High-Risk Myeloma Treatment Is Not One-Size-Fits-All

Goals of myeloma treatment can vary from patient to patient.

Patients with high-risk multiple myeloma need tailored treatments that take risk factors and lifestyle goals into account, explained Mark Davis, PA-C, a physician assistant from Texas Oncology, Southwest Forth Worth Cancer Center.

At a recent Community Case Forum hosted by Oncology Nursing News, Davis and colleagues discussed contemporary approaches for newly diagnosed multiple myeloma treatment.

“This is something I think that a lot of us, particularly in the [advanced practice provider (APP)] world can really help clinicians, because we’re so focused on chromosomal abnormalities but we often don’t take into account the time of progression,” Davis said.

He noted that a 1q amplification or gain (a genetic mutation observed in patients with myeloma) is only a high-risk feature if it is in combination with another chromosomal abnormality. Additionally, patients whose disease progresses within 2 years of transplant or maintenance therapy should also be classified as having high-risk disease.

High-Risk Myeloma Therapy Should Be Personalized

Davis said that treatment regimens for patients with myeloma should be created on a patient-by-patient basis.

“Treatment effectiveness can have different meanings to patients,” he said. For some patients, it’s the ability to continue activities of daily living. For others, it’s maintaining a good physical and mental well-being. And others recognize that being inactive can lead to impairment, which is associated with worse outcomes. So for every patient we encounter, they’re going to have different goals.”

APPs are essential in guiding conversations with patients to help determine what their goals are, and then which regimens may best fit them based on their goals, lifestyle, other comorbidities, and cost of treatment.

“All these drug therapies have roles,” Davis said. “For example, anytime you see cyclophosphamide as part of a regimen … that’s because patients might have renal impairment. It allows you to treat them more aggressively without compromising their kidney function.”

Another attendee also mentioned the need for patients with diabetes to avoid certain drugs that can exacerbate neuropathy.

“If they have diabetes and they already have neuropathy, bortezomib and Revlimid are going to increase [the adverse effect],” the attendee said.

Case Study of a Woman With Myeloma

Davis presented a case of a 76-year-old female with early-stage Parkinson’s disease that is currently controlled with treatment. She has ISS stage II myeloma and is not eligible for a transplant The patient presents with severe lower back and neck pain, has an ECOG status of 1, and has a goal of living longer, improving energy and mobility, and spending quality time with her grandchildren. She said she enjoys spending time outside but doing so is becoming limited due to increasing fatigue and mobility challenges.

The attendees were polled on what regimen should be prescribed for the frontline treatment of this patient. Results were evenly divided—50% of respondents said that they would consider bortezomib (Velcade), lenalidomide (Revlimid), and dexamethasone (a regimen known as VRd), including VRd lite. Meanwhile, the other 50% of patients voted for daratumumab (Darzalex) with lenalidomide, and dexamethasone (Dara-Rd).

“Both of those responses are what we would expect,” Davis said. “Frail and elderly patients are technically considered high-risk patients because historically, they’re unable to go with more aggressive therapies such as transplants.

Adverse Events May Lead to Treatment Alterations

Once patients have their therapy determined, the treatment can also change—by way of dose reductions or stopping certain drugs—due to adverse events. One attendee mentioned a frail patient who had to have their therapy altered due to toxicities.

“I have several patients on myeloma treatment who had to discontinue (bortezomib) and we had to keep them on Revlimid,” she said. “And we have to send them to pain management.”

Regardless of the therapy patients are on, newer treatment combinations help provide a positive outlook for those with myeloma.

“The outcomes are so much better with the treatments that we have, and patients can live longer, even if they don’t go in for treatment,” Davis said.