Dr. Holstein on Sequencing Strategies in Myeloma

Sarah Holstein, MD, PhD, associate professor of medicine, University of Nebraska, discusses considerations for determining an optimal treatment sequence for patients with myeloma.

In the relapsed/refractory setting, there are several classes of drugs with multiple FDA-approved agents in each class—naturally, sequencing is a challenge. However, Holstein says there are many factors to consider that will help refine this paradigm. For example, there are patient factors like whether or not they have high-risk cytogenetics. In that instance, Holstein would consider treatment with an immunomodulatory agent plus a proteasome inhibitor. Other important clinical factors that would drive sequencing are underlying comorbidities, she adds.

Physicians have to envision future lines of therapy before determining the current one, Holstein says. If a patient relapsed 5 or 6 years after receiving an autologous stem cell transplant, the best option might be to try a second transplant or another therapeutic strategy that would have an aggressive, immediate impact. This approach would differ from a patient who you would like to have remain on a certain therapy for an extended period of time, she explains.

There are also logistical factors to consider, like if a patient works full-time or lives a significant distance from the clinic. In those situations, physicians would probably want to avoid a therapy that requires infusions multiple times per week.