an option. Ironically, it’s harder to get R than B throughout the global community, so I don’t anticipate there’s going to be a lot of traction for RAD.
Dr. Haffizulla: I see. Well, thank you for sharing that and for telling us what to look forward to in the future.
Dr. Fonseca: No. My pleasure.
Dr. Haffizulla: We hope to have you back here very soon.
Dr. Fonseca: Any time.
Dr. Haffizulla: And to our viewers, thank you for joining us for this PracticeUpdate. I’m Dr. Farzanna Haffizulla.
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