What are the cycles of relapse and remission in myeloma?

What is the cycle of relapse and remission in myeloma? Is the first remission still the longest?

When we think about how long remission lasts with each line of therapy, what we've historically said is that the first remission is the longest and every subsequent remission is shorter. And that's not necessarily true for any individual patient. But if you take a population of patients, that's what we see.

What we're getting excited about today is with things like CAR-T cell therapy, where it's approved after four lines, and bispecific therapy after four lines. We're now starting to see durations of response of over a year, over a year and a half, over two years, which is much longer than what we saw in that patient's third and fourth treatment.

And so these new therapies, more effective therapies, might be breaking that mold, if you will, that each subsequent relapse is shorter. We're very hopeful, and that's one of the reasons why we want to move these therapies up earlier so we can get the benefit of those therapies earlier and have the second remission be even longer or the first remission be even longer than where we are now.

So it's true that multiple myeloma remains a generally incurable malignancy, an incurable blood condition. And so patients are diagnosed, treated, and over time, relapses can occur where the myeloma wakes up again and requires additional therapy.

Historically, we would say that with each relapse, the subsequent remission would be shorter than the one before. And this makes sense. If we use exactly the same medicines, and we use the same medicines in the beginning and then they stop working, and we reuse some similar medications, you get less benefit.

However, we're very fortunate that the field of myeloma research has moved very rapidly, and oftentimes when a patient has a recurrence, we can offer newer or even better therapy than they got initially. So we're seeing patients with subsequent remissions that last longer than their initial remissions. Some of the newer immunotherapies certainly have been paradigm-changing, and we're seeing patients that historically might have had a rather poor prognosis do wonderfully well with some of the new approaches.

So I think that old concept that each remission is destined to be shorter than the one before, thankfully, no longer really applies.