Vincent Rajkumar: Updated treatment approach to newly diagnosed myeloma based on new ASH 23 data

Vincent Rajkumar, Editor-in-Chief at Blood Cancer Journal, recently posted on X/Twitter:

“Updated treatment approach to newly diagnosed myeloma based on new ASH 23 data. Explanation for changes in thread.

What’s changed? I’m ok with quadruplet induction for standard risk based on the 2 phase IIIs at ASH23 Better PFS and MRD- Limited duration induction. OS will take a long time to emerge and risk/benefit is reasonable to incorporate Quads.

Which Anti CD38? Either Daratumumab or Isatuximab are ok as the AntiCD38 antibody to add to VRd for the Quad Decide based on cost and access. We had data on both at ASH23.

Why not KRd? No data that KRd is better than VRd in randomized trials. No data that Anti-CD38 KRd is better than Anti CD38 VRd in randomized trials Bortezomib is generic. KRd will add substantial cost and there is concern of cardiac toxicities in a small % of patients.

Why is VRd also a reasonable alternative for standard risk induction? Despite the PFS/MRD- benefits with Quads, real world VRd, transplant, risk adapted maintenance has excellent outcomes. In many countries Anti CD38 Moab’s are not available or are prohibitively expensive.

Why not Dara maintenance? No data that Dara maintenance adds significant benefit if Dara was given at induction. See Cassiopeia below. Given cost and long term risks, we need clear data that patients who received quad induction get benefit from Dara maintenance.

What is risk-adapted maintenance? Len alone for standard risk and Len plus bortezomib for high risk. As advocated for a long time in msmart and by Emory.
Note: No steroids in maintenance.

Is frontline transplant needed for everyone? No. I let standard risk patients make an informed decision. Early transplant is preferred— but late is ok if feasible and is strongly preferred by patients. No data that OS is better with early versus late in multiple RCTs.

What about patients not eligible for transplant? No changes in approach.

Risk stratification that I use is from here.

Important to note that many countries do not have access to major drugs. While we strive to get access, it’s good to remember that simple triplet induction (even VCd), transplant and maintenance provides outstanding benefit. Real world Canadian data.”

Source: Vincent Rajkumar/X