As the dust settles from all the activity surrounding new drug approvals and the potential for further approvals, it is time to reflect on what the future holds for myeloma patients.

The good news is that the future looks bright. The vast majority of patients will achieve excellent, deep responses with initial therapy. This can be enhanced with ASCT (autologous stem cell transplant) and sustained with maintenance. Powerful new triplet combinations are available and have a substantial impact.

The particular benefits of using carfilzomib (Kyprolis®) and daratumumab (Darzalex®) combinations early in the disease open up many new choices for key recommendations and upfront decision-making.

In the frontline setting, the Velcade® + Revlimid® + dexamethasone (VRd) regimen has emerged as a standard approach. For older or non-transplant eligible patients, VRd “lite” can be used, and, for more frail patients, either Rd or CyBorD (cyclophosphamide, bortezomib, and dexamethasone) are rather well-tolerated options. ASCT is still recommended when feasible and desired by the patient.

For high-risk patients, KRd is an option across the board and, combined with ASCT, can achieve especially deep responses. With the new, very promising data from the CASTOR (daratumumab + Vd) and POLLUX (dara + Rd) trials, the much earlier use of daratumumab (Darzalex®) becomes a consideration. For example, daratumumab Rd is very active and well-tolerated, and we expect that this combination therapy will be approved in approximately a year’s time for patients who have had only one prior therapy.

The true need

What remains is the true need for a way to handle patients with persistent or recurrent minimal residual disease-(MRD)-positive myeloma. Looking ahead, the framework will be MRD-negative disease for what we hope will be a majority of patients, but for high-risk and resistant myeloma, minimal residual disease will remain a problem.  New drug development will target agents capable of eliminating MRD-positive disease, especially as new information is gathered about these clonal populations in terms of immune phenotype, mutational patterns, and drug sensitivity. I foresee two approaches going forward:

1.      Strategies to eradicate MRD-positive clones. The new immune-oncology (I-O) approaches are promising, including CAR T cells against different antigen targets, NK cells, and checkpoint inhibitor combinations. Immunoregulatory approaches are an active area of research.

2.      Strategies to achieve chronic disease control at much lower levels of disease than were ever achievable in the past may prove very effective and attractive, despite potential ongoing side effects and costs.

Both approaches, I believe, will demonstrate merits.  This big-picture approach envisions average survival typically exceeding 5-10 years, with a focus on achieving the best quality of life along the way. With the likely advent of decisively better and even curative therapies, the goal is to maintain the best health for patients such that no doors are closed to explore future options.

As patients with relapsing disease still struggle, it is important to emphasize that we anticipate great progress in avoiding these resistant states. It has been a long time coming, but the tipping point to longer survival is NOW, and we must grasp every opportunity to achieve the best results for all patients! 

Image of Dr. Brian G.M. DurieDr. Brian G.M. Durie serves as Chairman of the International Myeloma Foundation and serves on its Scientific Advisory Board. Additionally, he is Chairman of the IMF's International Myeloma Working Group, a consortium of nearly 200 myeloma experts from around the world. Dr. Durie also leads the IMF’s Black Swan Research Initiative®.

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