The Impact of Evolving Treatment Options in Multiple Myeloma, Part 4

Bruce A. Feinberg, DO: Ryan can’t wait to jump in here. He’s got things to say, I can tell. Ryan has been with one of the leading institutions in managing this disease. I’ve got to believe that value-based care design has worked its way into the conversation. Are they starting to create the algorithm whereby patients may be stem cell harvested, but not transplanted? Where we’re going to start to look at, “Stop, can we not give maintenance?” Is that coming into the conversation at Emory [Winship Cancer Institute]?

Ryan Haumschild, PharmD, MS, MBA: It’s an exciting time, and we are big fans of MRD [minimal residual disease]. We’ve done a ton of research, as you’ve mentioned. Stopping transplant I think is a novel idea. I have a little more discomfort with not going to transplant than I do utilizing MRD for maintenance therapy, and recognizing that if someone’s MRD negative twice, maybe once they’re on maintenance, pulling them off, or going down to 1 therapy. I foresee it in the future. There are lot of clinical trials out there looking at how you can utilize MRD to stratify patients pretransplant. It’s going to be interesting to see how far we can take it.

There are 2 things to think about with MRD status. No. 1, if you discontinue therapy, there is a positive impact on quality of life. We know with IMiDs [immunomodulatory drugs] and lenalidomide in patients who are on monotherapy for long periods, they can be well controlled but there are impacts to quality of life. We know that patients either have to come in and be monitored, or there are adverse effects associated with that. There is interest there in how we can maybe reserve therapy or pull patients off therapy, which again plays into the conversation we had earlier about treating multiple myeloma as a chronic disease. I think you do that when you can justify and utilize minimal residual disease as an indicator.

Then lastly, value-based care. We know that IMiDs are some of the most expensive medications. Multiple myeloma is a disease state, and we want to continue to treat patients with these innovative medication therapies because it’s best practice and we can also provide better long-term overall survival. But if we can identify somebody with minimal residual disease, pull them off therapy, still let them have a great response, and save those health care dollars, we’re reducing the cost of care and decreasing the total cost of care of myeloma as a whole. I think that’s a great goal to utilize while we’re improving health outcomes at the same time.

Bruce A. Feinberg, DO: Tom, let’s say it’s a private practice that has, 50 doctors, 70 doctors, 80 doctors, not just a mom-and-pop shop, but a very sophisticated practice working with academic institutions. This is a disease, because the transplant is an early and almost universal piece of the treatment story, are your experts within the practice deciding on your pathway? Or do you have this collaborative relationship with an institution, whereby you’re working hand-in-hand to determine how many cycles? What are the goals of induction? When are they going to get harvested? When are they going to get transplanted? Who’s calling those shots?

In a private practice or community, with most diseases, such as lung and breast cancer, you’re making all those calls, but in myeloma, I’m curious about the hand off and how that is working.

Thomas Ollis, MS, RPh: The hand off for a transplantable patient goes from our community oncologist up through one of our academic centers. The decisions are made on a local level. We do talk to each other. There are consults, but for the most part, if the patient is transplantable, they’ll refer that case to one of our experts within our system.

Bruce A. Feinberg, DO: When you do those referrals, is it within a pathway of sorts, where if they achieve X response within 6 months, then referrals are made?

Thomas Ollis, MS, RPh: There are no pathways, we don’t have pathways. We stick with our NCCN [National Comprehensive Cancer Network]guidelines. The pathway kicks in when the patient hits the academic setting. On the community level, we’ll say, “We need to kick this up. We need this to go into some different hands.” That is when all those pathways may or may not kick in.

Bruce A. Feinberg, DO: I’m going to go back to Joe and Ryan with my next question because I’m curious about what your beliefs are, given the nature of this disease, do we need a pathway? Is the NCCN guideline enough to guide a nonmyeloma specialist physician in treating the patient, do you think? Or do we need something more structured?

Joseph Mikhael, MD: Respectfully, although I’m a big fan of the NCCN guidelines, if you’ve looked at the myeloma section, I jokingly say it reminds me of the Cheesecake Factory menu. It’s literally a huge laundry list.

The NCCN guidelines help facilitate the coverage and support, and although myeloma is a growing disease in its prominence within the community, most patients with myeloma in this country are still seen by a community oncologist who spends less than 10%, if not 5% of their time on myeloma. It’s hard for them to walk through this massive laundry list, as opposed to having guidance. I do think their guidance is helpful. Emory, for example, has been one of the guiding centers in the country. When I used to be at the Mayo Clinic, and now at T-Gen [Translational Genomics Research Institute], City of Hope as well, we guide people based on their risk status and their eligibility for transplant. I think that will help, because left just looking at the NCCN list, it’s hard to make sense of it all.

Transcript Edited for Clarity