Today was IMF Satellite Symposium: Getting Clear Answers to Complex Treatment Challenges in Multiple Myeloma: Case Discussion.

This was a great opening session to get our brains warmed up for the ASH discussions. I was somewhat anxious about attending ASH since I had not been there in five years and a lot has changed in the level of research. There are so many new classes of drugs and new combinations to consider, so I was not sure that I could keep up. It didn’t take long to get into the flow of the talks and the treatments being discussed.

At the Symposium, there was a “Rock Star” panel of Myeloma doctors and they presented patient cases that were very real, with special conditions, including elderly patients, high risk, and renal complications.The first talk was about diagnosis of high-risk smoldering multiple myeloma (HRSMM) compared to the diagnosis of active multiple myeloma. Velcade, Revlimid, and Dex (VRd) are still the standard and giving best results for active myeloma, but there may be special circumstances to consider, as just listed. For HRSMM, new lines of treatment are extending progression-free survival (PFS). Clinical trials are looking at different treatments for SMM, including single agents. The examination of SMM and trying to diagnose MM at earlier stages is good news.  Many patients are not diagnosed until bone fractures and organ damage makes it obvious that something is wrong. Current data is monitoring progression of SMM so that doctors and patients have real information about the likelihood of progression, especially for high-risk.

The second talk about induction therapy took into account “host factors” such as age, tumor burden, risk factors, and renal failure. It was concluded that three drug combinations, such as VRd,  are the standard of care and are more effective than a two-drug combination. However, tests are now including Darzalex (daratumumab) with RVd to improve the responses. It was pointed out that in many countries, the economics of four drugs will not work for most patients.

The next presentation reviewed minimal residual disease (MRD) in monitoring myeloma in remission. Both the Next Generation Flow (NGF) and Next Generation Sequencing (NGS) methods are going deeper into the samples to find the myeloma and will continue to improve tracking of the disease.  Discussion of PET/CT revealed that these tests are not standardized, but continue to be recommended. Some myeloma centers are not doing PET/CT scans on a regular basis because the results may be inconclusive and infections may distort the information. All doctors agreed that blood-based MRD tests are needed to reduce the number of bone marrow biopsies. Using MRD as an end-point in clinical trials will reveal differences in treatments sooner, possibly getting new drugs to patients on a shorter timeline. MRD data being gathered will define the guidance for therapy and insight into those patients expected to stay in long-term remission.

The next discussion was about treatment at first relapse. With the nine new drugs, there are so many combinations, especially when some of the older drugs, like Cytoxan (cyclophosphamide) are included in the combinations. Access to the new drugs vary by regions and could influence the choices. As in initial treatment, several factors need to be considered: age; other health issues; type of relapse; prior lines of therapy; cytogenetic abnormalities; economic issues; as well as patient preference.

The IMF Satellite Symposium was a great discussion of treatment options on the myeloma journey.