VIDEO: Patient treatment planning in myeloma begins with transplant eligibility decision

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For a newly diagnosed patient or for a patient, you know, in my clinic, the first decision tree is about transplant for me. So is this patient transplant eligible or ineligible? For us, that's not really defined by age. The oldest patient we've transplanted at Emory was 80 years old. It's really about comorbidities, functional status, performance status. If that person is transplant eligible, I feel like I can get them through transplant safely, I still think that's standard of care upfront. And there's a select number of patients where a deferred transplant makes sense, but that's a very select group of patients: standard risk, you know, younger, reliable, will follow up, those kind of things. I think for most folks, I think upfront transplant makes sense.

When we looked at RVd, transplant, or rev maintenance, the medium PFSs for those patients is around 6 1/2 years. And that's really just not matched by anything else to-date. And that certainly could change. So for transplant eligible patients, I think Dara-RVd followed by transplant, and then risk-stratified maintenance. Meaning standard risk patients seem to do fine with REVLIMID (Lenalidomide, Celgene) alone. I think for high risk patients, we know that REVLIMID is usually not sufficient. So enhancing that maintenance with a proteasome inhibitor, like carfilzomib (Kyprolis, Amgen), or a clinical trial to see if we can enhance that PFS. Historically, those folks have about half the PFS of standard risk patients. If someone is transplant ineligible, I tend to use the MAIA regimen, meaning daratumumab (Darzalex, Janssen) with lenalidomide and dexamethasone (Decadron, Merck), try to taper off that dex around, you know, month six to 10 and have it off, have people on monthly dara and len.

That's a very effective regimen. And then those updated analysis the medium PFS was just over five years. It's well-tolerated. And then I think it gets a little bit more complicated in first relapse. First, for transplant eligible patients who've had a good response, I look at a daratumumab-based regimens, either dara-pom or maybe dara-car. And now we even have CAR T-cell therapy in that space. So I think a lotta that has to do with how the patient responds to therapy and what their performance status is and their, you know, how they want to approach their care. At that mark, I think, for transplant ineligible, I think there's a lot of other options. I think things are also changing. You know, again, dependent on their performance status and things at their time of relapse.