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Blood Cancers Video Library: Multiple Myeloma – Is there a preferred induction therapy?

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GRACE joined a number of top faculty in the area of hematology in Whistler BC, for the 3rd Annual Summit on Hematologic Malignancies.  Sagar Lonial, MD, FACP, Professor and Chair, Department of Hematology and Medical Oncology, Emory University School of Medicine, Chief Medical Officer, Winship Cancer Institute of Emory University, speaks with GRACE about a controversial question regarding the  optimal induction regimen for a newly diagnosed myeloma patient.  Dr. Lonial believes it is clear now in 2016 that combination therapy represents the best way to move forward.

 

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Multiple Myeloma – Is there a preferred induction therapy?

Sagar Lonial, MD, FACP

Professor and Chair, Department of Hematology and Medical Oncology, Emory University School of Medicine,

Chief Medical Officer, Winship Cancer Institute of Emory University

 

A question that’s had a fair amount of controversy surrounding it over the last two to three years is: what’s the optimal induction regimen for a newly diagnosed myeloma patient? I think it’s important to realize that it’s clear now in 2016 that combination therapy represents the best way to move forward. That typically represents a three-drug combination versus either a two-drug doublet of bortezomib and dex, or lenalidomide and dexamethasone.

There has been a big question of whether bortezomib should be combined with cyclophosphamide, or old fashioned chemotherapy with dex (the VCD regimen) or whether it should be combined with lenalidomide and dexamethasone. There were two trials presented in the last year that really helped us to answer this question. The first is, in a phase III trial, RVD clearly beat lenalidomide and dexamethasone. So a three-drug combination beat a two-drug combination in terms of how long patients stayed in remission and in terms of overall survival. This was the first phase III trial using RVD as induction and it’s an important data set for us to have because now we have phase III data demonstrating significant improvement for bortezomib, lenalidomide and dexamethasone in combination.

That phase III data supporting the use of VCD, bortezomib with cytoxan and dexamethasone, does not exist. The only data we have was a head-to-head comparison of VCD with BTD, the RVD regimen I mentioned earlier, but substituting thalidomide, the older imide, in for the lenalidomide. What we learned again in the last six months is that the imide combination with bortezomib, BTD, was clearly superior to the cyclophosphamide combination with bortezomib, or VCD.

This all gets very confusing, and the acronyms can be very challenging to keep track of, but the take home message in my view is that the role of traditional chemotherapy, alkylating agents—doxil, doxorubicin and cyclophosphamide—as part of initial induction therapy, is being replaced by the use of a proteasome inhibitor and an imide together, the RVD regimen, and that regimen in 2016 represents the standard of care for almost all newly diagnosed myeloma patients.

 

 

 


 

 

 


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