Melissa Alsina, MD

Melissa Alsina, MD

Expert Perspectives

 

Decisions in the Clinic: Treating Patients With Multiple Myeloma

Headshot

Melissa Alsina, MD

Practice Community
Tampa, FL
Practice Niche
Hematology
Hospital and Institutional Affiliations
Associate Professor of Medicine, Blood and Marrow Transplant and Cellular Immunology Program
H. Lee Moffitt Cancer Center

 

Question

How is the treatment of multiple myeloma changing, particularly as newer agents receive approval or expanded indications (eg, daratumumab granted Priority Review for the first line, denosumab approved to prevent skeletal-related events [SREs])?

Answer

There have been tremendous advances in the treatment of both newly diagnosed and relapsed myeloma, which have had an important impact on survival and quality of life. However, there is still work to be done, and, fortunately, the collaborations of clinical and basic researchers, pharma, and patients and their families have enabled the momentum to continue. We continue to see new drugs being approved and move quickly to the upfront setting.

Question

How has maintenance therapy changed, and what is its role now for patients with multiple myeloma?

Answer

I think at this time is clear that lenalidomide maintenance in myeloma is important both in the transplant and non-transplant setting. This is based on several randomized studies showing both a progression-free survival and overall survival benefit. There are ongoing studies trying to improve the results with lenalidomide, using for example lenalidomide and ixazomib. Very important to consider how maintenance therapy may affect quality of life and do necessary adjustments so that patents can enjoy longer lives free of myeloma and with quality.

Question

Where are we now with CAR-T therapy for multiple myeloma? What can be expected in the near future, in terms of incorporating it into practice?

Answer

Several studies have shown very good responses ranging from 60% to 90% with BCMA [B-cell maturation antigen] CAR-T therapy in relapsed/refractory myeloma. I think initially it will be approve for relapsed/refractory disease, but will start evaluating the role of this therapy in earlier stages of the disease, particularly in patient populations where long PFS [progression-free survival] and OS [overall survival] still remain a challenge, such as high-risk myeloma or plasma cell leukemia.

Question

Do you think immune checkpoint inhibition will have a place in the treatment landscape for multiple myeloma, given the increased risk of death in clinical trials? Is the mechanism for the increased risk of death known?

Answer

The increased risk of death is not well-understood, and it seems to be when these agents are given in combination with immunomodulatory drugs (IMiDs). I do not think these drugs will have a role in the treatment of myeloma, at least in combination with IMiDs.

Question

What new approaches are you excited about for the treatment of multiple myeloma in the future?

Answer

I am very excited about BCMA CAR-T therapy. I am also excited about ongoing research to determine the role of minimal residual disease evaluation in treatment decisions, as well as the incorporation of an anti-CD38 monoclonal antibody as part of induction and maintenance therapy.