With more therapies in the clinic, knowing what drugs should be given in what combination and in what order can be challenging. Noopur Raje, MD of Massachusetts General Hospital in Boston presented one of the major myeloma sessions on this important topic at the recent ASH 2016 conference. She mentioned that today's 5-year survival is 47% and most patients will relapse within 3-4 years. With every relapse, the remission duration typically becomes shorter. So while patients and doctors are starting to see a pathway to a cure, there is still clearly need for greater improvements. Factors that could improve outcomes include:
Dr. Raje mentioned a more personalized medicine approach that takes into account many factors to find these better treatments and applies them personally:
The theme of triplets vs. doublets was strong. She showed that triplets were better for overall survival and can get 90% of patients into a complete response. She noted that in many of the new clinical trials, Relimid/Velcade/dex (RVD) was the typical triplet combo used. For those with some renal failure, Cytoxan/Velcade/dex (CyBorD) might be a better choice.
Dr. Raje mentioned that specialists are now asking if a fourth drug should be added to the mix to improve outcomes. She mentioned that in one study, cyclophosphamide (Cytoxan) was combined with a standard triple combination and didn't show improved results. So she suggests that the ongoing studies that add other drugs like daratumumab, elotuzumab, and panobinostat will likely be better options than Cytoxan.
Dr. Raje mentioned that patients who become MRD negative have significant progression free survival and better overall survival. This could be because disease control means better outcomes or push out the time to next treatment. She also noted that not all patients get there (and do just fine) and patients who are MRD negative can still become MRD positive.
Things she considers at relapse include: 1. What kind of relapse? Was it immediate and fast or slow growing and after prolonged remission? 2. Are there new high risk features? Some subclones can mean more mutations according to Dr. Jens Lohr. 3. What drugs have been used so far? 4. What was the response to previous treatments? 5. Is the patient fit? 6. What other health issues does the patient have?
about the author
Myeloma survivor, patient advocate, wife, mom of 6. Believer that patients can help accelerate a cure by weighing in and participating in clinical research. Founder of Myeloma Crowd by HealthTree and the HealthTree Foundation.