Blood Cancer in the Elderly: European Expert Forum, Rome, 19—20 March 2011

Professor Meral Beksac (Ankara University School of Medicine, Turkey)

Addition of thalidomide to myeloma treatment improves response in elderly patients

ecancer.tv is now pleased to welcome Meral Beksac. Professor Beksac, you’re from Ankara University and you were one of the experts in the multiple myeloma session. I thought it was a great session, what were your impressions?

I think it was a very concise session which summarised almost every issue regarding treatment of myeloma, excluding prognostic factors. But I think age is a major prognostic factor so that’s the major issue of this meeting and also the myeloma session was concentrated on the treatment of elderly patients and also those patients preceding the myeloma phase which is the smouldering myeloma.

And you are chair of groups in Turkey specialising in myeloma; you’ve been doing trials, you’ve been concerned with trials in Turkey. What were your views about the initial therapy and the maintenance therapy, and indeed even transplant that we heard about just now?

We have participated and actually run our own trial which is using thalidomide in conjunction with melphalan prednisone, which is the classical treatment. We compared to the control arm which is the classical MPR. So this trial we ran was initially planned at the same time as the other five European trials but we were able to finish last year and we were able to publish that. And today in the induction treatment, this is a treatment modality which is discussed a lot, and now we were lucky and today also presented the meta-analysis on the use of thalidomide as an induction treatment selection.

Can you give me the data that you have then?

Sure. We included 115 patients which were randomised to MP versus MPT and the treatment regime was a year, which consisted of eight cycles, each with six week intervals. We were able to see a big advantage of the thalidomide in terms of response; VGPR rate was almost 20% more in the thalidomide treated patients and we had a progression free survival advantage. The overall survival advantage is not clear but it’s a matter of patient size and the differences in the treatment arms that you achieve and the meta-analysis helped us a lot. The cumulative data was analysed in the European Myeloma Group and now we are very happy to see that the addition of thalidomide improves CR progression free and also overall survival. So we were happy to have a contribution into this meta-analysis.

So the clinical implications from this meta-analysis and your own data for practising…?

Yes, I think it supports that thalidomide is a good drug; it adds to the classical treatment of melphalan prednisone and it can be used for a year with no major concerns; the toxicities we observed were not major issues. The only limitation with thalidomide is the long term use is limited by the neurotoxicity which is a matter of debate which was discussed a lot today.

What do you think are the implications for using lenalidomide, other IMiDs, and indeed we’ve heard about proteasome inhibition, other agents on the way? What do you feel about all of this?

I think that the development of lenalidomide was based on the toxicity of thalidomide, which is the first generation of IMiDs then which is followed by lenalidomide which saves from the neurotoxicity. In our own experience we have been using lenalidomide outside of clinical trials and independent, at first, by compassionate use now it’s on the market and neurotoxicity is not a matter of concern, so it’s also effective. So in elderly myeloma patients it’s a good option.

We’ve heard about sequencing treatments and about maintenance therapy, briefly what are your thoughts about that?

For front line use the only two novel agents which are registered for use currently are thalidomide and bortezomib. So the proteasome inhibition is another option and that also has concerns with neurotoxicity. So if you sequence the treatment with a short-term, effective treatment, MPT, MPB or MPVT, and then, without causing much major neurotoxicity or if you observe neurotoxicity coming, moving to lenalidomide as an escape and it’s also an effective second line agent.

And in older patients, briefly, what are your thoughts about auto-transplant?

In our country we are really pushing hard to perform autologous transplant in elderly patients and those patients who are, in general, less than 65 are evaluated for a transplant option. But in those cases we don’t give them an MP-based regimen but then we have to use either a bortezomib-based regimen if they have a 13q minus delta.

Can you go older than that though?

About going older than that, it depends on the patient’s fragility and also independence or absence of comorbidities. In those cases we try to push, go up until the 75 years of age for autologous transplant.

So finally, could you give me some practical messages for doctors coming out of the multiple myeloma session, just very briefly?

I think that the message is very clear. For myeloma the treatments that we are giving today has improved response tremendously and as a consequence the survival has increased. But this comes from the addition of multiple agents but we have the cost which comes with the toxicity. So as long as the patient is durable, is resistant against the toxicities we have to go up to the maximum and transplant is the maximum. But we can also integrate the novel agents to the transplant treatment so it’s the whole package. Either before or after the transplant, the addition of novel agents to the transplant as long as the patient can survive.

Professor Meral Beksac, thank you very much for joining us on ecancer.tv.

Thank you.