Closing the Amgen One Myeloma stream, Professor Keith Stewart from the Mayo Clinic in Phoenix, Arizona weighed in on what he thinks will be the future of multiple myeloma (MM) treatment. He kicked off the discussion by focussing on the newly-diagnosed patient.
- Staging disease with genomics and advanced imaging
“I think this is a question we’re already asking – can imaging improve diagnosis? Already studies are suggesting methionine-based positron emission tomography (PET) is more accurate in identifying focal lesions than glucose-based PET,”1 noted Prof. Stewart.
- 4-drug combinations + consolidation until MRD
Prof. Stewart explained, “Probably more likely first in the States than here, I think 4-drug combinations will become the norm for the newly-diagnosed patient. I expect this will have implications on whether transplant is still required. If we don’t transplant, we might need to keep people on treatment for longer.2 There will be implications for toxicity, cost and method of delivery that will all need to be worked out first.3 What I am surer about is minimal residual disease (MRD) negativity as a destination rather than a journey. It will become our new standard of care benchmark.”
- Targeted therapies in subsets
“Another thing I think we are heading towards is personalised therapy,” he explained. “Biological subsets such as t(11:14) will receive different treatments than they do today.”4
- Clonal mutations tracked for evolving drug resistance
“With the improvements in single-cell sequencing we’ve heard about here at this conference, emerging drug resistance will also likely be more easily tracked in real time, enabling prompt revision of treatment strategy,”5 noted Prof. Stewart.
- MRD stability as an endpoint for therapy escalation/de-escalation
“As we’ve heard today, we expect to understand more about MRD negativity – what time to assess, where to sample, how to assess it, how frequently and when it might be reasonable to escalate or de-escalate therapy accordingly as these are all questions that at the moment remain unanswered. But I am hopeful we have answers before I retire,” he added.
- New targets exploited at relapse
Thinking about the first relapse, Prof. Stewart thought several molecules in development will play a role in this space. “With the pipeline of new agents entering trials, I think we’ll have more choice of new targets when it comes to that first or early relapse. In my practice, we look at relapse as an opportunity for a fresh start and as new, potent agents become available I think we should be trying to use them as early as we can.”
Then, beyond that, Prof. Stewart pondered on even more advancements coming into play.
- 4-drug induction to maximal response
- CAR T-cell consolidation
- MRD negative BiTE maintenance
- MRD positive consolidation with antibody and oral therapy followed by BiTE maintenance
“As we move beyond the next five years, these optimistic predictions are what I hope to see available to us and our patients. While there’s still work to be done, we don’t want to waste time saving them for last resort. I hope to see the likes of 4-drug combinations, CAR T-cell consolidation, BiTE maintenance and combination therapy options available to help us break the cycle of relapse. Here’s hoping,” he said with optimism.
This article was sponsored by Amgen, which has no control over editorial content. The content is entirely independent and based on published studies and experts’ opinions, the views expressed are not necessarily those of Amgen.
- Lapa C, et al. Theranostics 2017;7(11):2956-2964.
- Jakubowiak AJ, et al. Blood 2012;120:1801-1809.
- Kumar SK, et al. Lancet Oncol 2014;15:1503-1512.
- Garand R, et al. Leukemia 2003;17:2032.
- Kortüm KM, et al. Blood 2016;128:1226.