Day 2 of ASH represented the calm before the storm, as only a couple of abstracts on myeloma were featured on Sunday compared to the more than a dozen presentations that will be highlighted on Day 3. Updates from Day 2 included a real-world comparison of quadruplet versus triplet regimens in standard- and high-risk newly diagnosed multiple myeloma and an assessment of the real-world utilization of autologous stem cell transplantation (ASCT) in newly diagnosed patients.
Preferred treatments for induction therapy (the first in a series of treatments used to treat multiple myeloma) typically consist of three-drug (triplets) or four-drug (quadruplets) regimens given over three to six cycles, each of which typically lasts 3 or 4 weeks. The combination of Revlimid (lenalidomide)-Velcade (bortezomib)-dexamethasone (RVd) is highly effective for patients with NDMM. However, the addition of Darzalex (daratumumab) to RVD (D-RVD) has shown improved depth of response and trend towards a benefit of progression free survival (PFS)—that is, the length of time during and after treatment in which a patient is living with a disease that does not get worse.
In this presentation, Dr. Nisha Joseph and colleagues from Emory University (Abstract 647) analyzed the real-world response rates and long-term outcomes for both standard- and high-risk patients. High-risk disease was defined as having chromosomal alterations including del(17p), t(4;14), and t(4;16). The real-world analysis included 1000 NDMM patients treated with RVD and 326 NDMM patients treated with D-RVD induction therapy. The results showed:
Dr Joseph and colleagues concluded that D-RVD is a highly effective induction regimen that can improve upon outcomes in a historical NDMM population treated with RVD in terms of depth of response and PFS benefit. This analysis provides evidence of benefit with the addition of daratumumab to RVD in increasing depth of response and provides an early glimpse of the promising PFS and OS benefit not only in standard risk patients, but also in patients with high-risk cytogenetic and disease features.
High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) remains standard of care in multiple myeloma (MM) in eligible patients and is proven to improve progression free survival. However, some patients do not receive ASCT as part of their treatment. It is well documented that racial and socioeconomic disparities in the use of ASCT exist in myeloma treatment. Barriers to patients receiving ASCT as part of their treatment may include low income, insurance status, and poor access to care at an academic health center. In this presentation (Abstract 532), Dr. Chakra Chaulagain and colleagues at the Cleveland Clinic Florida evaluated data from the National Cancer Database and found that the ASCT opt out rate in real-world is low (approximately 2%) but still represents a missed opportunity to provide standard of care for myeloma patients. Older patients (aged over 60 years), females, African American patients with non-private health insurance (that is, those covered by Medicaid, Medicare, or another government insurance), higher comorbidities, and those with an income of less than $63,000 per year were found to be less likely to receive an ASCT.
Among 43,653 patients evaluated in the study, those treated at non-academic medical centers were less likely to receive ASCT than patients treated at academic facilities. Patients living in the South Atlantic region of the United States were less likely to receive an ASCT compared to other regions of the country. The researchers conclude that their findings reveal significant racial, economic, and geographic variation regarding the use of ASCT across the US which should be further studied. Understanding the barriers to the use of ASCT is crucial for optimizing patient care and tailoring effective interventions.
Be sure to hear what myeloma experts Dr. Nisha Joseph and Dr. Alexander Lesokhin, had to say about the day’s presentations here.
Stay tuned for more updates from day 3 at ASH 2023!