CAR T-Cell Therapy for the Management of Multiple Myeloma - Episode 2
Drs Deepu Madduri and Parameswaran Hari explain the high rates of use of healthcare resources in relapsed/refractory multiple myeloma and recommend strategies that may reduce resource utilization and treatment variability.
Parameswaran Hari, MD, MRCP: Analyzing triple class-refractory patients and the multiply relapsed patient, health care resource utilization becomes a major problem. These are the patients who despite only having a short time to live based on approved FDA agents—the future is looking good [for these patients] as new agents are approved—but as of now, these are the patients who end up in the hospital quite a bit. They’re the patients who may have significant plasmacytomas or extramedullary disease, who need radiation, or who have profound blood count drops and need transfusions. Overall, patients end up having a lot of needs, both inpatient and outpatient, with multiple visits to doctors and a significant worsening of quality of life over and above the health care resource utilization. They also are typically unable to work, and that imposes a major economic burden on the patient.
Deepu Madduri, MD: For some of these patients we can give some of these therapies as outpatient, so they’re usually coming to the clinic quite regularly, often 3 weeks on and 1 week off. Sometimes, people are coming once a week every week. Often, when these patients are progressing rapidly and we need to debulk their disease, they may have to be admitted into the hospital to get a 4-day continuous chemotherapy called DCEP [dexamethasone, cyclophosphamide, etoposide, and cisplatin] or VD-PACE [bortezomib, dexamethasone, cisplatin, doxorubicin, cyclophosphamide, etoposide]. Sometimes we may have to admit these patients to get a bone marrow transplant, like a second transplant, if they haven’t had one, or a stem cell boost to debulk their disease so that we can buy some time for them to go onto another therapy. Typically, patients with multiple myeloma [MM] are immunosuppressed, so you do see these patients coming in because they’re infected because their immunoglobulins are not that high. Therefore, we routinely administer IVIg [intravenous immunoglobulin] for patients when their IgG [immunoglobulin G] level is low, so there may be times when they are admitted. Additionally, they may have to be seen in the ED [emergency department] for evaluation of infections, colds, etc.
Parameswaran Hari, MD, MRCP: As with any academic myeloma practice, with our practice being a very economic practice, our primary goal is to enroll these patients, who are triple-class refractory, multiply relapsed, or multiply refractory, on to clinical trials. Clinical trials offer the most effective and cutting-edge treatment that patients can receive. With the plethora of good immuno-oncology approaches in MM, I feel that these treatments offer a significant chance for a patient to receive a free therapy. Clinical trial agents are typically free to the patient. Moreover, the ability to get into a deep remission is the single most effective way of reducing the health care resource utilization.
A patient with MM who is in remission typically has good blood counts, good performance status, less pain and other issues that land them in the hospital, with less risk of getting fractures or new plasmacytomas that need admission to the hospital. Essentially, getting to a deep remission basically trumps the resource utilization. Although the resource utilization for the agent itself might be high when these agents get approved, over time, the length of remission basically reduces the further resource utilization in terms of hospitalizations and medical needs.