
The Tremendous Complexity of Treating RRMM
In this interview from our coverage of the European Hematology Association 2024 Congress, Joseph Mikhael, MD, MEd, FRCPC, FACP, International Myeloma Foundation, discusses the complex principles that underlie treating multiple myeloma (MM) in the US.
Joseph Mikhael, MD, MEd, FRCPC, FACP, is chief medical officer of the International Myeloma Foundation, where over the last few years he has led the
In this interview from our coverage of
Transcript
Can you discuss the US approach to treating patients with early relapsed/refractory MM?
The treatment of myeloma is complicated, as we know, at all levels: frontline, early relapse, late relapse. But there's been a lot of interest in early relapse of late, especially with the incredible number of phase 3 trials that have guided our thinking and the way we approach patients with early relapse. And I had the privilege here
I would say principle number 1 is that we don't have a sinkable algorithm, where we say we always treat patients with this, then with that, then with the other. It's much more directed on patient factors, disease factors, based on how the patient is doing, what they've been exposed to before. So it's more of a strategy than just a script of doing it, now that we have multiple options.
Principle number 2 is that we want to introduce new mechanisms of action. We really do have 4 major classes now of drugs: the proteasome inhibitors, the immunomodulatory drugs, the monoclonal antibodies, and now
I would say principle number 3 is that we want to make sure we don't, if you will, save the best for last. We try to use the best combinations we have early on to get a deep and most durable response when we have access to those therapies because we know that with each line of therapy, there are fewer patients that are available for transplant.
And then lastly, I would say a very important principle is always—as my father taught me when I got accepted to med school—we have 2 ears and 2 mouth for a reason. We have to listen to our patients. We have to constantly be assessing the toxicity a patient is having and dose adjust accordingly. For a lot of our patients, we can deescalate their therapy—in particular, dexamethasone, for example—but very often the other drugs that we're using, perhaps dose reduction or dose delay based on that so that it is sustainable, so that we can have the maximal input.
And with these principles, ultimately we found that we have lots of choices. If someone has not seen a CD38 monoclonal antibody, we classically use a CD38 antibody with either carfilzomib or pomalidomide. If someone has, we may consider another class, like selinexor. If they've not seen carfilzomib or pomalidomide, we often include those. So we do have a lot of choice.
And then very lastly, now just as of April 2024, we now have the opportunity of introducing CAR [chimeric antigen receptor] T-cell therapy in early relapse, even as early as 1 prior line
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