CHC-WEST 2016: News in Hematology - Multiple Myeloma
Dr. Nizar Bahlis - University of Calgary
The survival of myeloma patients has dramatically improved over the past decade due to the introduction of novel classes of drugs and a better understanding of the disease biology. Our ability to predict the prognosis of myeloma patients has also improved with the introduction of the cytogenetics and FISH based classifications and the revised international staging system (R-ISS). However, these prognostic tools remain suboptimal and need to include the new prognostic information accounted for by the sequencing of the myeloma genome. The improvement in the disease outcome and the depth of response also lead to a revised definition of multiple myeloma to account for patients previously classified as high risk smoldering myeloma, in order to prevent the organ damage in these patients. Similarly, the improvement in the depth of response that can be achieved today with the available therapies also resulted in new IMWG response criteria to include the assessment of MRD by next generation sequencing, flow cytometry and PET-based imaging.
The treatment of newly diagnosed myeloma is also now proved to require 3 phases including induction, consolidation and maintenance which also often referred to as “continuous” therapy. This concept is applicable for transplant eligible as well ineligible myeloma patients. Key therapeutic concepts were also validated in recent trials and include:
- Triplet combination regimen with IMiD and PI are superior to doublets as well as triplets with the third drug being cyclophosphamide (VTD or VRD are superior to VD, RD or VCD);
- Autologous stem cell transplant still relevant in the era of novel therapeutic and improves the response and PFS of patients treated with RVd based induction (IFM/DCI 2009 trial);
- Importance of achieving the deepest response possible, in particular, MRD negativity.
- In the relapse setting several combinations therapies are resulting in unprecedented outcomes in particular, the addition of monoclonal antibodies (Daratumumab, Elotuzumab) or novel proteasome inhibitors (Carfilzomib and Ixazomib) to lenalidomide-based back bone regimen.