Practice Update: Oncology

Q & A 33

Current Concepts in Stem Cell Transplantation for Multiple Myeloma Interview with Sagar Lonial MD by Farzanna S Haffizulla MD, FACP, FAMWA Dr. Haffizulla: We know there have been a preponderance of newly approved myeloma agents that might someday replace first-line stem cell transplantation. Do you think that that might be the case? Dr. Lonial: So you know, the idea of replacing transplant with new drugs or combinations of drugs has been a goal of many over the last few years, and every time we look at either three drugs or four drug combinations, the outcomes continue to be better by consolidation with a transplant, so I’m not sure that it’s going to go away immedi- ately anytime soon, but what we may identify, particularly from the recently published IFM/DFCI Trial, is trying to identify which patients can wait. That may actually happen, but I’m not sure we’re going to give up transplant anytime soon. Dr. Haffizulla: Okay, so really no deferring stem cell transplantation until it aligns? Dr. Lonial: So we talk about that a little bit. In our center we have 3 criteria that patients have to fulfill to talk about delayed transplant. One is they have to have achieved a BGPR after 4 cycles of ther- apy, they have to have tolerated their first 4 cycles well enough that they could take 4 more, and they have to have standard-risk mye- loma. If they achieve those 3, then many will say I want to delay, I want to delay, I want to delay, and we give them that option, but it’s not something I’m terribly excited about mostly because the data with transplant consolidation continues to look really good, and as we talk about curing patients deferring aggressive therapy to give them the highest chance at cure by delaying transplant may not be in their best benefits. Dr. Haffizulla: Well, on that note and given your expertise, I wanted to highlight that for our viewership. We want to thank you again for the work that you’re doing, and we’re looking forward to hearing more from you. Dr. Lonial: All right. Thank you. Dr. Haffizulla: Any particular last few studies before we close off that you wanted to highlight? Dr. Lonial: You know, I think really the antibody studies at ASCO were really exciting, the CAR T cells targeting BCMA are really interesting, and I think that’s really the big highlights from this meeting. Dr. Lonial is Chair and Professor, Department of Hematology and Medical Oncology; Chief Medical Officer, Winship Cancer Institute, Emory University, Atlanta, Georgia.

disease. I think the technology has evolved to an extent that we are doing now single cell sequencing. Mario Suva from Boston has published a very, very nice work really showing the evolution of an oligodendroglioma from single alterations really showing all the path, all the heterogeneity of that tumor. I think given that, we will be able to fully get the picture of that disease. This is first. Second, also important, the immunotherapy trials that are being done at this point in time are not only aiming at just pro- viding efficacy data. Several of them, specifically the smaller ones, are now trying to provide data on the immuno-moni- toring, immune function, really understanding and give us an understanding what they are doing. So whether peptides or not or whether other approaches will be the future, whether it will be cells, CAR T cells, whether it will be lysates, I think it’s not really fully shaped out but I think those immunotherapy approaches clearly combinations, personalized approaches for the immunotherapy, combinations with one or the other checkpoint inhibitors. We may learn that in brain tumors other checkpoints have a bigger role than the classic checkpoints. Talking about the last year, we have to talk about some of the negative data as well. So the EGFRvIII directed immunotherapy trial ACT IV has been negative. So, no signal off that treatment. The trial MATRIX 143 has been presented at the World Meeting of Neuro-Oncology in Zurich and also not shown any additional effect of nivolumab versus bevacizumab in that disease, so we get more understanding. I would go for the combination approaches, both with the drugs and with immunotherapies, and would really focus on molecular-driven trials and molec- ular-driven data approach. Dr. Caudle is a board-certified Family Medicine physician and Assistant Professor in the Department of Family Medicine at Rowan University-School of Osteopathic Medicine in Stratford, New Jersey. www.practiceupdate.com/c/54339

Dr. Haffizulla is the Assistant Dean of Community and Global Health at Nova Southeastern University’s College of Allopathic Medicine. She practices general internal medicine in Davie, Florida, within her own internal

medicine concierge practice. www.practiceupdate.com/c/54434

VOL. 1 • NO. 3 • 2017