Dr Braunstein on the Evolution of ASCT in Multiple Myeloma

Marc J. Braunstein, MD, PhD, associate professor, Department of Medicine, course codirector, Hematology-Oncology System; New York University (NYU) Long Island School of Medicine; fellowship program director, Hem/Onc, NYU Langone Health – Long Island, discusses the evolution of autologous stem cell transplantation (ASCT) and ongoing treatment needed to better determine when ASCT should be recommended for patients with multiple myeloma.

ASCT maintains its vital role in the multifaceted treatment of patients with multiple myeloma, particularly for high-risk patients, Braunstein begins. A notable trend in the current patient population involves the administration of quadruplet regimens, yet the existing body of randomized data falls short in conclusively determining whether individuals undergoing a quadruplet induction regimen still need subsequent stem cell transplantation, he states. Although most randomized studies have concentrated on triplet induction regimens, an ongoing imperative exists to delve into the nuanced question of whether quadruplet induction can obviate the imperative for stem cell transplant, he says.

The selection of optimal proteasome inhibitors (PIs) for induction treatment remains a subject of ongoing debate within the medical community. Numerous studies have delved into the prospect of integrating carfilzomib (Kyprolis) as part of both triplet and quadruplet induction regimens and have consistently demonstrated benefits with this agent, Braunstein expands. Similarly, positive outcomes have been evident in studies exploring the integration of lenalidomide (Revlimid), bortezomib (Velcade), and dexamethasone, with or without a monoclonal antibody. In the relapsed/refractory setting, adding carfilzomib to standard regimens significantly enhances overall survival, he emphasizes. However, a void exists in direct head-to-head data, specifically in comparing prior triplet induction regimens that featured either bortezomib or carfilzomib as the PI of choice, Braunstein states. Notably, studies investigating triplet regimens in patients who forewent stem cell transplant have failed to elucidate a substantial difference in outcomes between triplets containing bortezomib or carfilzomib in the upfront setting, he says.