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Unqualified for Transplant: What Are My Choices?

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Published on December 3, 2019

During this Ask the Expert segment, leading expert Dr. Noopur Raje from Massachusetts General Hospital joined Patient Power to share some decision-making guidelines for multiple myeloma patients who haven’t had a transplant or are transplant ineligible. Watch as Dr. Raje discusses treatment goals, options and response rates.

This program is sponsored by Janssen Biotech, Inc. This organization has not editorial control and Patient Power is solely responsible for the content. It is produced by Patient Power.

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Transcript |

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That's how you’ll get care that's most appropriate for you.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Dr. Raje:                    

People who haven’t undergone a stem cell transplant—I think we need to use the same kind of principles you use for the transplant eligible patients. I think the goal for all patients whether you get a transplant or you don’t—the goal should be to try and get to the best possible response that you can get with whatever treatment is being used, and you have to try and also address the depth of the response. So, deepening that response as much as possible is critically important, and because we have more and more data to support that the deeper the responses in these patients the better the outcomes.

The good news is we have drugs even in the non-transplant setting, which can get to MRD-negative disease even in this patient population. So, I think the goal should not change whether you are transplant eligible or not eligible. And we tend to use combinations of drugs to get patients there. And really, I don’t think myeloma is one size fits all. It’s really important to see what the other sort of medical problems are in a particular patient before choosing what the treatment should be. But in general, we will still use an IMiD. We’ll still use a proteasome inhibitor whether we add on a monoclonal antibody or now right now is something up for discussion, but there’s good data with an IMiD with a monoclonal antibody like daratumumab. And with these combinations, we are seeing very high response rates.

I think the big thing to remember if you haven’t had a transplant, even in transplant ineligible patients, most times we will continue therapy up until progression. And the reason to do that is the depth of response increases over time. So, for that reason, it’s important not to just give initial treatment and stop it early. Because if you stop it early, you are going to see disease become active again. So, you want to continue treatment, and you want to continue treatment for protracted periods of time so that you continue to increase that depth of response, which we’ve seen happen over time. And it can take a year or year and a half for the depth of response to keep increasing. And the outcome really depends on that.

So, along the way, obviously, like the transplant eligible patients, you have to make sure that you do other supportive care strategies as well. So, bone health is important. Taking calcium/vitamin D is important. Doing some of the prophylactic things that we’ve talked about in the transplant eligible patients also applies to this population as well and making sure you’re getting your flu vaccine, your shingles vaccine, etcetera, is really critically important in this patient population.

Again, when the disease comes back, the same approaches that we have for the transplant eligible patients we will use. The question is the dosing and the intensity. And a lot of it depends on what the performance status of that patient is, and I think it’s critically important to adjust the doses of treatments in these patients so that they’re able to tolerate treatment and they’re able to stay on treatment because that ultimately defines the outcome of these patients.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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