Two practicing physicians discuss clinical pathways and decision-making tactics used at their respective institutions for RRMM management.
Jonathan L. Kaufman, MD: At our institution, the way we use clinical pathways is deciding as a group what treatments we’re going to use. We meet and have agenda items that come up regularly. For example, we will meet and say, “What are we going to do for newly diagnosed patients who are transplant eligible?” We make this decision every 6–12 months as new data come in. For example, when we saw 4-drug therapy in the newly diagnosed setting, daratumumab plus RVd [lenalidomide, bortezomib, dexamethasone] was superior to lenalidomide, bortezomib, dexamethasone—at least from an initial efficacy standpoint—we as a group decided to shift there. We also have that same discussion for transplant candidacy. What’s the appropriate maintenance therapy, high risk or standard risk? What do we do at first-line relapse? What we have historically done, and after the approval of the combination daratumumab, pomalidomide, and dexamethasone, we use that as our second-line therapy. Because we uniformly use it as our second-line therapy, we were able to go back retrospectively to review and learn that those patients who progressed very early after diagnosis were less likely to respond to that therapy. Those patients who [progressed] later were much more likely [to respond]. We made a treatment pathway, followed it, analyzed that information, and now have updated our pathway to hopefully improve outcomes.
We have a large network of referring physicians who will call us regularly in these situations, and we will walk through this algorithm, this pathway with them. It’s not only the patients solely treated at Emory, but it’s our entire network, typically, in the state of Georgia and throughout the Southeast.
Joshua Richter, MD: At the moment, my institution does not use pathways. Because we have a large myeloma center, we have the freedom to choose different ways to go with different lines of therapy. However, clinical pathways can be extremely advantageous to institutions that don’t have that same exposure to myeloma. For example, the average hematologist-oncologist sees zero–10 cases of myeloma per year, whereas personally, I see 60–100 a week—let alone that my center has 10 myeloma physicians. Myeloma pathways can be extremely helpful in this setting.
As far as the IMiDs [immunomodulatory drugs], most of the sequencing IMiDs data we have come from the way that the trials were designed. All lenalidomide-based regimens were studied in patients who had prior thalidomide. All pomalidomide-based regimens were studied in patients who had prior lenalidomide. We are now looking toward the next generation of IMiDs, the so-called CELMoDs [Cereblon E3 ligase modulator], with iberdomide and mezigdomide. They are following suit for patients who have already seen lenalidomide and pomalidomide. Thalidomide is not utilized in the United States very much. It’s mostly used in induction regimens in Europe where they use thalidomide up front and then lenalidomide in the relapse, with pomalidomide in the relapse after that. In the United States, our sequences, both in clinical practice and in guidelines, have been to use lenalidomide-based regimens up front and only then move on to pomalidomide-based regimens in the relapsed and refractory setting.
This transcript has been edited for clarity.