Sagar Lonial, MD, FACP: Combination regimens have really helped us to advance the outcomes for patients with myeloma, mostly because we’re using drugs that target noncancer-related targets in the context of myeloma—corticosteroids, which we know kill myeloma cells; IMiDs [immunomodulatory drugs], which we know target cereblon; and proteasome inhibitors, which we know are important for targeting the proteasome, an important survival pathway in plasma cells. What makes combination therapies so powerful is that these drugs are not 1 plus 1 equals 2, but 1 plus 1 equals 3 or sometimes 5 when you put them together. And that’s the real strength of combination therapy.
The IMiDs have really helped contribute to some of these improvements in outcomes, in part because they’re relatively easy to take. They’re oral, so that does make them easy to take. And in terms of adverse effects, other than some suppression of blood counts, they are very well tolerated, making them really a go-to for frailer, older patients. But because of their activity, they’re easy partners in the context of combination therapy.
I think that when you’re talking about cost of therapy in the setting of multiple myeloma, it’s important to realize that we’ve more than doubled the overall survival of patients with multiple myeloma. Fifteen years ago, 2 to 3 years was the median survival. Now most large national series say 7 or more years. At our center, if you’re standard risk, we have a median survival of well over 10 years. And to me, that’s an important part of the equation because it’s not just the cost of the therapy but what the long-term benefits are. And 8 to 10 years of overall survival, to me, seems like a pretty good value if you think about the benefit. I think it’s hard not to think about cost of care, and there’s no question that that’s an important part of what we do. But a large part of what I do as a translational investigator, as a clinician scientist, is really to try to eradicate plasma cells and focus on using our best drugs to get us to the point where the highest number of patients are either cured or have the longest duration of remission we can achieve.