Friday, November 30, 2018
November 30th is actually the day before ASH officially begins, often called “Symposium” day.
However, my first session was last night’s Bone Marrow Transplant Clinical Trials Network (BMT CTN) Myeloma Intergroup MRD and Immune Profiling Meeting, a group focused supporting myeloma clinical trials involving transplants and immunotherapies.
There were probably 100 physicians attending this 3.5 hr meeting moderated by Dr. Phillip McCarthy. The agenda consisted of several 10–20 minute presentations on topics such as minimal residual disease (MRD) testing within several upcoming trials as well as incorporating MRD and Immune Profiling in the context of CAR-T therapies.
Some takeaways from this meeting:
- There was considerable discussion about the impact of an SCT on subsequent immune suppression, which can cause infection and quicker relapse. Dr Zaid Al-Kadhimi indicated that on of the causes of immune suppression is the GSCF most of us take to mobilize our stem cells for harvest.
- Dr. Ken Anderson (Dana Farber) noted “Using Darzalex (daratumumab) for many years can deplete your gamma globulins.”
- Dr. Nikhil Munshi (Dana Farber) indicated that it’s not enough to know you have, for example, del 17p but rather to what degree. “More than 60% sub clonality (cells carrying a particular mutation) in 17p predicts poor outcomes.” FISH tests can provide this information
- Dr. Ed Stadtmauer showed that correlation of MRD in the CAR-T may be a less prognostic indicator than in other treatment settings. For example, in early BB2121 CAR-T results, 16 of 16 patients were MRD negative, but 8 relapsed. “Persistence of T-cells” might be a better prognostic indicator.
Today I attended the GMAN meeting and IMF Symposium. GMAN (Global Myeloma Action Network) was established about 5 years ago recognizing that multiple myeloma is a global disease but different countries face different issues (awareness, education, access, expertise) supporting myeloma patients. Our large meeting is during the summer but this year we had representatives for Turkey, Germany, Australia, Croatia, Latin America (Brazil), Canada, and the U.S. in addition to Pharma reps. We shared experiences in best practices such as caregiver involvement, awareness via posters, publications for translation and distribution, and usage of volunteers.
I then attended the IMF Symposium “New Strategies for Myeloma Care: Next Steps for the Future.” I estimate about 1000 people attended and watched Dr. Brian G.M. Durie moderate a panel of myeloma experts. Panelists included Drs. S. Vincent Rajkumar, Philippe Moreau, Shaji Kumar and Jesús San Miguel.
The format is quite interesting:
- A patient case is presented.
- Multiple-choice questions are presented about one of the five topics.
- The audience votes on their answers, and the results are displayed.
- Next, a presenter describes the best treatment practices and reasons for these practices.
- All presenters vote on the multiple-choice question.
- Finally, the audience votes again. (Have minds been changed?)
The doctors provided their insights on these case presentations:
- Case Discussion 1: Risk Stratification of Plasma Cell Disorders
- Case Discussion 2: Are we ready for personalized therapy in Newly Diagnosed MM?
- Case Discussion 3: Considering the Recent Data on Transplantation, Consolidation, and Maintenance After Induction Therapy
- Case Discussion 4: Advances in the Optimal Choice of Therapeutic Strategies for Patients With Relapsed/Refractory Disease
Interesting comments included:
B.Durie “For double- or triple-hit (2 or 3 high risk factors), KRd induction should be considered instead of standard VRd.”
J. San Miguel further stated “The best treatment should be used early so Daratumumab may be added to RVd or KRd in the future.”
And SV Rajkumar countered “Myeloma is more like a marathon than a sprint. Consider saving more expensive treatments for later.”
On transplants & maintenance
S. Kumar “Revlimid maintenance is recommended for all Standard risk MM patients while Velcade maintenance should be given to High Risk MM patients.”
P. Moreau “Tandem transplants beneficial over single SCT in both High-Risk as well as Standard-Risk MM patients.” (This a contrary to a recent U.S. study called STAMINA which showed no benefit. It was noted that perhaps the tandem benefit seen in Europe may be due to less access to better induction treatments.
When asked how doctors should treat MM patients relapsed 2 or more times, J. San Miguel commented “The only way to recommend treatment is to be in front of the patient and understand the many patient variables.”
And SV Rajkumar offered his principle “Use a triplet and make sure the patients is not refractor to at least 2 of the 3 drugs.”
A meeting with Celgene rounded out the long day.
Wishing you the best of health!