EBMT 2022 | Current approaches for the management of patients with high-risk multiple myeloma

One of the challenges that I think we’re all continuing to struggle with is how to optimally manage patients with high-risk myeloma. There’s a lot of different algorithms out there for what to do. We’ve seen data in a number of different areas. But unless you’re in a situation where patients have lots and lots of circulating plasma cells, our approach at Emory is to use a KRd-based induction for four cycles, collect stem cells, take them to transplant and then use KRd consolidation and maintenance for three years afterwards.
There certainly is a discussion amongst many of our colleagues to potentially add in daratumumab for those high-risk patients. I remain agnostic on that point right now based on analyses from each of the induction therapy trials showing that the one group where the benefit seems to be marginal is the high-risk subset of patients, given small numbers of patients enrolled in each of these trials. There is a meta-analysis that suggests that may not be the case. But again, there are potential methodology issues of meta-analysis as well that may make interpretation of that data a little variable as well.
Certainly, I don’t disagree when patients add in daratumumab. But our approach right now is to use KRd really based on the FORTE study, where the high-risk and double hit patients seem to do remarkably well in terms of MRD achievement and sustained MRD negativity, which we know is really important in high-risk myeloma and continued use of high dose therapy and transplant, which I think has now been validated both in standard-risk and high-risk, but, clearly, maybe even more important in the high-risk cohort of patients where their PFS and OS is much shorter and much inferior if you omit high-dose therapy and autologous stem cell transplant.