I attended a symposium chaired by Dr. Brian Durie which centered on providing information on the best options for therapy in 2015. However, it was focused on debates around several questions. The panel was superior, with members being some of the very best myeloma specialists in the world. There was Dr. Jesus San-Miguel from Spain, Phillppe Moreau from France, Shaji Kumar from the United States, Antonio Palumbo from Italy, and Bruno Paiva from Spain. Dr. Durie started the forum by remarking what a wonderful preamble we had going into ASH with the approval of three new myeloma drugs in the last month. Two immunotherapy drugs of Daratumumab, Elotuzumab, and Ixazomid an oral protesone inhibitor.
The questions were as follow:
Will New Diagnostic Criteria and Early Treatment of MM Improve Survival or Result in a More Aggressive Disease at Relapse?
Dr. San-Miguel made the case for early treatment referencing a recently published high risk smoldering clinical trial which companied Rd vs watchful waiting which showed better PFS (progression free survival), and OS (overall survival). Dr. San-Miguel was also excited about a new clinical trial, KRd, transplant, and maintenance for high risk smoldering disease. Dr. Phillip Moreau was more cautious and believed we can not have a treatment based on one trial. Because 30% of high risk patients will not progress to active myeloma in two years so we might be over-treated these patients. To this layman, I think Dr. San-Miguel has got it pegged.
Should Risk-Adapted Therapy Be Used for Patients with Newly Diagnosed MM?
On this question Dr. Shaji Kumar took the pro side of the debate and mentioned the mSmart program. I noticed the mSmart program was recently updated and now recommends VRd for standard risk patients from the previous Rd regimen. Dr. Palumbo took the more aggressive approach and thought the best treatment should be used with all patients. Me being a Total Therapy patient which is a very aggressive approach and younger at diagnosis has a tendency to want to swing for the fences, but I do understand infirm and frail patients may go for less intense therapy.
Should Minimal Residual Disease Be Used to Guide Treatment?
Dr. Bruno Paiva believes MRD or Minimum Residual Disease is not ready for prime time. He believes NGS or Next Generation Sequencing will be a better more accurate testing method.. Dr. Antonio Palumbo believes even with NGS there will still be some myeloma left so continued maintenance is required. He noted 45% of patients who are MRD negative are not PET/CT negative or they have active lesions in their bone marrow. I remember once Dr. Barlogie had mentioned he noted this as well and believed a better measure of disease control would be the combination of MRD negative and PET/CT negative. On this one it looks like the jury is still out.
Emerging Systemic Therapies: Best in Patients With Newly Diagnosed MM or Those With Relapsed Disease?
This debate was not that clear to me. Dr. Shaji Kumar made the point that it depended on the circumstances, and Dr. Moreau believed they should never be used until they have been proven effective in a phase 3 trial.
I was wondering if some of the views were taken just for the argument sake, however I was still surprised at how well prepared and convincing each debater was. Also surprising was how much progress we have make in the last few years in the consolidations of the treatment continuum, yet there is still such diverse views.
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