What long-term strategies should myeloma patients understand?

What long term strategies should myeloma patients understand?

We ask the question whether your upfront treatment really matters and why it's important to see a specialist.

Myeloma is the long game, and we want to make sure that we are thinking of all of the downstream stops.

It's like a chess game, so I give you one example. Let's say a patient up front has the chance at getting four drugs, but they're never offered that other opportunity and they're just given three.

If that happens, their initial response, which we often think of as being the best response, might be less deep than somebody that had been offered that opportunity.

Then when it comes time for their second treatment line, it has come sooner. They've had less time to have a nice deep remission. And at this point, there are somewhat fewer treatment options available to them.

There's no four drug combinations available on the second line setting that are FDA approved, for example. And now they've sort of missed out on that chance for a very deep remission.

That's only one such example. We want to make sure that whenever people are trying to start on a new line of therapy, that we really consider what the downstream ramifications of that are going to be, so that we know that we can plan for the future.

In terms of opportunities that may be missed, if one treatment is selected without consideration for another?

There's no concrete example that comes to mind. But one might say that, you know, there are often very attractive clinical trials that are available to people at every step of the journey.

And depending on what therapies have been received in the past, that can kind of change the eligibility for those attractive trials in the future.

So, for example, let's say just for example, a trial has an exclusion criteria that they can't have received drug acts. But the patient out in the community, got that drug maybe for just a month, you know, without considering for this trial in the future, when it comes time to really look for another treatment option.

Now, this option is no longer available to them.

A lot of open, a lot of open questions that need to be answered with really good comparative effectiveness research is what is the right sequence of treatments for patients with myeloma?

How is it that we are going to be able to control this disease as long as possible, while minimizing toxicity?

I think we moved to an era where we know that, multidrug combinations, three drug combinations, maybe four drug combinations really do provide the deeper responses, especially early, and can help keep patients in those responses for a much longer periods of time.

And the trick here is to, to hit hard and fast, at least in my opinion, and then back down to the least toxic, least invasive, strategy possible to keep that disease in.

Ideally remission as long as possible. So in my hands this tends to mean, maintenance revlimid, indefinitely.

But again, that's something that just sort of discussed with patients depending on their risk, their, some of their risk stratification, features at diagnosis.

And then the trick is going to be then to Reemploy either similar drugs or different combinations. But but again a combinatorial approach at relapse to again try to hit hard, get the disease under control, and then be able to back down, and sequence drugs to both make the toxicities as tolerable as possible, make administration as tolerable as possible, and keep those responses as durable as possible.

And so you don't want to burn bridges unnecessarily by switching drugs too quickly, but you also want to be able to use, good effective therapy throughout the treatment course that you have a good chance and a really solid hope of it, providing good response and durable responses every time that you need to employ new, new treatment strategies.

Now and in the years gone by, sometimes we would have to be careful about making a decision. Who would it be, a transplant candidate or not?

Because there were drugs, for instance, like Malvern, which we don't use a lot of today, but that would make it very difficult to be able to collect stem cells if patients down the line thought about collecting stem cells.

Now, the question is a little bit less relevant, but it's still important. We have learned, for instance, that, the use of drugs like the problem, it can sometimes make it harder to collect stem cells. So we like to do it earlier.

And in fact, there's some recent clinical trials that have looked at four drug combinations. There was a study from France that was presented last year.

It's one of our meetings that they used the combination with daratumumab, carfilzomib. revlimid and dexamethasone, and they had a wait list for six months until patients, then went on to collect stem cells, and they had a 20% failure.

That's a pretty high number. So they have to change the protocol so that stem cells had to be collected earlier.

So those after three cycles of therapy. So you know, those things still, still matter.

The other one, which I think is very important and I actually personally believe we don't talk enough about this is the importance of the monitoring of peripheral neuropathy, especially when one is living so many years ahead.

Peripheral neuropathy can be a significant, a factor in decreasing the quality of life of anyone who is diagnosed with myeloma.

Yeah. For us, the main culprit is evaluated. And bortezomib is the drug that has the highest rate of neuropathy.

So I think as we, as we make long term plans, as we think about the future, that's one thing that is critically important to keep at the forefront.

So I talk to patients. I tell them we will be talking about neuropathy. Make sure you bring up the topic when you go for treatment.

Just, you know, tell the nurses, yes, I do have neuropathy. So you make them in a mindset because if you get a little neuropathy and you interrupt it's fine. But we don't want people getting into more serious problems with their arms.