Selecting the best regimen at first relapse

During the Multiple Myeloma Hub Steering Committee Meeting in November 2022, key opinion leaders met to discuss how to select the best regimen at first relapse. The recorded discussion was chaired by Professor María-Victoria Mateos and featured Sagar Lonial, Morie Gertz, Paul Richardson, Heinz Ludwig, Hermann Einsele, Sonja Zweegman, and Mohamad Mohty.

The panel discussed treatment options and challenges for different patient populations at first relapse, and the factors that can affect treatment options. Some of these factors are demographic (e.g., age), clinical (e.g., frailty), and treatment-related (e.g., first-line treatment).

This discussion focusses on two patient scenarios, one being a lenalidomide-sensitive patient and the other being a lenalidomide-resistant patient. The conversation opens with discussion on the rarity of the lenalidomide-sensitive scenario and the recommended treatment following the results of the POLLUX trial. The discussion then continues with the lenalidomide-resistant scenario, where the experts evaluated studies such as APOLLO, i.e., daratumumab plus pomalidomide and dexamethasone (DaraPomDex), and carfilzomib in combination with daratumumab and dexamethasone (Dara-Kd), considering progression-free survival and potential further lines of treatment. The experts also considered the impact that COVID-19 has had on the way treatment is administered and concluded with a discussion on frailty as a factor determining treatment options.

Additional questions raised and discussed included:

• What is the future role of CAR-T and bispecific antibodies at first relapse?
• How to treat primary refractory patients who show poor response to bortezomib-based induction?
• What is the significance of MRD negativity after 1 year of maintenance treatment?
• What is the optimal sequence of treatment for patients who relapse after daratumumab in early lines of treatment?