Considering the Uses of Myeloma Treatments After Relapse

Binod Dhakal, MD, associate professor of medicine in the Division of Hematology at the Medical College of Wisconsin, discusses using a variety of combination therapies as bridging or later-line options for patients with relapsed multiple myeloma.

When talking about treatment options for patients with multiple myeloma, Dhakal emphasizes the importance of shared decision-making with patients due to the variety of available therapies and the patient's individual circumstances. Not all patients are eligible for CAR (chimeric antigen receptor) T-cell therapy, and travel and comorbidities are factors to consider.

In some patients, the use of selinexor (Xpovio) with bortezomib (Velcade) and dexamethasone for early and late relapses may be an appropriate choice, according to Dhakal. Selinexor can also be used with pomalidomide (Pomalyst) or with carfilzomib (Kyprolis) as a bridging therapy or between immunotherapies. Dhakal shares success with younger patients who have exhausted other treatments, benefiting from selinexor therapy as a last line as new therapies are being developed.

TRANSCRIPTION

0:10 | I think when you choose a regimen in [patients with] multiple myeloma, you always have to have a discussion with the patient regarding the shared decision making in terms of how or what kind of treatment is going to be the best option for them. Not all patients can be CAR T eligible, not all patients will have resources to travel and still, after CAR T, the patients do relapse. So, I think depending on what the stage the patient is, I think each of these treatments would have their value. There are multiple treatments, as the patient goes through the journey of multiple myeloma, I think all these treatments will have their value. Similarly, to a particular patient we first look if they're CAR T eligible. If they're not CAR T eligible, then we discuss these options. For example, looking at something which the patient can get locally, doesn't have to travel, and also look at the other comorbidities, that the patients should be able to handle it or not. I think in that the selinexor with the [bortezomib] combination could be an important addition for early relapse.

1:18 | In the late relapses, I think...selinexor is already approved in combination with dexamethasone [in] late relapses. I have used that in between the immunotherapies. For example, of course, the patients who cannot get to immunotherapies, that is an option, but the patients who are in between the immunotherapies, I have used that as multiple strategies. For example, in between 2 bispecific antibodies when you want to just keep a break for the T cells. Sometimes I have used it in combination with other agents as a bridging therapy, because these patients have seen all the treatments, and the one thing they might not have seen is selinexor. So I have combined selinexor with pomalidomide, sometimes with carfilzomib, and I have given as a bridging [therapy]. Similarly, those combinations I also have used in between immunotherapies. So those are the multiple ways that I have been at least using it in my practice.

2:10 | Sometimes, even younger patients, I have now 3 patients who were very young, but they have bad myeloma. They have been exposed to everything. They have exhausted both CAR T and bispecific antibodies. The last line, I have used that selinexor in combination and I have been able to provide some benefit to those patients, while we're waiting for another agent with the different mechanism. So this can be an important addition in that setting as well.