DR LOVE: I want to just quickly query you about a few papers that relate to the issue of induction and maintenance therapy. And we don’t have to talk about them in depth, but kind of just bottom line. When you really look back on the last year, we’ve seen a huge switch in up-front 3-drug therapy.

And a lot of that came out of the SWOG study, which was presented at ASH. Rafael, briefly, what did they look at, what did they find and how did that affect the way you take care of patients?

DR FONSECA: This was a very important study. It was a Phase III study that compared a doublet versus a triplet, so bortezomib/lenalidomide/dexamethasone versus lenalidomide and dexamethasone. By all parameters, the study was won by the triplet combination when it comes down to response rate as well as survival statistics, so everything that was time dependent. I think this study is interesting because it, more than anything, validated a practice that was already ubiquitous in the United States, which was really using the triplet.

For anyone who was perhaps still holding out there, saying, “Well, there might be patients that I may want to do the doublet,” I think it’s possible, but that should be more the exception.

I think this is probably the final study that tells us that combinatorial approaches for newly diagnosed myeloma, particularly — and we’ll talk more about this — particularly, we’re thinking that we can provide very durable complete responses, probably curing a subset of patients. You have to start with a triplet.

DR LOVE: I think it’s pretty straightforward in terms of Rd, but what about CyBorD? And I know that’s a regimen you’ve been interested in.

DR FONSECA: Sure.

DR LOVE: Any thoughts about CyBorD versus, say, a triplet like RVd?

DR FONSECA: It’s a group who’ve moved on to a lenalidomide-based combination; however, it’s real important — and this is important not only in the States but throughout the rest of the world — that I think the combination of cyclophosphamide and bortezomib is highly active.

There was a much-cited French study, the IFM study, that was presented at ASH and subsequently published, that suggested that VTd was better than CyBorD, with the problem that there was more peripheral neuropathy, as we would expect with thalidomide.

The problem with that study is that it used the old schedule for the bortezomib, where there was only 2 days of overlap of cyclophosphamide and bortezomib. Now the EVOLUTION study that was led by Shaji Kumar really shows that the regimens are quite similar. And as people start asking questions about pharmacoeconomics, et cetera, I could see where, both within the United States and abroad, you could think, for instance, of a near future where you would have a CyBorD plus dara up front. And I think a few people would argue about that being possibly a very, very active regimen. But I think, again for our audience, we would consider, for the majority of patients, VRd the standard.

Diagnosis and management of smoldering myeloma

Induction, consolidation and maintenance therapy for MM

Treatment of relapsed/refractory MM

Novel approaches under investigation for MM