Management of Patients with RRMM

Kenneth Shain, MD, PhD: The IMW [International Myeloma Workshop] was a fantastic meeting put on by a great group of individuals. It was a great forum for us to learn and see what’s going on, both the stuff that we’ve participated in and what others have created and how we want to look at taking care of myeloma as a whole. One thing we need to think about that we didn’t discuss today is how we start taking care of patients a little differently using both therapies, as well as our ability to assess response and disease and care for our patients.

One thing I took away from the IMW was that there’s a lot of good things going on, but are there better ways in which we can treat patients? And who are the right patients to treat in certain ways? That means customizing or personalizing therapy a little. Can we use different biological end points to make those decisions? One that might be low hanging is a technical advancement or ability to make sure we can measure disease. That’s called minimal residual disease [MRD] testing and achieving minimal residual disease negativity. This means that if you have no measurable proteins in your blood, your imaging is negative. Within your bone marrow, we cannot find 1 in 100,000 or 1 in 1 million myeloma cells. If you’re MRD negative, we can’t find 1 in 100,000 and hopefully less than 1 in 1 million cells are myeloma. We call it an MRD-negative disease state.

That has become a significant goal of therapy for a lot of patients. We have a lot of questions. Should we drive everybody? Is that where they should go, or is it good for those who get there? Once you’re there, how long do you have to be there before we can stop therapy? Because in the context of myeloma, everything is continued therapy. One major thing I walk away from the INW with is that we’re all trying to address those questions differently. Is MRD the appropriate end point? Who gets there, and how long do we keep people there? It helps us make decisions about what we might need to add to therapy to get someone there.

More important, when can we stop or ease off therapy if someone has been there for long periods of time? Long periods of time are open ended. Where are the patients in terms of goals? How do we add things safely and smartly? Other questions that need to be answered: 4 drugs up front vs 3 drugs might get more people there. Maintenance therapy for a fixed duration with an MRD endpoint. These are all exciting questions.

These are goals we might want to think about achieving. All the drugs that we just talked about earlier, including immunotherapies, CELMoDs [cereblon E3 ligase modulators], and novel therapies, are all ways that maybe will help our patients get there, get there more often, and keep them there for longer periods of time. We have a lot of new tools, but 1 of the coolest new tools is our ability to try to get the disease that we can’t measure and use that to make decisions about how we manage our patients. That’s 1 thing I walk away from IMW with.

We’ve talked a lot about the therapeutics themselves. One thing that might get a little overshadowed with these new therapeutics and the excitement around the drugs we’ve talked about is how we think about using these things to manage the patients a little differently. We can make some decisions based on the depth of response and amounts of disease and other personalized components to myeloma.

Transcript edited for clarity.