Drs Kaufman and Richter outline important considerations physicians should be aware of when selecting IMiD therapy for a patient with RRMM.
Jonathan L. Kaufman, MD: When choosing the regimens for patients with relapsed/refractory myeloma, I use 3 factors. One is patient-related factors. What has the patient tolerated before? What are their blood counts like? What adverse events have they had? Are they able to come into the clinic regularly and get infusion therapy? Are they a patient who can reliably take oral medications at home? The next ones that we think about are disease-related issues. Is this a rapidly progressive myeloma? Is this slower, indolent? What drugs are the patient refractory to? That leads to the third, which is understanding what the patient had previously [been treated with]. If a patient is progressing on one group of drugs, one might want to switch to another group. We put those 3 things together to make our treatment plan.
Joshua Richter, MD: There are so many options to manage myeloma. There is no clear guideline about how to approach patients in the relapsed and refractory setting. For the most part, we choose 3 different modalities to make our decision: patient-related factors, treatment-related factors, and disease-related factors. Patient-related is if the patient old or young, fit or frail. Do they have comorbidities? Treatment-related factors are what therapies have they had before? Did they do well with them? Did they have a lot of toxicity? With disease-related factors, is their disease bulky? Is it progressing fast? Is it causing organ dysfunction? IMiDS [immunomodulatory drugs] play a large role in this. Lenalidomide is one of the key components of our upfront therapies, both in induction and maintenance therapy, as well as in early relapse. One of the decisions we go by is, as we move into the relapsed setting, are you lenalidomide refractory? A majority of patients in the United States will be treated with lenalidomide upfront and remain on it until progression or intolerance. Once you progress on lenalidomide, what dose did you progress on? If you were getting 10 mg as maintenance, could we up that to 25 mg and combine that with another drug to give you a lenalidomide-based triplet? Or were you progressing on 25 mg, and now we ought to move on to a drug like pomalidomide as our base IMiD for the next line of therapy? These are some of the factors we consider in trying to come up with an individualized approach throughout the relapsed and refractory realm.
There are so many factors we consider, including cost. There are lot of direct and indirect costs to our care. Thankfully, many of the drug companies that make the more expensive oral oncolytics have patient-assistance programs to help with this. We try to provide the optimal regimen, and if there is a significant financial burden, there are a number of venues to offset that, either through patient-assistance programs, through the companies themselves, or through advocacy groups like the Leukemia & Lymphoma Foundation or the Chronic Disease Fund, or even some private funds will offset this.
This transcript has been edited for clarity.