The Impact of Evolving Treatment Options in Multiple Myeloma, Part 2

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Ryan Haumschild, PharmD, MS, MBA, comments on the use of triplet regimens as the standard of care treatment for patients with multiple myeloma, and Thomas Ollis, MS, RPh, shares a community practice perspective.

Bruce A. Feinberg, DO: Ryan, when you think about where we are, are we in the era of triplet drug use? Whether it’s a single drug, doublet, triplet, or even quadruplet, to what extent is it heterogeneous within an environment? Emory Healthcare, Winship Cancer Institute has been one of the leading centers for the treatment of myeloma, well-known for this disease, and one of the early advocates for RVD [lenalidomide, bortezomib, dexamethasone], the 3-drug combination. My question is, does everyone get that? Or even within Emory and the history, do some patients still just get a melphalan, prednisone-type approach if they’re 85 years old and have comorbid disease? To what extent is there heterogeneity? We’ve had this journey over time as Joe was explaining, we’ve been in the triplet era. The question is, are we moving past that?

Ryan Haumschild, PharmD, MS, MBA: It’s a great question, Bruce, and I feel like we are on the cutting edge. Like you’ve mentioned, we do a lot of research, which is great because we’re driving best practice both through clinical trial but also now we’re translating that to more the standard of care. I do believe that triplet therapy is going to be the same approach we have for most patients. Everything’s individualized. There are some patient-specific factors, as you mentioned; whether a patient is up there in age, do we want to try them with triplet therapy off the board? Typically we are trying to create at least some type of pathway approach to care, so considering if a patient’s transplant-eligible, if they’re not transplant-eligible, and then are they high-risk or are they standard? I think we try to create those approaches across all of our faculty members, both in community oncology and not. Using triplet therapy—and even I dare say quadruplet therapy, adding on that CD38 at the beginning—really helps drive best practice, and we feel like it gives patients their best chance. Right now our goal is we want multiple myeloma to be a chronic disease. We want patients to continue to live on, and I think by approaching it early with triplet therapy gives our patients the best chance.

Bruce A. Feinberg, DO: Tom, you’re in a practice that’s quite sophisticated, but not truly an academic practice. Right?

Thomas Ollis, MS, RPh: Right.

Bruce A. Feinberg, DO: Consequently you’ve got other pressures. Now in this era of shared risk and OCM [oncology care model], you’ve got to start to weigh, what’s the bang for the buck? What is the patient getting with that fourth drug, is it an overall survival benefit or a progression-free survival benefit? If I’m going to get them down to minimal residual disease and they’re still going to get transplanted, does it make a difference if I got to that with two drugs in eight months or four drugs in five months? How does a practice start to evaluate and use that kind of data?

Thomas Ollis, MS, RPh: Being a community practice, we’re closest to the patient, so we don’t have the luxury of Ryan or Joseph there in academic institutions. However, we’re looking at the triplet, that’s the standard of care. I had a couple of discussions this week with some of our physicians and the quadruplet therapy is gaining some traction. We’re using it for patients who are a little bit younger and stronger. That’s what I’ve heard, so we’re looking at them both.

Bruce A. Feinberg, DO: Well, I’m just hoping at my age and fitness that I fit both young and strong, because that’s certainly in the eye of the beholder.

Transcript Edited for Clarity