VIDEO: Considerations to help develop personalized treatment plans for myeloma patients

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So this is a very good and important question. So in my opinion, there are three big categories that needs to be considered before deciding the type therapy for our patients. The first group is really the characteristic of the multiple myeloma disease. This includes all the prognostic scorings at the stage of myeloma, the ISS stage, and the cytogenetics profile, but also, for instance, the kinetic progressions, the expression of specific antigen, and prior therapies. For instance, if I have a patient that has very rapid disease progression, sometime we need to use medication that we know act very quickly such as bridging with steroids, even giving chemotherapies with Cytoxan or VDPs, different type of regimen and adding a proteasome inhibitor in order to bridge and obtain a rapid disease response. Another good example of kind of, like, choosing which type of therapies, the sequencing of medication that target the same antigen. For instance, how do we sequence CD38 monoclonal antibodies? And in this case, some recent study has shown that at least we need a 6 to 12-months washout to have antigen reexpression and reactivation of response. And more studies are coming up about how do we sequence the anti-CD38, either, like, biospecific or CAR T.

Apart from, like, the characteristic of the myeloma disease, another important factor is really the patient itself. So for instance, historically and both in clinical trial and also in real-world patient, we use this classification of transplant-eligible and transplant-ineligible. And historically, age over 65, comorbidities such as oxygen dependence, heart failure, or dialysis were considered a contraindication for autologous stem cell transplant. Even though we know that nowadays most of the transplant center, including Ohio State, but all the transplant center are really comfortable in transplanting people that are up to 75 years of age and also around dialysis. And the other really concept that we are really interested in, especially in my center here with our Care Clinic, is distinguishing the concept of chronological age versus physiological age. So it's really important, especially for patient that are older than 65, to have this type of, like, assessment to define the performance status and also what we call, like, the frailty of the patient. That is their ability to perform the regular activities during the day, ADLs, and all of that. And then obviously, we kind of mentioned comorbidities. So there are some comorbidities that are still, like, contraindication really for transplant or for, like, more aggressive therapies such as CAR T. But also specific organ dysfunction can kind of, like, incline me or my colleague to choose a specific type of drugs compared to another.

So for instance, we know that bortezomib, even though with the sub-Q formulation is less neurotoxic can still cause peripheral neuropathy. So if my patient already has, for whatever other reason, maybe has diabetes or some other diseases, severe peripheral neuropathy, we might need to dose adjust. So dose of bortezomib kind of reduce or like, space it in order to prevent further damage. And also another example is carfilzomib that can cause a little, in some cases, arrhythmias and heart failure. So patient that has, like, severe heart failure might not be the best candidate for this approach. And then the third point that is really important, especially for a physician like me that works not really in rural area but, like, in academic center that kinda, like, see lots of patient from, like, out of state or from different community center, it's really kind of, like, discuss access to care and patient preference. For instance, transplant CAR T therapies and clinical trials all have, like, specific logistics. So it's really important to talk with my patient about their willingness to spend time in the hospital or even, like, spend time in some kind of, like, housing close to the hospital, their ability to take time off from work, have a 24/7 caregiver for, like, especially for kind of, like, the immediate time after these type of therapies. And then what are their concern about in terms of, like, quality of life or potential toxicities. And this comes out a lot when we kind of, like, discuss with patient if it's they prefer a really a CAR T therapy approach that implies stay in the hospital for, like, 10 days, two weeks, and then having to kind of, like, follow closely back and forth or doing, for instance, biospecific where your admission time is shorter, and we've been kind of trying to move with outpatient, and then potentially they can receive those subsequent doses in their community oncology center. So kind of, like, considering all these factor is really important to develop, like, a personalized treatment plan that balance all effect of efficacy, safety, quality of life, and also FDA-approved labels for our patients.