New and Upcoming Treatments Are Vastly Changing the Myeloma Space

Although the amount of treatment options for the frontline setting of multiple myeloma may be limited, extensive research is helping these efforts along.

Noa Biran, M.D., from the Myeloma Division at the John Theurer Cancer Center, recently sat down with OncLive, a sister publication of CURE, to discuss major breakthroughs and new treatments for patients with multiple myeloma.

Triplet regimens — like the combination use of Velcade (bortezomib), Revlimid (lenalidomide) and dexamethasone – are showing promise in newly diagnosed patients, according to the SWOG S0777 trial.

In the trial, researchers randomized patients — who did not go on to transplant – to receive either upfront Velcade, Revlimid and dexamethasone, or Revlimid and dexamethasone alone.

Patients treated with the triplet regimen demonstrated improved progression-free survival (PFS; 43 months versus 30 months, respectively) and overall survival (OS; 75 months versus 64 months, respectively) compared with the doublet combination.

“(Triplet combinations) achieve a very rapid and deep response. That usually translates into a longer duration of remission,” Biran said. “It’s important to keep transplant-ineligible patients on a triplet regimen.”

Looking solely at patients in the transplant setting, those who underwent double autologous stem cell transplantation (ASCT) also showed an increase in PFS, according to findings from the phase 3 EMN02/HO95 study.

The benefit was most commonly seen in patients who had a poor prognosis. “This extended to patients who received tandem transplant and was seen especially in high-risk patients,” Biran said.

The patient population with bone lesions has a new treatment option, too. This January, the Food and Drug Administration (FDA) approved Xgeva (denosumab) to prevent skeletal-related events, based on '482 study which compared Xgeva to zoledronic acid.

Since Xgeva is a RANK-ligand inhibitor, and not a bisphonate, it does not go through the kidneys. Since about 40 percent of patients with multiple myeloma have renal insufficiency at the time of their diagnosis, Biran explained, an agent that does not compromise renal function is key.

Chimeric antigen receptor (CAR) T-cell therapy is showing landmark success in many hematologic malignancies, and currently being examined in the relapse setting for patients with myeloma.

“When there is further long-term follow up of CAR T-cells in the relapse setting, it will likely be brought into the upfront setting,” Biran noted.

In the meantime, additional research efforts could be focused toward treatment options for high-risk patients, Biran said. “The standard-risk patients are living for decades. However, our high-risk patients, despite all these improvements, are still living a median survival of two years. We need to focus on how we're going to help these patients.”