Treatment Options for Patients with Multiple Myeloma in Early Relapse

Brea Lipe, MD: Once a patient does relapse, Dr Forsberg, what do you think about these patients, their treatment options that we have, a patient like this, particularly? What do you think about bortezomib based backbone or patients with a lenalidomide based backbone, particularly in the maintenance setting, often patients are at lower doses of lenalidomide? What are your thoughts about relapse?

Peter Forsberg, MD: The answer is we have a lot of options, especially in the early relapse setting. We have a host of different agents that have been approved in that setting in different combinations. And I know that's one of those scenarios where guidelines can be fairly broad and can seem a little bit sort of less defined. I do think that in patients who are progressing on lenalidomide maintenance, I think a lot of how we decide on best consideration incorporates patient characteristics, treatment history, what they've been on recently. Because I do tend to think that this scenario of a patient progressing on lenalidomide maintenance, whether that's post-transplant or a non-transplant scenario, often sort of shapes the second line consideration. And I usually wouldn't be inclined to use a lenalidomide containing combination in somebody who's developed progressive disease during lenalidomide therapy. I do think that enough of a refractory defining scenario to not necessarily adjust to a higher dose lenalidomide or use it as part of a combination with other agents. But I do think we have a lot of different partner combinations to sort of think through, and that sort of includes proteasome inhibitor containing combinations, immunomodulatory combinations, including lenalidomide and pomalidomide, CD38 monoclonal based regimens. We have plenty of data about different three drug combinations together, often compared against two drug combinations. So not as much head-to-head three drug triplet combos compared. I think a lot of what we sort of may use to inform treatment decision making include patient characteristics, comorbidities, and treatment history to select the agents that are most likely to be sensitive to and to tolerate well. In terms of your approach, actually in terms of selecting appropriate treatment for patients at first relapse are there particular factors that you think are the most important considerations when choosing second line therapy?

Brea Lipe, MD: It's very variable and I always find it hard when we're asked to develop sort of guidelines or an algorithm, because it is the benefit of treating myeloma and the nuance of it is something that I spend a lot of time with, and I find very rewarding. And that's really allowing us to treat the patient in front of us. We're able to look at what their cytogenetic risk categories might be, what their responses were to prior therapy, how long they were on prior therapies, what's the last time since they were on treatment at all. What are the toxicities that they have or have carried with them through their treatment. I think all of that allows us to craft an option for our patients, because I would agree with you that my preferences for triplet combinations in the relapse setting. And- but amongst that, we have so much to choose from now, we really have a bounty of wealth in terms of options for our patients. It comes down to a discussion between you and the patient. Obviously, we always like to think about clinical trials, but outside of a clinical trial, it's really a conversation between you and the patient, and helping to determine a treatment regimen that suits the goals that they have for their life. A lot of times what I might do for them because of the biology of their disease doesn't necessarily fit into their life's goals at that moment. We really have the opportunity to craft our therapy for patients if they need an oral regimen, because they live too far away, if they travel too often, if they need to be on more monitored therapy, because they have a tough time with compliance at home. I think we can modulate amongst all of those things. And those are all important to take into consideration. It's both the biology of the disease, the history of the disease that they have and the patient preferences.