SPd has the additional advantage of being an all-oral regimen, meaning that appointments relative to its therapeutic administration can often be facilitated via telemedicine, thereby reducing the number of clinic or hospital visits that might be associated with an intervention that does not come in an oral form.

“Myeloma is a good reason to be concerned with going to the hospital,” Kauffman said. “You do not want to go to the hospital when you’re immunosuppressed.”

However, it is important to note that selinexor therapy does come with an increased risk for toxicity. “Particularly problematic has been the gastrointestinal toxicity,” said Kumar, who serves as a consultant in the division of hematology in the department of internal medicine at the Mayo Clinic Cancer Center in Rochester, Minnesota. “Patients can get quite sick and need to be on prophylactic antiemetics more than what we’ve seen with other myeloma therapies.”


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Additionally, despite selinexor’s novel mechanism of action, some oncologists have expressed skepticism that the BOSTON trial results are reflective of any real patient benefit.

“[Bortezomib]-dex was not a standard of care in the NCCN or in any treatment recommendation because numerous trials had already shown the superiority of triplet regimens at the time of accrual,” said Aaron Goodman, MD, a hematologist/medical oncologist at the Moores Cancer Center at University of California San Diego Health. “70% of the patients who were randomized to [bortezomib]-dex had already been treated with [bortezomib] in the past,” Goodman added. He indicated that administering a regimen that patients had already received might have artificially depressed the efficacy of the control arm, boosting selinexor by comparison.

“I’m not denying that it has activity in disease,” Goodman said. “We just don’t know where and when to use it.”

Between the added toxicity, high price tag, and modest potential benefits, Goodman said that he couldn’t imagine choosing a selinexor regimen for 1 of his patients with advanced disease. “There’s many alternatives,” he said. “It definitely doesn’t make the majority of patients with end-stage myeloma feel better.”

Preferred, category 1 treatment regimens for patients with previously treated disease currently include carfilzomib/lenalidomide/dexamethasone; daratumumab/bortezomib/dexamethasone; daratumumab/carfilzomib/dexamethasone; daratumumab/lenalidomide/dexamethasone; isatuximab-irfc/pomalidomide/dexamethasone; ixazomib/lenalidomide/dexamethasone; and pomalidomide/bortezomib/dexamethasone.

References

  1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Multiple Myeloma; version 4.2021. Updated December 10, 2020. Accessed January 22, 2021.
  2. Grosicki S, Simonova M, Spicka I, et al. Once-per-week selinexor, bortezomib, and dexamethasone versus twice-per-week bortezomib and dexamethasone in patients with multiple myeloma (BOSTON): a randomised, open-label, phase 3 trial. Lancet. 2020;396(10262):1563-1573. doi:10.1016/S0140-6736(20)32292-3