NCI-CCC Myeloma Tumor Board Question   

For many clinical trials, a screening bone marrow biopsy is necessary to get a new baseline. Do you do the same in real-world practice?

Previous questions have focused on the newly diagnosed setting and choice of bisphosphonate versus denosumab. IMWG guidelines do recommend resuming zo...

Do you only offer it for patients with a documented IgG < 400? Do you check the IgG at all, or are you doing primary prophylaxis?

For example - minimum number of months of therapy, driving distance to clinic, at least a CR with or without MRD negativity?

Please assume that IVIG is fine (as it is for many Jehovah's Witness patients, since IgG is often not considered a blood product per se).

Specifically, do you offer closer follow-up for certain patients after local radiation?

Is the therapeutic purpose of the proteasome inhibitor to maximize total dosage per week or number of infusions per week?

Would you do a 24-hour urine and echocardiogram in all of these patients? Cardiac biomarkers, PT/PTT, or any other such blood tests?

This question seems quite specific but happens quite often. Multi-drug chemotherapy runs the risk of profound cytopenias and infections, while bispeci...

I.e. dosing regimen frequency, side effect profile, duration of follow up, etc.

Modified HyperCVAD? V(R)D-PACE? DCEP? Are there any data to favor one over the other?

Do you utilize rituximab or any other specific management strategies?

Would you prefer CAR-T or bi-specific or neither? If CAR-T, how do you approach lymphodepletion? 

Which PI and at what dosing intervals? Dexamethasone or not? Emory has now published data with VRd consolidation as well as KPd consolidation, while ...

If so, why?

i.e., 60+% bone marrow plasmacytosis, light chain ratio >100, and/or >1 MRI lesion

In addition to reversing hypercalcemia, initiating myeloma therapy, etc.

Ide-cel? Cilta-cel? Teclistamab?

For example, would you use a tool like the Hydrashift assay? Would this change your management? 

If tolerated through Cycle #1, how aggressively do you try to titrate the selinexor dose up toward 100mg weekly or 80mg twice-weekly? And does your a...

How much weight do you give to a hgb/hct threshold versus symptoms?

In this case, the patient had received daratumumab/lenalidomide/dexamethasone as part of a cooperative group trial. Would you say that the patient had...

Does sequence matter?

Would you consider Dara-CyBorD or a MM triplet/quadruplet such as VRd or Dara-VRd? 

What factors (i.e. timing from transplant, dose, prior therapy) impact your decision? 

Does a progressing kappa/lambda ratio > 100 at any point in time warrant treatment, or does one wait to treat patients in the setting of a slowly i...

For pts w/ eGFR between 30-60

Frailty Index per Palumbo et al. PMID 25628469Is it practical to apply in clinics? Have you made decision changes based on it?

Venetoclax has demonstrated efficacy in patients harboring t(11;14) mutations but is not FDA approved for MM. Can you expand on what situations you ma...

For example: shorten IMiD duration each cycle, add scheduled G-CSF, add antibacterial prophylaxis, etc.

How do you decide how long to continue?

CAR-T (any specific preference of product?) vs bispecific antibodies vs any other specific agents not previously utilized?

Is a repeatedly abnormal serum immunofixation all it takes for MGUS?

Would you continue with daratumumab maintenance per ANDROMEDA or switch regimen?

What about multiple anaplastic plasmacytoma without bone marrow involvement?

Would you use MRD status to guide your decision making? 

If so, venetoclax/dexamethasone by itself or do you include a PI?