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March 15, 2021

63-Year-Old Female Experiences Slow Relapse

Evelyn, now 63, was diagnosed with multiple myeloma when she was 58. She is a district manager for her company and has an erratic travel schedule. She is a current smoker.

She was considered standard risk. She had Vd induction followed by an autologous stem cell transplantation.

About three years ago, her M-protein level began to rise. She has been on Lenalidomide as maintenance for the past two years. However, her M-protein level is still rising. She is now considered to be in biochemical relapse, confirmed by recent positron emission tomography and bone marrow biopsy. However, she has not experienced any new genetic abnormalities.

Evelyn explains to her medical team that she is divorced and has two college-age children. She needs to continue working because of her health insurance and children’s educations.

What are the options for treatment?
What are the pros and cons of each treatment option?

  • March 15, 2021
    Elo or dara or kyprolis + rev or Pom + dex
    This is a situation I like elo to save bigger guns for a symptomatic relapse Could be reasonable also just to escalate rev dosing to save Pom for later line.
  • March 15, 2021
    Given what we know about safety and efficacy data as well as potential benefits for quality of life outcomes, adding Daratumumab and Dex would have potential clinical benefits as best next step for this patient.
  • March 14, 2021
    Fortunately, there are several options available for Evelyn. She is relatively young and possibly will need all the available agents or a combination of the agents during her lifetime. At this time when she has just a biochemical progression without any BM or PET progression one could utilize elotuzumab in addition to lenalinomide and Dex. If she does not tolerate or progress on it then a combination of Daratumumab with a proteasome inhibitor and Dexamethasone is my choice.
  • March 14, 2021
    There are several options one can consider:
    Kyprolis/Pom/Dex, Daratumumab/Pom/Dex, Daratumumab/Kyprolis/Dex, Isatuximab/Pom/Dex. As far as proteosome inhibitor is concerned, Kyprolis would be a better choice. KPd would offer a mPFS north of 26 months which is excellent. One thing I would not do is, add something to Len and carry on. This women is Len refractory. Our best bet would be either Pom or Kyprolis or CD 38 based regimen or a combination of these.

    With Kyprolis, she would be tied to 3 weeks on and one week off schedule and may not be suitable with a travel work schedule.

    Based on her work, DPd would be a reasonable option with non-cross reacting agents and Pom instead of Rev. After 12 weeks Dara would go down to once every 4 weeks and a s.c option would make her visit to the infusion center short.
  • March 14, 2021
    Would certainly consider to add Daratumumab to her current Lenalidomide, given data of response and good tolerability to the regimen, particularly based on the patient request to continue her quality of life and less disruption to her social needs. More aggressive options also available.