Professor Joy Ho – Royal Prince Alfred Hospital, Sydney, Australia
Professor Je-Jung Lee – Chairman, Korean Multiple Myeloma Working Party

JH: Hello, we’re here with ecancer at EHA 2017. I’m Joy Ho from Sydney, Australia and here with me is Professor Lee from Korea. We’re here to discuss the new developments in front-line regimens in newly diagnosed myeloma. So we’re going to talk about what we normally do in our respective countries first and we will obviously have to cover both transplant eligible and non-transplant eligible patients. So maybe, Professor Lee, you could talk about what combinations you use in Korea at the moment?

JJL: In Korea for patients with transplant eligible we usually use bortezomib containing regimens such as VTD or VCD as front-line treatment.

JH: And in non-transplant eligible patients?

JJL: In non-transplant eligible patients most patients are treated with a VMP regimen and recently an LD regimen was approved.

JH: I see, so that’s quite similar but not completely the same as Australia as in transplant eligible patients we actually have an Australian registry and the vast majority get VCD. But we are not allowed even to use thalidomide and bortezomib together so, for us, VTD is in fact not possible. Obviously, as we’ve heard in this congress, where VRD, though not clearly shown in head-to-head comparisons to be superior, we have no option of using that at all. Whereas in non-transplant eligible patients whereas in past years VCD has been the most commonly used regime in the past twelve months or so Rd has now been approved and therefore there has been a continual shift, especially for patients who want to have oral therapy, to have RD rather than VCD. In terms of the abstract which was utilising the addition of ixazomib to lenalidomide and dexamethasone, would that impact on your practice do you think?

JJL: Yes, in this EHA meeting we encountered ixazomib combining regimens such as ILD better than ixazomib alone, showed very impressive outcomes. Nearly 100 patients showed a response so most of the patients showed the response rate, this very impressive one, and also the safety issue is very acceptable. So [?? 2:50] is very measurable in the future and tolerable in terms of response and safety. Another very important thing is the eligibility of the patient, the oral regimen, it consists of an oral regimen so it’s very compatible to the patient.

JH: I agree because in a lot of the non-transplant eligible patients the oral regimes are much more palatable, especially the more elderly. I think Korea has been a participant, and so have we, in the relapse trials for ixazomib/lenalidomide/dexamethasone. So a number of centres in both countries have had experience with the combination and we still have to wait because we’ve only got response rates at the moment for the front-line but one would think if there is significant improvement in PFS and OS eventually that the addition of an oral proteasome inhibitor may very well be taken up in Australia perhaps, we don’t know that. But there’s always the concern that at the moment we can’t even use an immuno-modulator and a proteasome inhibitor together, hopefully that will change. In transplant eligible patients do you see any developments in Korea in terms of the abstracts? There was one from the UK looking a quadruplet as well as triplet therapies.

JJL: If you are taking [?? 4:34] a big gap between Europe and Asian countries. So all over Europe and the United States use the VLD regimen, however we suggest to use the PTD or PCD, there is a big gap. In this EHA meeting I found that the carfilzomib containing regimens, KLd, or even some trials use a quadruplet regimen containing carfilzomib, cyclophosphamide, lenalidomide dexamethasone regimen, show very impressive results. In [??  5:18] treatment, the most important thing is to achieve a very deep response and delay to the progression free survival prolongation. So that kind of approach is impressive in this year’s meeting. Actually although the quadruplet regimen consists in future trials of using bortezomib, IMiD containing, plus some kind of monoclonal antibody, that kind of one is a very expensive approach, in real practice it’s not eligible to Korean patients. However, this kind of KCRd regimen is very reasonable in the future to adopt in Korea.

JH: I think that’s a very good point because the KCRd regimen in the UK trial, at least one of the quadruplets is actually cyclophosphamide as opposed to a monoclonal antibody which may be more accessible to Asian countries and Asia Pacific countries including Australia. Once again I guess the response rates are impressive with the quadruplet but whether it will translate to differences in PFS and OS remains to be seen. And there has always been a concern with carfilzomib in terms of the endothelial hypertension cardiac type effects, in terms of use of first-line and the fact that it seems relatively safe is also reassuring to use it in first line. I have to say in Australia that that probably would seem still far away because we do not yet have carfilzomib even in relapsed myeloma so bringing it to front-line will be more difficult, it would not be the immediate priority for Australia to adapt that.

JJL: That kind of situation is the same in Korea.

JH: Going back to the issue of the use of ixazomib in the non-transplant eligible patients, as you pointed out when we spoke earlier, that the trial had ixazomib as maintenance. Do you see in the transplant eligible patients the role of consolidation and maintenance? Have you gained anything from the presentations so far?

JJL: Absolutely. The concept of consolidation and maintenance is very important to prolong the patient’s survival. Unfortunately in our country they do not permit that kind of approach at this time so in the future we need to adopt this kind of approach into Korea. So I guess the most commonly used consolidation regimen is bortezomib, the lenalidomide/dexamethasone regimen, [?? 8:33], and for the maintenance therapy most of the trials used lenalidomide long-term treatment.

JH: On that point in Australia it’s still quite difficult, and my colleagues and I often think about it, because we don’t really have a defined consolidation regime. So, for instance, our transplant eligible patients would have the four cycles of VCD and go straight on to transplant. The only maintenance drug we have is actually thalidomide. So it becomes quite a challenge, given the obvious improvement in the lenalidomide maintenance trials to first achieve that but how we then try to also incorporate consolidation into transplant eligible patients will be a continuing challenge. So I think we’ve actually covered quite a bit. Thank you very much for joining me, Professor Lee, and thank you for joining us at home.