There are five important points to consider when treating early relapse in patients with multiple myeloma, a conference has heard.

Speaking to the H3 conference hosted by Janssen Oncology in Sydney, Professor Andrew Spencer, Head of Malignant Haematology & Stem Cell Transplantation and the Haematology Clinical Research Unit (CRU) at The Alfred Hospital in Melbourne, said data from the AIHW on blood cancer deaths¹ in Australia showed that people with acute myeloid leukaemia (AML) and multiple myeloma (MM) continued to have sub-optimal outcomes, particularly when compared to other blood cancers.

“There is no data to show that there’s been any improvement in outcome on a population basis despite some experts describing ‘stunning progress’…  there’s still a lot of unmet needs and challenges in the disease,” said Professor Spencer in his talk called ‘navigating the upfront treatment and early (1st) relapses in MM in Australia: current status and future directions’.

According to Professor Spencer one of the major issues driving poor outcomes in patients was the tendency to adopt a ‘one size fits all’ approach to myeloma despite it being ‘blatantly obvious’ that it was a heterogeneous disease.

“The approach really neglects the biology of the disease and I think that’s why some patients do poorly,” he told delegates.

Managing the first relapse is important

Multiple myeloma has a remitting/relapsing course and managing the first relapse for the myeloma patient is incredibly important, he said.

“It’s exactly at this time point that they may have restoration of their well-being, a good quality of life, be off therapy for a considerable period of time, or may have returned to work,” he noted.

Once a patient relapses the biology of the disease starts to become more difficult to treat and it’s generally a downwards slide, particularly in elderly patients, he said.

There is a paucity of data around the sequencing of treatments that could be used to inform clinical practice. Another challenge in treating patients with multiple myeloma is that the availability of treatments often depended on geographical jurisdictions.

For example, thalidomide, bortezomib and lenalidomide are all accessible ‘fairly readily’ in Australia as frontline therapy. Whereas bortezomib, thalidomide, lenalidomide and carfilzomib are used at first relapse.

Wait and see approach should be challenged

Data from the Myeloma and Related Diseases Registry showed that the median progression free survival (PFS) in patients in Australia is 30 months² but there were subsets of patients who did not do as well.

Professor Spencer said that a lot of confusion existed around what to do when a patient shows signs of relapse, particularly for clinicians who don’t work in myeloma all the time.

Historically, clinicians had been used to adopting a wait-and-see approach and not re-treating patients until there was a need to do so.

“I would actually question that strategy because the more tumour you’ve got on board the more cellular divisions are going on… It’s not the approach we take in any other forms of malignancy,” he told delegates.

“I would put it to you that if a person is progressing and you’ve got access to an effective agent then you should get on and treat them rather than sitting on your hands waiting for them to get sicker and sicker”.

Five points to consider when treating relapse in MM

Treating patients who have relapsed is a complex situation but there are five points that should be considered, Professor Spencer advised delegates.

There was a need to look at prior therapies to determine if there was a rationale for switching therapies, or indeed staying on the same therapy. Looking at the duration of response to therapy was also important.

“Generally if a patient has had a long response [to treatment] then they’re likely to do well no matter what… the biggest challenge is those patients with no or short responses to therapy.”

The nature of relapse was also relevant, for example patients that had extramedullary manifestations tended to do poorly.

The treatment strategy at first relapse was also entirely context dependent, Professor Spencer said.

“In Australia because of the reimbursement environment the way we treat myeloma is fairly restrictive… we can only use certain drugs at certain times.

And it was also important that the wishes of patients were factored into treatment decisions, he said.

“Some people want every treatment available and some elderly patients will be happy to have a more palliative approach,” he added.

References

1. Australian Institute of Health and Welfare 2017. Cancer in Australia 2017. Cancer series no. 101. Cat. No. CAN 100. Canberra: AIHW.
2. A. Spencer et al., Understanding Real World Frontline Therapy for Multiple Myeloma in Australia, Real-World Evidence Meeting Series, Melbourne 2018.