BACKGROUND: A wide variety of multidrug combinations are available for the treatment (tx) of relapsed and/or refractory multiple myeloma (RRMM). Aims: To gain a greater understanding of the decision-making criteria that MM specialists use when selecting regimens for second-line (2L) and third-line (3L) therapy for patients (pts) with RRMM in Germany.
METHODS: MM specialists extracted data between 30 June and 8 September 2023 from medical records of pts who initiated approved 2L and 3L therapy for MM in 2021. Tx regimens, most important tx goal (list of 7 goals provided), and 5 key reasons for prescribing (list of 28 reasons provided) were reported in addition to pt characteristics. All data were summarized descriptively.
RESULTS: MM specialists (33 hospital-based, 16 office-based) with a median of 17 years of tx experience extracted data from a total of 268 pt records (2L, n=170; 3L, n=98). Pts had a mean (SD) time from initial MM diagnosis to initiation of 2L or 3L of 27.5 (24.4) and 40.5 (26.1) months, respectively. In 2L and 3L, 17 and 16 different regimens were documented, respectively. Table 1 documents pt characteristics and top reasons for prescribing most frequently used regimens in 2L/3L. Main 2L regimens were: the triplet daratumumab (D), lenalidomide (R) and dexamethasone (d) (DRd 16.5%); the triplet carfilzomib (K), d and D (KdD 12.4%); the doublet Kd (11.2%); the triplet KRd (10.0%); and the triplet D, bortezomib (V) and d (DVd 9.4%). Mean (SD) age ranged between 59.3 (11.1) years for KdD and 72.7 (8.1) years for Kd. Time to relapse after first-line (1L) was shorter among pts receiving DRd or KRd; high-risk cytogenetics were most reported among pts receiving KdD or DRd. The main reasons for prescribing Kd were age and good efficacy; good efficacy and fitness for DRd, KRd or DVd, and unfavourable cytogenetics, performance status and symptomatic relapse for KdD. Of the 28 reasons listed, MM specialists never selected co-medication, pre-tx with anti-CD38 antibody, anticipation of bad compliance, or compatibility of profession and tx. Inducing deepest possible response and prolonging progression-free survival (PFS) or overall survival (OS) were most commonly selected as the most important tx goals for triplet regimens (Fig 1). For Kd, these were symptom control and prolonging OS. Most (95%) Kd pts did not receive a transplant in first line (1L). Main 3L regimens were: the doublet pomalidomide (P) and d (Pd 15.3%); the triplet DRd (13.3%); the doublet Rd (13.3%); and the triplet elotuzumab (E), P and d (EPd 12.2%). Mean (SD) age ranged between 59.9 (12.0) years for Rd and 72.0 (6.8) years for Pd. Time to relapse after 1L was shorter among pts receiving Rd or EPd. Top reason for prescribing Pd and DRd was good efficacy; for Rd this was age and for EPd regain quality of life (QoL). Other top reasons varied, but the reasons co-medication, pre-tx with anti-CD38 antibody, compatibility of profession and tx, manageable distance to centre, and patient wish were never selected. Prolonging OS and PFS were the most common tx goals for all regimens except Rd, where prolonging OS and regaining QoL were the most important (Fig 1).
SUMMARY/CONCLUSION: For this rather young cohort of pts with RRMM, with a substantial representation of high-risk pts, experienced MM specialists selected a variety of 2L and 3L regimens with the most frequent primary tx goals to induce the deepest possible response and to prolong PFS and OS. Good efficacy was considered to be the primary reason for prescribing, followed by pt characteristics and other mode of action.
