Consider Patient Characteristics, Goals When Planning Myeloma Treatment

“There are a lot of different regimens [for patients with] myeloma, and so in picking a regimen, there are many different factors to consider, beyond just what is effective."

As a variety of drug combinations enter earlier lines of the multiple myeloma treatment landscape, deciding on a treatment plan is not one-size fits all, explained Amy Browning, MSN, APRN.

“There are a lot of different regimens [for patients with] myeloma, and so in picking a regimen, there are many different factors to consider, beyond just what is effective,” she said at a Community Case Forum event hosted by Oncology Nursing News. Browning, a nurse practitioner at Advent Health in Orlando, Florida, also mentioned that clinical teams must also consider patient preference, toxicity, quality of life, comorbidities, financial toxicity, infusion preference, and patient goals when determining the best plan for a patient with multiple myeloma.

As an example, Browning presented a case study of a 76-year-old female who was diagnosed with stage II myeloma, per the International Staging System (ISS) criteria. The patient is not a candidate for transplant and:

• Has early-stage Parkinson’s disease, which is currently well-controlled
• Presented with severe lower back and neck pain
• Enjoys spending time outside
• Is experiencing fatigue and mobility challenges
• Has an ECOG performance status of 1 at the time of diagnosis
• Expressed goals of living longer, improving energy and enhancing mobility
• Noted quality time with her grandkids was important.

As the forum discussed treatment options, Browning focused on 3- and 4-drug regimens that are used in the treatment of patients with newly diagnosed multiple myeloma who are not eligible for stem cell transplant: bortezomib (Velcade) plus lenalidomide (Revlimid) and dexamethasone, or VRd; daratumumab (Darzalex) plus lenalidomide and dexamethasone, or D-Rd; as well as daratumumab plus bortezomib/melphalan/prednisone, or D-VMP.

“More is better, as long as they can tolerate [the regimen]. With more drugs [comes] more side effects, so manage that efficacy with toxicity,” she said. “Depending on how ineligible the patient is for transplant and their comorbidities, you can take away [drugs] or dose reduce as needed, but you want to push as much as you can and balance efficacy with control of the disease.”

Patients who are old and frail may experience more side effects, such as diarrhea and neuropathy, one attendee mentioned. Additionally, comorbidities—such as diabetes or cardiac issues—can also affect treatment choices.

For the 76-year-old woman in the case study, the frontline regimen was chosen based on data from the MAIA trial (NCT02252172), which showed that adding daratumumab to lenalidomide and dexamethasone improved progression-free survival (PFS) compared to lenalidomide and dexamethasone alone. The median PFS was 61.9 months and 34.4 months in the 3- and 2-drug regimens, respectively, according to an extended follow-up of 7.5 years.

After 9 months of therapy, the patient’s ECOG status increased to 2. She was adherent to lenalidomide approximately 75% of the time, and to daratumumab 100% of the time. She experienced a complete response (CR) and her chemistry labs are stable. The patient also experienced neutropenia that was refractory to Granulocyte colony-stimulating factor (G-CSF).

To address the existing neutropenia, one attendee recommended moving the patient to a 2-drug regimen. “Because she’s in a CR, she doesn’t need as much efficacy.”

“I would also see what dose of [lenalidomide] she was receiving, because if she was getting a full 25 mg, a lot of times [clinicians can] just hold it and then restart at 15 or 10 mg,” another attendee said, while someone else chimed in, “or they can reduce the number of days [she takes the drug].”

At the 12-month mark, the patient is still in CR and expressed a burden from treatment for her cancer and Parkinson’s disease. As a result, she queried about stopping treatment until relapse occurred. Considering that relapsed myeloma tends to be more aggressive, Browning said that this might be a good time to engage the caregiver in treatment planning and discussions. Advanced practice providers can discuss why the patient is experiencing medication burden, make sure she is no longer on steroids, and consider subcutaneous daratumumab if the infusion is the biggest downside that the patient discusses, for example.

“We have to dose reduce if they’re having side effects, because if not, they’re going to end up stopping treatment,” an attendee said.

At the 15-month mark, the patient’s ECOG score went back to 1, renal function was good, but she had a fever and was experiencing shortness of breath. She was successfully treated with levofloxacin for pneumonia, and then labs showed hypogammaglobulinemia with an IgG of less than 400.

“We're pretty aggressive with replacing with [intravenous immune globulin] and helping decrease risk of infection in all patients. That becomes even more important in people who get BiTE or CAR T[-cell therapy] but good for upfront patients as well,” Browning said.

At this point, some experts mentioned the possibility of further dose reductions or even going on a “chemo holiday” where the patient stops treatment for a time before resuming treatment.