Oral Domiciliary Therapy of Multiple Myeloma with Cyclophosphamide, Pomalidomide and Dexamethasone Regimen in the Covid Era - A Pilot Study

Abstract

Background: Multiple myeloma is the 11th most common cancer in India, with a prevalence of 1.1% and a diagnosis age range of 65 to 74 years. Various doublet or triplet combinations of steroids, immunomodulatory medications, proteasome inhibitors, and monoclonal antibodies are used in standard myeloma therapy. Covid 19 pandemic has been extremely challenging especially when it comes to the management of cancer patients. As the incidence of multiple myeloma (MM) is increasing rapidly in Asian countries, and the Asian patients seem to respond differently compared to the western population to the various commonly used treatment regimens, these patients require special consideration and care to ensure optimum treatment and at the same time, precautions must be taken to decrease their exposure to COVID-19. Considering these aspects, we decided to use an all-oral treatment of CyPomDexa (Cyclophosphamide, Pomalidomide and Dexamethasone) for the treatment of myeloma both as a first-line regimen as well as for relapsed and refractory patients who had not been exposed to this regimen in the past, and to observe the feasibility and efficacy of domiciliary, oral treatment with cyclophosphamide, pomalidomide and dexamethasone (Cy-Pom-Dex) for myeloma patients during the COVID-19 pandemic. Methods: A Prospective, observational, single-arm, pilot study was conducted from 1st March 2020 to 30th September 2020 in patients who were newly-diagnosed (NDMM) or relapsed multiple myeloma (RMM) at a tertiary care Centre in Bengaluru. The patients were started on oral treatment with CyPomDexa during lockdown mandated by the COVID-19 pandemic. This regimen was chosen as a replacement for cyclophosphamide, bortezomib, dexamethasone (CyBorD), which was the previous standard of care in our centre. Haematological and biochemical parameters of the patients were checked pre-treatment. Weekly complete blood counts and biochemistry was checked with home collection of blood samples. This was combined with weekly video consultations. Face-to-face visits were conducted monthly, and myeloma parameters were checked at the end of every 2 months. Results: 6 patients underwent the planned treatment. Among these 4 had NDMM and 2 had RMM. 1 patient who received CyPomDexa from the first cycle was lost to follow-up (COVID 19 positive). Among the remaining 5 patients ,3 (50%) achieved VGPR (very good partial response) and 2 (33.33%) achieved SCR (Stringent Complete Response) after 4 cycles of therapy. Conclusion: This regimen achieved good disease control in all the evaluable patients, within 4 cycles. A larger, prospective study is however required to draw definitive conclusions.