Recent years have brought a growing and potentially-bewildering set of treatment options for multiple myeloma, noted experts at the 58th American Society of Hematology (ASH) Annual Meeting in San Diego, at a panel held Sunday, December 4.
Oral proteasome inhibitors, new IMiD immunomodulators, kinase inhibitors, monoclonal antibodies, and immunotherapies like chimeric antigen receptor (CAR) T-cell therapies and PD-1 immune checkpoint blockade are just a few of the newer categories of myeloma treatments. Recent FDA approvals for myeloma treatments include thalidomide, lenalidomide, melphalan, daratumumab, elotuzumab, and ixazomib.
Those advances have come alongside new tools for monitoring disease progression and treatment response, noted Noopur Raje, MD, of Massachusetts General Hospital Cancer Center in Boston.
“What’s happened with all of the new treatments we have is the addition of better imaging modalities and better genetics tools as well as disease monitoring,” Raje said. “We have all these different pieces of the jigsaw puzzle. Can we figure out the best way to put this puzzle together?”
Supportive care with bone-targeting agents and other medications is another piece of the puzzle that is “important from the get-go,” Raje noted. Prophylactic treatment should be undertaken to protect patients against thrombosis and infection, for example.
The ‘backbone’ of contemporary myeloma care
The immunomodulatory drugs thalidomide and lenalidomide are becoming the “backbone” of contemporary myeloma care, Raje noted. Particularly with younger patients, “continuous improvement” is seen in response to combinations of newer agents, she said.
“We are seeing close to a 100% response rate,” she said. “Combinations will allow us to improve responses and cure an even higher fraction of patients.
Because most myeloma patients eventually relapse, researchers are working to identify the optimal sequencing of different treatment regimens. Much has yet to be learned.
Reviewing clinical trial findings, Raje ticked through a long list of initial and second-line myeloma therapy agents: the proteasome inhibitors bortezomib and carfilzomib, immunomodulatory drugs like lenalidomide, alkylating agents like melphalan, cyclophosphamide, doxorubicin, and bendamustine, and dexamethasone and other steroids. Other myeloma treatments have been approved but not for frontline treatment.
“High-risk disease needs new drugs,” she noted. “Immuno-oncology will play an important role.”