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How Would You Treat a 60-Year-Old Woman with Relapsed Refractory Myeloma?

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September 28, 2020

Triplet therapy is central, but other approaches may work, too

  • SurvivorNet‘s experts say triplet therapy is best for relapsed refractory myeloma following lenalidomide treatment
  • Daratumumab, pomalidomide, dexamethasone or carfilizumab, pomalidomide, dexamethasone are two options
  • High-risk factors such as 414 translocation could change the approach
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A 60-year-old woman was previously treated with a standard VRD combination followed by a stem cell transplant on lenalidomide maintenance therapy, which was stopped due to diarrhea. Three years later she had an increase in her “M protein” and her myeloma has returned. How would you approach her treatment?

Colleagues can have different¬†approaches. SurvivorNet‘s experts agreed that triplet therapy is the best response for relapsed refractory myeloma following lenalidomide treatment, although they differed on the specific approach. “I would probably go with¬†daratumumab, pomalidomide, dexamethasone,” says Dr. Nina Shah, hematologist-oncologist at UCSF Medicine. “This person is 60, so you want to keep them going as long as possible.”

Dr. Natalie Callander, hematologist-oncologist at UW Health, says she would do a deep dive into the patient’s baseline characteristics, looking for high-risk factors like a 414 translocation. “In that case, we would potentially go all out and change up completely; in other words, take out the IMiD and then use a CD38 antibody, say carfilzomib.”

“Carfilizumab with pomalidomide and dexamethasone is something that we have very good experience with here and could be considered,” adds Dr. Robert Orlowski, chairman, ad interim, and director of myeloma at MD Anderson Cancer Center. But, he says it would be “reasonable” to consider VRD induction and a stem cell transplant, and then use a different maintenance combination.

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