Frontline Treatment Decisions Are Crucial in Myeloma

Patricia Mangan, RN, MSN, APRN-BC

In recent years, 5-year survival rates have increased for patients with myeloma. However, the majority of patients will still relapse after their treatment — some faster than others – highlighting the importance of establishing the longest possible remission the first time around.

“As the disease in some patients can progress, it can start to become more active,” said Patricia Mangan, RN, MSN, APRN-BC, a hematology nurse practitioner at the University of Pennsylvania Abramson Cancer Center.

Mangan, who is also the nurse lead of the hematologic malignancies program at Penn Medicine, recently discussed myeloma at the NCCN 2020 Virtual Congress on Hematologic Malignancies Nursing Forum.

Indications of active myeloma include calcium elevations, renal insufficiency, anemia, or bone disease.

“[When patients have] those myeloma-defining events of greater than 60% plasma cells in the marrow, or lichen ratio greater than 100, when normally it’s a 1:1 ratio, that’s giving us a sense that your patient is having a lot of changes and more aggressive growth of the disease, and may warrant starting treatment sooner,” Mangan said. “And finally, the last feature of a myeloma event is in higher sensitive X-rays, [with] a bone lesion that is greater than 5 mm by an MRI or PET scan.”

Once patients express these indicators of active myeloma, their frontline treatment is typically a 3-drug regimen including a proteasome inhibitor, immunomodulating agent, and steroids or dexamethasone. Then, eligible patients may have an autologous transplant.

“Once someone is diagnosed and they need to start treatment, there’s a quick decision of: Is this person potentially eligible for stem cell transplant or not? Do they have comorbid issues? Are they not fit or too old to undergo transplant?”

Mangan emphasized that these decisions need to be made by the treatment team early on. If a patient is transplant eligible, they will undergo the transplant then be given maintenance therapy.

For patients who are not candidates for transplant, clinicians should attempt to get as deep a remission as possible with treatment and then, “start to peel off some of that initial treatment to get them on a maintenance of that to maintain remission,” Mangan said.

However, most patients — especially those who are not eligible for transplant – will relapse.

“One thing to stress is that typically, your first remission is the longest,” Mangan said. “Once you choose to treat someone with myeloma, you want to do it as aggressively as they can tolerate to get the biggest bang for your buck.”

Thankfully, there are more effective options than ever to treat relapsed myeloma, including novel agents like monoclonal antibodies, antibody drug conjugates, and others.

“We can keep people doing well for a long period of time … our myeloma patients are survivors,” Mangan said. “They’re living much longer with each new year of treatments tha come out.”