DR LOVE: For practical purposes, what do you think? What kind of prescription do you think that patient would walk out of your office with?

DR FONSECA: Probably we’d start the paperwork for the lenalidomide. The patient would walk out with a prescription for dexamethasone. We would make a strong emphasis on DVT prevention. And we probably will start with at least that, perhaps adding the subQ bortezomib in lower doses.

DR LOVE: So do you think you would wait and see how the patient did with the len/dex or would you bring in the bortezomib?

DR FONSECA: I have done that. And I have done that particularly with the more advanced-stage patients — just start with the len/dex — particularly if I know the genetics. In someone who would have high-risk factors, who were particularly hyperdiploidy, I would be willing to try that.

DR LOVE: What actually did you do?

DR RAJE: I actually treated him with the triplet, but we dose adjusted everything. And we needed to, so —

DR LOVE: RVd.

DR RAJE: We did do RVd. We did lenalidomide at a much lower dose because of his creatinine clearance.

DR LOVE: What dose?

DR RAJE: Fifteen, 1-5. The bortezomib we used once a week as a subcutaneous dose. And what we do here is really give them 2 weeks off from the lenalidomide. It’s a 6-week cycle. So they get the bortezomib days 1, 8, 15 and 22. They get the lenalidomide for 21 days. And it’s a 35-day cycle, so it allows these folks to really recover quite nicely.

The dexamethasone in these older patients, you really have to cut back on. We don’t do any more than 20 mg of dexamethasone in these patients because it’s a really hard drug to tolerate. And that’s kind of the first drug that I will try and dose reduce with them if they have trouble with it. So that was what he was started on.

DR LOVE: Basically RVd lite, so to speak?

DR RAJE: Correct.

DR LOVE: And what happened?

DR RAJE: He completed his RVd. What we usually do is between 9 and 10 cycles, initially, of the RVd lite. Over time, we had to dose reduce a little bit more. Lenalidomide went, I think, around 5 or 6 cycles — I don’t remember — we dropped it to 10 but continued the bortezomib at the doses. He didn’t end up with any kind of neuropathy. And after about 10 cycles, he’s now on maintenance lenalidomide alone. He has dropped from 10 to 5 of maintenance lenalidomide. And that was mainly for diarrhea. But otherwise is in a complete response right now, doing extremely well.

DR FONSECA: I’m curious, and I was going to ask a little bit about the duration of that induction, if I may. A lot of what we do in the elderly patients is empirical, so we try to tailor it for the patient. But what makes one go to 10 cycles of injections versus 4 versus 6? What are your thoughts behind that approach?

DR RAJE: This was done, Rafael, as part of a clinical trial. And I do think keeping that dose intensity for as long as possible, elder or not, is what really deepens responses in patients. So the way we had designed the trial was 10 cycles of the triplet and then continuing treatment for even beyond, for as long as they can tolerate, and after about 14 or 15 cycles, dropping it to just the pill form. Having said that, it’s really hard for patients, specifically at that age, to continue all 3 drugs. Dexamethasone is the first drug we tend to drop, specifically when we are going more towards the maintenance phase.

But at least continuing the dose intensity for as long as you can is something I strongly believe in. I don’t think we have great data in the older patient population. We have some data with the FIRST trial now. We have some data with the SWOG trial with the triplet combination in the transplant-deferred patient population, where continuing treatment for up to 8 cycles and then putting on maintenance should be the way to do it. I don’t think we have any more than that.

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