DR LOVE: So let’s move on to the next topic, which is induction and maintenance treatment of myeloma. And I thought to get into that, Noopur, we could start out with your 87-year-old patient.

DR RAJE: Yes. The reason I brought up one of my older patients is we always talk about the young ones, Neil. And they’re the ones who fit into all of the clinical trials. In reality, if you think about myeloma, the majority of myeloma you’re going to see out in the community, it’s certainly older than 70. This is a patient population which is not necessarily a transplant-eligible patient population. Which is part of the reason why I brought up my 87-year-old.

So he had smoldering myeloma to begin with. He was diagnosed with smoldering myeloma, I believe it was, around 84 or so. And he had this IgG protein, which was close to 3 grams. It really didn’t change a whole lot. We had PET scanned him at the outset, and he was completely negative. And then, over time, we were following his IgG, which did not change. He became a little more anemic, which is where I repeated scans on him. And it was only on CAT scans that we found lytic bone disease at age 87, where then we defined him as symptomatic multiple myeloma.

Clinically he felt totally well, though.

DR LOVE: Before we get into what you did, I’m just curious, Rafael, in general, he’s otherwise healthy, in good condition?

DR RAJE: Yeah, absolutely. Has some cardiac issues. He has a pacemaker in place, but that’s not unusual for somebody his age.

DR LOVE: So how would you be thinking about a case like this, Rafael?

DR FONSECA: I’m interested to see, of course, what Noopur did. But I think, number 1 is you have to look at the age, the fitness of the person and the comorbid conditions. That’s probably number 1. And for anyone who’s watching this video, you have to pay a lot of attention to if they have diabetes. What doses of steroids can we use, if they have diabetes?

Do they have any history of depression or any psychiatric disorder, where dexamethasone, again, could be playing a role. We look at the issues of peripheral neuropathy with diabetes, renal function, hypertension, if one thinks about things like carfilzomib. In that patient population, paying attention to the nonmyeloma part of the patient is so critically important.

DR LOVE: Before you go on, what about comorbidities? Any diabetes, peripheral neuropathy, anything?

DR RAJE: No diabetes, no neuropathy. I mentioned the cardiac disease, coronary artery disease. He had a pause a few years back, which is why he had a pacemaker in place, but otherwise, in general, doing fine.

DR LOVE: Renal function okay?

DR RAJE: Renal function, fine for his age. Not perfect. He had a creatinine clearance of about 40.

DR LOVE: So what do you think?

DR FONSECA: I think based on that, I think it’s quite likely we’re going to find some comorbidities. Now let’s assign a plan that would allow us to go gentle and to go for long. That’s usually what I think of when we think about the patients that are more elderly. We’re going to go in a way that I’m not going to be looking for speed for response. I want to make sure we have a good response. I sure don’t want to give suboptimal therapy to the person, but can we do that with either dose-adjusted or more patient-friendly regimens?

DR LOVE: Specifically, what do you think you might think about?

DR FONSECA: Well, standard right now is a backbone of lenalidomide/dexamethasone. And in most patients — and we’ve put this, for instance, in our mSMART criteria — we think early introduction of a proteasome inhibitor. I’m very, very eager to see the upcoming trial results for the ELOQUENT-1, which is elotuzumab for the elderly.

DR LOVE: Up front?

DR FONSECA: Up front. I like that idea. And the reason is that the elderly tend to have more benign genetics. They’re highly enriched for hyperdiploid. Hyperdiploid patients do particularly well with IMiDs. And of all the drugs we have, elotuzumab is one of the best-tolerated ones. So I think that may be an interesting combination. And it has shown, based on the data that we have seen and has been presented and published, that for the high-risk patients, it does work as well, which overcomes some of the limitations for IMiDs. So I’m putting a little bit of my future hope that elotuzumab/lenalidomide and dexamethasone may be particularly active in this population.

Diagnosis and management of smoldering myeloma

Induction, consolidation and maintenance therapy for MM

Treatment of relapsed/refractory MM

Novel approaches under investigation for MM