Treatment for relapsed and/or refractory myeloma Dr Oonagh Sheehy Consultant Haematologist This talk will cover…. Take home messages • What are relapsed and refractory myeloma • Myeloma is a very complex individual cancer • Treatment options at relapse • Many patients who relapse can be successfully treated and will have a second remission • Treatment options for refractory disease • Most patients who get remission will relapse Belfast City Hospital Belfast Health and Socal Care Trust Plasma Cell – The Enemy Within Myeloma Bone Marrow Remission 1 Natural course of myeloma Some definitions Natural course of myeloma Remission: Absence of paraprotein in blood and myeloma cells in bone marrow following treatment Plateau: Stable disease following good response to treatment, reduced but detectable paraprotein levels Relapse: Disease progression following a previously successful course of treatment Refractory: No response to treatment whether initial treatment or relapse 1st line treatment MGUS: Monoclonal gammopathy of undetermined significance 2nd line treatment 3rd line treatment 1st line treatment 2nd line treatment 3rd line treatment MGUS: Monoclonal gammopathy of undetermined significance Natural course of myeloma First Relapse Options • Treated with Thalidomide (CDT) – can have Velcade (VD) next • Treated with Velcade (VMP / VD / VTD)– can use thalidomide combination (CDT / MTD) • ? Retreat with Velcade – depends on funding • Individual circumstances may necessitate an alternative – but this would need approval by HSCT 1st line treatment 2nd line treatment 3rd line treatment MGUS: Monoclonal gammopathy of undetermined significance 2 First Relapse Options First relapse options Fancy another transplant?? • Same as first line treatment • Different treatment – may depend on NICE approval or Cancer Drug Fund • In N.I. tends to be whichever agent between thalidomide or Velcade patient hasn’t already had Second Transplant First relapse options Supportive Treatment Option if: • Individual is keen! • Age <70 • Heart, lungs and other major organs in good shape • Have stem cells stored or can mobilise enough at this stage • Have had a reasonable response to first transplant • Clinical study (trial) – May provide options not otherwise available – Not all patients will be eligible • Relevant at all stages – initial therapy, relapsed and refractory disease • Multi – faceted: physical, emotional and practical 3 Supportive Treatment Supportive Treatment Supportive Treatment Bone Disease Low blood count Anticoagulants – aspirin, clexane or warfarin Second relapse options • Same as previous treatments • Revlimid® (lenalidomide) –similar to thalidomide but less toxic –NICE approved with dexamethasone • Other drug combinations –DT-PACE –ESHAP • Clinical studies – if eligible • Second transplant if still an option Refractory options • Try different treatment • Sequence of treatments similar to relapse • Clinical trial – good option as newer drugs can still be effective 4 Future strategies This talk has covered covered in more detail this afternoon • Bendamustine • What are relapsed and refractory myeloma – Not licensed for relapse/refractory myeloma – Cancer Drugs Fund (England) • Clinical studies – novel drugs • Treatment options at relapse – Imnovid® (pomalidomide) – Kyprolis™ (carfilzomib) – Ixazomib (MLN 9708) – Elotuzumab – Daratumumab – Panobinostat Take home messages • Myeloma is a very complex individual cancer • Treatment options for refractory disease MUK resources signpost • Myeloma – your essential guide • Revlimid Infoguide • Most patients who get remission will relapse • Bendamustine Horizons Infosheet • Many patients who relapse can be successfully treated and will have a second remission • Clinical Studies Infoguide • Myeloma TV • Infoline ** please visit the Myeloma UK Patient Information stand in the foyer area for further information 5