Mohammadbagher Ziari, MD
Assistant Clinical Professor
Department of Medical Oncology & Therapeutics Research
City of Hope
Corona, CA
CASE SUMMARY
A 70-year-old woman received a diagnosis of stage I multiple myeloma. She had a medical history of stage 3 chronic kidney disease and moderate renal impairment, and fluorescence in situ hybridization testing showed deletion 17p. The patient declined autologous stem cell transplantation and received lenalidomide (Revlimid), bortezomib (Velcade), and dexamethasone (RVd). Her best response was a very good partial response (VGPR), and lenalidomide maintenance continued.
Two years later she had her first relapse while on lenalidomide maintenance. On routine follow-up, the patient reported having mild fatigue, but continued to work full time. Her bone marrow plasma cells, light chains, and M protein were rising while her kidney function was worsening, and she now has stage IV chronic kidney disease. The patient received daratumumab (Darzalex) plus pomalidomide (Pomalyst) with a best response of VGPR. One year later a second relapse was discovered, and her kidney function continued to decline.
DISCUSSION QUESTIONS
ZIARI: Based on the NCCN [National Comprehensive Cancer Network] guidelines, there are preferred regimens for [patients with] early relapses with 1 to 3 prior treatments. If the patient has a relapse after more than 6 months, the regimen used primarily can be repeated. Patients who are still sensitive to bortezomib and lenalidomide have options that include ixazomib [Ninlaro], lenalidomide, and dexamethasone, which is a category 1 recommendation, and then RVd.
For bortezomib-refractory patients, one can use any of the regimens that have lenalidomide or a combination of daratumumab, carfilzomib [Kyprolis], and dexamethasone. For patients with lenalidomide-refractory disease, you can do daratumumab, carfilzomib, and dexamethasone; or daratumumab, bortezomib, and dexamethasone; or isatuximab [Sarclisa], carfilzomib, and dexamethasone.1
CHALLAGALLA: Most of them are exposed in my practice already. So in this patient, if shes still not going to go to stem cell transplant or CAR [chimeric antigen receptor] T-cell therapy, I think I would go with isatuximab, carfilzomib, and dexamethasone.
SOLANKI: Theres still selinexor [Xpovio] and other drugs. This has become such a chronic disease.
ZIARI: RightI mean, now that your patient has relapsed with Dara-Pd. We have used the anti-CD38, the IMiD, and the PI. The unmet need seems to be a new agent, probably with a different mechanism of action.
BHANDARI: I think this is when we start getting into either sending the patient for some trials at a tertiary center or sending the patient maybe for evaluation for CAR T-cell therapy or another BCMA [B-cell maturation antigen] type of therapy.
DISCUSSION QUESTION
ZIARI: What do you consider? Is there any other MOA that you think we need to address?
ARJUNAN: Yes, I think thats always a thought in my mind when were switching therapies. In this patient, I think you certainly would be looking at switching MOA, so you kind of think about selinexor, elotuzumab [Empliciti], and some of those other drugs out there. The big concern I have, regardless of the MOA, is the tolerance issue. It becomes worrisome trying to get these patients who are a little bit beat up on their first line of therapies onto some of these other ones.
ZIARI: You touched a great point, exactly. We have other regimens that are recommended like bortezomib, liposomal doxorubicin, and dexamethasone or carfilzomib and dexamethasone. There is CyBorD [cyclophosphamide (Cytoxan), bortezomib, dexamethasone]; carfilzomib, cyclophosphamide, and dexamethasone; or ixazomib, cyclophosphamide, and dexamethasone. Also, [we have] selinexor, bortezomib, and dexamethasone, or other selinexor-based regimens such as daratumumab and dexamethasone.
We also have venetoclax (Venclexta) and dexamethasone only in [patients with] t(11;14). Elotuzumab, pomalidomide, and dexamethasone is another option for a patient who had an IMiD [immunomodulatory drug] and PI [proteasome inhibitor] and progressed within 60 days of completion of last treatment. Pomalidomide and dexamethasone is category 1, and selinexor, pomalidomide, and dexamethasone is another option. There are other older regimens like DCEP [dexamethasone, cyclophosphamide, etoposide (Toposar), cisplatin (Platinol)].1 I dont know if any of you have used it recently, but I know that a long time ago I used it, but not anymore.
DISCUSSION QUESTIONS
ZIARI: You have used RVd and the patient was on maintenance lenalidomide and then progressed in 2021 [after 2 years]. After the first relapse, the patient was on Dara-Pd and now that you have utilized those MOAs that we talked about, it comes to the second relapse. Now you have options like an XPO1 inhibitor and CAR T-cell therapy, an anti-BCMA, or others. We have used a PI, anti-CD38, and IMiD.
MAZHARUDDIN: Well one thought that comes to mind is that the patient seems to have been off the bortezomib when they progressed. So it kind of opens the potential of reintroducing a proteasome inhibitor.
CHALLAGALLA: I agree with that. I think I would use carfilzomib, selinexor, and dexamethasone.
ZIARI: Would you do selinexor, bortezomib, and dexamethasone?
CHALLAGALLA: [This patient] doesnt have any history of cardiomyopathy or CHF [congestive heart failure]. Id like to avoid neuropathy. I would still try to push her toward stem cell transplant or CAR T-cell therapy because she does not seem to be refractory but is just relapsing.
SOLANKI: In the BOSTON trial [NCT03110562], most of the patients had been exposed to multiple agents. But they reintroduced bortezomib in those patients, and some of them got it within the last 6 to 9 months or less than 1 year, and they still showed a response. In fact, in the [bortezomib and dexamethasone] arm of the study, there was a response to bortezomib.2 So if [this patient] is otherwise suitableI dont know what her creatinine clearance is, was it good enough for CAR T-cell therapy?
ZIARI: Yes, youre correct.
DISCUSSION QUESTION
ZIARI: There is the genetic risk, like deletion 17p. Also, patient comorbidities like renal impairment and hypertension, or prior toxicities such as neuropathy. Is neuropathy something that you see in your patient after you use triple regimen for 2 lines of therapy? Is it something that you see despite using subcutaneous proteasome inhibitors? Is this something that is a challenge in your practice?
KANNAN: Its concerning. I think it affects their quality of life because its a chronic disease. Most of my patients develop it with bortezomib-based therapy at first-line therapy, so it tends to be a major problem.
ZIARI: What do you think, Dr Kannan, about the regimen that you would choose for your patient who had 2 lines of triple treatment in the past and now youre going to third-line therapy? What would you use?
KANNAN: Sometimes Ive done carfilzomib-based therapy because theyve had RVd followed by Dara-Pd. Ive tried selinexor. I push them toward CAR T-cell therapy, obviously if they are not refractory, but I still dont understand why this patient did not have a bone marrow transplant. Or did they have a transplant in between? If they have not had a transplant, they should be considered for transplant with the option of CAR T-cell therapy for the future, but I would collaborate with my [transplant physician] for them.
ZIARI: How far [away] is the transplant or CAR T-cell therapy center?
KANNAN: 20 miles.
ZIARI: I see; not bad, not bad at all. The MOA is important, too, if your patient has progressed on a treatment. If you use something new, think of the safety, exactly as you mentioned about neuropathy and different safety issues. We want to just use something that will not only keep the longevity but also the quality of life the same as much as we can. Always consider cost to the patient too: how much is out of their pocket and the distance theyre dealing with. I dont know how much geography is a problem when it comes to using oral regimen vs not oral regimen. Is it something concerning if the patient lives far away from you?
KANNAN: I dont think distance is a problem, but cost can be a major problem in our patient population, which is a little bit lower socioeconomically, and that affects [adherence].
ZIARI: That is true in every single practice, and you feel it more in the community practice.
CASE UPDATE
The patient was started on selinexor plus Vd based on her worsening renal impairment, deletion 17p status, and prior therapies. She achieved a VGPR.
DISCUSSION QUESTIONS
ARJUNAN: Ive used it once. We ran out of options for the patient. I was working in conjunction with [The University of Texas] MD Anderson [Cancer Center]. It was tough. A lot of fatigue, diarrhea as well, and it was quite a lot of monitoring.
ZIARI: Did you use it after multiple lines orin combination with bortezomib or anything else?
ARJUNAN: I used it after multiple lines.
ZIARI: You used it as a doublet treatment with dexamethasone or with bortezomib?
ARJUNAN: Yes, a doublet treatment with dexamethasone.
CHALLAGALLA: Ive used it as a doublet treatment, too, in an elderly person with terrible neuropathy. The indication was triplet therapy with bortezomib, but there was no way I could use bortezomib, so I did the 80-mg selinexor with dexamethasone.
I mean, its a different mechanism, except you must watch out for hyponatremia in this older population from the nausea, vomiting, and diarrhea, and I think we are all pretty good with the hematologic toxicities. We are pretty good at treating them. I think its the neurologic toxicity and the hyponatremia that we need to be careful of.
ZIARI: I have the same experience that you both had before. Just the hyponatremia is something to monitor closely, and fatigue too.
ZIARI: The BOSTON study data showed the efficacy and the adverse effects [AEs] of selinexor. Some of you have experience with it and some of you dont. But based on the data, how would you discuss this with your patient?
BHANDARI: Were there any patients on dialysis on that study?
ZIARI: They included patients who had kidney function less than 40%,2 so patients on dialysis [were] included.
ARJUNAN: Yes, so I think its a discussion about the data, to some extent. What concerns me about these data is that [the study] used, in my opinion, kind of a comparator arm that was questionable. About 70% of the patients had prior exposure to bortezomib already and then theyre using that as a comparator arm, so its kind of like youre expecting that comparator arm to fail, basically. I dont see what the data show me beyond telling the patient, Hey, maybe let us add selinexor, which has a different mechanism of action. It might help you. But I think when were looking at the data, its hard to use that as a convincing reason.
I dont know if there was, perhaps, a better comparator arm that could have been used in this trial instead of Vd alone. But otherwise, its about discussing the AEs and just counseling [the patients] through that. It is kind of difficult because with the other options you might have other toxicities. [As with] belantamab [Blenrep], you have the ophthalmic toxicity. So its weighing what the patient would be tolerant to.
ZIARI: I think there are data that we have also that compared pomalidomide, bortezomib, and dexamethasone with Vd. Also, they did a similar [study] but with Dara-Vd vs Vd and looked at the PFS [progression-free survival] difference too. I guess for the data that we have, the control arm was the old regimen that in the past had been a standard. Thats the reason that they always have something in addition to the doublet, with a different MOA to see if it is better than the standard.
DISCUSSION QUESTIONS
CHALLAGALLA: We always dose reduce. Nausea/vomiting is easily controlled, but we dose reduce if there [will] be AEs.
ZIARI: For the dose that we reduce to, there are data about that dose, so that you dont lose the efficacy. Have you used olanzapine [as an antiemetic]?
CHALLAGALLA: Thats the problem I have with all these drugs. There is no drop in efficacy by dose reduction, so why do we have to use the full dose and make the patient suffer?
ZIARI: In the BOSTON study, most patients had [dose modifications] eventually. You can always lower the dose too. This is what weve learnedthat maybe a lower dose is not a problem. I mean, again, in the BOSTON study, eventually they had most patients on the 80-mg dose.
SOLANKI: This question came up way back when panobinostat [Farydak] was introduced. It clearly disappeared mainly because it had severe GI [gastrointestinal] toxicity, mainly diarrhea. This has been a recurring problem with drugs, like now with selinexor. What Dr Challagalla pointed out is a recurring theme. We say, Oh well, 70% of the patients had to have dose reductions. Well, how did we come up with this dose in the first place?
The same thing happened with bortezomib way back. We used to use much higher doses, and then we went to weekly dosing. It turns out that the total dose of bortezomib we give is considerably less than what was originally used, and we still see wonderful responses. So theres a significant issue with the starting dose that is used in trials. Nobody seems to report what was the delivered dosehow much did the patient get, not what was planned.
ZIARI: In the BOSTON study they did. The majority [of patients received] 80 mg.
SOLANKI: I think what happened with the BOSTON [From the Data2] trial was because of the design, it became a once-a-week regimen of selinexor, and that considerably decreased the GI toxicity. Still, there was considerable dose reduction in those patients. So its still a pretty tough drug, although I was surprised how effective the combination was in patients who were penta refractory. Even in the Vd arm, there was a response rate of about 35% or 30% which is remarkable, so it was an interesting study, but not an easy one on the patients.
ZIARI: I have patients on this and I have been dose reducing, even down to 40 mg and they still have a response to it. I have 2 patients currently on it and down to 40 mg once a week, and I see the efficacy. I had to dose reduce to different things. But one other thing I do is olanzapine on day 1 of the treatment, and then I do it for 3 days in a row. I ask the patient how they feel after 3 days. If theyre fine, then I just ask them to use it as needed. If you do it days 1 to 3, and 1 hour before the starting day, then continue for 3 days or use a different cocktail plus hydration, it pretty much gets easier. Typically, after the first 2 months, the patient tolerates it and the AEs get less and less.3
DISCUSSION QUESTION
CHALLAGALLA: My choice would depend on the comorbidities of the patient. If the patient has severe neuropathy, bortezomib is out. Cardiomyopathy, carfilzomib is out, or kidney disease too. If theyve been exposed to daratumumab, I dont think I would use any anti-CD38 drug again because I dont believe that reusing it is going to be helpful. I dont know whats the right answer. It depends on the patient. In my practice, if I have used RVd and then daratumumab, etc, then XKd [selinexor, carfilzomib, and dexamethasone] seems most reasonable because if the same patient had kidney disease, I would have probably used pomalidomide before.
ZIARI: I see. So if you want to use a combination with selinexor, where do you think it fits in your line of treatment?
CHALLAGALLA: One can use selinexor and dexamethasone. One could use anything. We have so many choices right now, and we must weigh the AEs and patients comorbidities, then choose. Thats the way I would think.
ZIARI: Thats correct. We have great choices available now, but youre talking about a different MOA when you use selinexor. Weve pretty much run out of many other MOAs, and we were thinking about something new.
REFERENCES
NCCN. Clinical Practice Guideline in Oncology. Multiple Myeloma, version 1.2023. Accessed February 22, 2023. https://bit.ly/3KqmxUF
Grosicki S, Simonova M, Spicka I, et al. Once-per-week selinexor, bortezomib, and dexamethasone versus twice-per-week bortezomib and dexamethasone in patients with multiple myeloma (BOSTON): a randomised, open-label, phase 3 trial. Lancet. 2020;396(10262):1563-1573. doi:10.1016/S0140-6736(20)32292-3
Xpovio. Prescribing information. Karyopharm Therapeutics Inc; 2020. Accessed February 22, 2023. https://bit.ly/3eG0OqV
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Roundtable Discussion: Ziari Assesses Therapy Sequencing in ... - Targeted Oncology
