Dr. Durie discusses the use of a four-drug combination as front-line therapy, such as Darzalex® (daratumumab) Velcade® (bortezomib), Revlimid® (lenalidomide), and dex, compared to a three-drug combination.
The BOTTOM LINE: Opting for a four-drug combination as the first therapy has produced enhanced outcomes. The broad range of active backup therapies mitigates concerns about depleting treatment options, making it a potentially advantageous approach for myeloma patients.
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This week's "Ask Dr. Durie" comes from a patient who was tracking information coming out of the ASH meeting held in San Diego this past December. The patient was very excited about the results received with using a four-drug combination as first therapy—as front-line therapy, and two papers were presented on this, one with Daratumumab, Velcade, Revlimid, and dex, the PERSEUS trial, and another one with isatuximab, Kyprolis, Revlimid, and dex, the ICARIA trial.
Both of those studies showed that the outcomes, the length of the remission, in particular, the length of the first remission, was improved using the four-drug combination versus the three-drug combination and this was in the setting of patients who were also eligible to receive an autologous stem cell transplant (ASCT). But this patient is concerned that, okay, this is great, but we're using up all of our drugs upfront?
Are we concerned about what will be feasible later if we're still not fully curing myeloma? Will there be enough options available later so that we can recoup, if there is any new myeloma, a relapse happening later even although the first remission may be quite long, but four or five or six years or even longer?
And fortunately, the answer to this question is a decisive yes because we are so fortunate right now that so many new immune therapies are available, several already approved by the FDA, and many more in clinical trials. And so, we do have a lot of very active options that can be used as backup therapy for the future. And so although we could have concerns about potentially the costs of using four drugs and the added side effects, there's really not a concern that we can recoup later because of all of the options that we have; this is undoubtedly going to be feasible. So, BOTTOM LINE, if it's attractive and feasible, using a four-drug combination is probably going to be the way to go, with the understanding that fully active backup therapy will be available most likely in the future.
Professor of Medicine, Hematologist/Oncologist, and Honoree MD at the University of Brussels, Dr. Brian G.M. Durie is a co-founder of the IMF.
