Early and Late Relapse in Myeloma: Navigating the Complex Treatment Waters
Posted: Monday, October 25, 2021
Despite an influx of treatment options and improved disease control, relapse is still inevitable for most patients with multiple myeloma, according to Natalie S. Callander, MD, of the University of Wisconsin Carbone Cancer Center, Madison. During the NCCN 2021 Virtual Congress: Hematologic Malignancies, Dr. Callander discussed appropriate evaluation of patients with relapsed multiple myeloma—whether it be defined by laboratory parameters or new events. She also explored treatment options for both early and late relapse.
In the first-line setting, most transplant-eligible patients will receive a triplet combination using a proteasome inhibitor, an immunomodulatory imide drug, and an antibody drug followed by autologous stem cell transplantation (ASCT) and then maintenance therapy. Transplant-ineligible patients, on other hand, will typically receive a triplet combination (often bortezomib, lenalidomide, dexamethasone or daratumumab, lenalidomide, dexamethasone). “We anticipate that these patients will be stable for a very long time on continuous therapy,” said Dr. Callander.
In the early relapse setting, clinicians should consider using a monoclonal antibody for those who have not received one or changing either the immunomodulatory imide drug, the proteasome inhibitor, or both, she suggested. Clinical trials are another option, or clinicians can refer transplant-naive patients to ASCT.
According to Dr. Callander, patients who experience late relapse (after four prior therapies) are the most challenging to treat, and the fitness and stability of patients become increasingly important to assess. For patients with late relapse, a clinical trial is recommended, if possible, but many patients are ineligible because of poor blood cell counts or other factors, she noted. Additional treatment options include selinexor combinations, belantamab mafodotin-blmf, melflufen, or chimeric antigen receptor T-cell therapy (for stable patients), and alkylators. Salvage autologous stem cell transplant should also be considered for this challenging population.
Disclosure: Dr. Callander reported no conflicts of interest.
