Pharmacy Podcast Network: You are listening to the Pharmacy Podcast Network (PPN). New technologies are leading to deeper responses and longer survival for patients with multiple myeloma. But these complex care plans lead to questions about how to optimize care. Clinicians are challenged with leveraging the best available evidence and meeting individual care needs in diverse patient populations across different settings.

i3 Health has released a two-part podcast series about the latest advances in multiple myeloma treatment. Don't miss these two episodes with pharmacists Dr. Joseph Kalis and Dr. Eric Cannon. Learn more at i3Health.com, that's i3Health.com.

Todd Eury: Pharmacy Podcast Network had an amazing opportunity to get together with i3 Health. You can find more information about this organization empowering pharmacists and health care professionals through education. Mobile education today—if you're listening, if you're driving in your car, jogging, walking your dog, make sure you take a look at i3Health.com after today's podcast.

I'm excited that we have a returning guest that we're going to be talking with as a lead on today's subject. But first I just wanted to tell you, i3 Health's mission is to enhance the proficiency of multidisciplinary health care teams by providing evidence-based, fair-balanced, approved activities that address and identify the professional practice gaps in unmet educational needs.

We love leveraging podcasts and mobile education to do this. We know how busy you are. We know how crazy life can get. So, if you consume some continuing education (CE) through podcasting, i3 Health is a source of education. Today we're celebrating an activity that i3 Health has developed around multiple myeloma. The one and only Dr. Joseph Kalis is back, and it's great to have Joe back. I want to introduce Joe again to the Pharmacy Podcast Network. It's great to have you here.

Joseph Kalis, PharmD, BCOP: Thank you, Todd. Pleasure to be back again and to speak with you both.

Mr. Eury: I'm not driving today's bus, Joe. We have a host today that I'm excited to introduce to the Pharmacy Podcast Network. Keira Smith has been with i3 Health for some time, and she's helped to craft this series. I'm excited to have her here. Keira, welcome to the PPN.

Keira Smith (i3 Health and Oncology Data Advisor): Thanks so much, Todd and Joe. It's great to talk with you both today.

Todd Eury: We have a serious subject today that continues to morph: treatment for multiple myeloma. Keira, I'm excited that you're hosting today's conversation with Dr. Kalis. I'm going to turn it over to you and let the two of you take us and our listeners into this presentation.

Keira Smith: Great, thanks so much. At i3 Health, we're really excited about this continuing pharmacy education (CPE) activity that was launched recently that Dr. Kalis chaired. So, Joe, going back to the background for this activity, what is the need for pharmacy education surrounding multiple myeloma, and what are the educational gaps that you as well as other pharmacists tend to encounter in your practice?

Dr. Kalis: Those are some great questions, Keira, very glad that you posed them to me. I'd say that the need for pharmacy education in multiple myeloma really starts off with a good understanding of what the disease state is. As a student and then as a resident and now in practice for 10-plus years, it's something that I've grown in familiarity with over time and by working with patients and exposure to the disease.

But I think the word Todd used just a few moments ago about this, "morphing," is a great way to think about multiple myeloma. We've got a disorder of the fully mature or permanently differentiated B cells and the ones that make antibodies for our immune system. In myeloma, what's happening is that the genetic instructions have gone awry. Something's faulty where antibodies being made are no longer functional. We might have pieces or parts of an antibody.

For a learner—be it a pharmacist student or an educated member of the public who might be listening in today—that's something that I think really informs the treatments we're using. But for me, coming back to the core of what's happening and why it's happening really helps to organize and centralize some of the treatments that we're using.

I'd say as far as educational gaps, I'm going to come back to that term "morph"—the Mighty Morphin Power Rangers were something that I was familiar with growing up—but it's such a rapidly evolving landscape of treatments. It seems every month we have new drugs or new indications approved from the FDA or we're using new combinations. But I'd say the educational gaps have really just been being able to keep up with everything and also to keep that information organized in a certain way so that you can pull it up at a moment.

Keira Smith: Definitely. I agree that things are changing so fast. I was just recently at the American Society of Hematology (ASH) Meeting, and it seemed like almost every presentation was about a new target in multiple myeloma, so it's really exciting to see.

Dr. Kalis: It definitely is. I've done some other programs and a fair bit of other educational opportunities with things like targeting B-cell maturation antigen (BCMA) or other drug targets. I think as time goes on, we're going to see more and more agents and more targets discovered and taken advantage of for treatment. I think there's a lot still to come in multiple myeloma, and it's something I'm personally very excited about.

Keira Smith: Definitely, that's super exciting. So, how does this activity help to address some of these educational gaps as well as cover the rapidly evolving fields?

Dr. Kalis: The activity in question here through i3 Health really did a nice job putting together some of that foundational knowledge for pharmacists and listeners about what multiple myeloma is and what some of our options are for initial treatment, both in the transplant-eligible patients and those who are ineligible for transplant. You've got a plethora of options out there—I guess plethora is my $10 word for the day—but knowing which options to use when and then what patients are eligible for which option is something I think this activity really did quite nicely.

Keira Smith: As far as all of these latest advances, especially the ones that have come out most recently, what are the ones that you think are the most applicable to practice that you're personally most excited about?

Dr. Kalis: Some of it, I think starting first and foremost, is first-line therapy. We've got the tried and true regimen VRd (bortezomib/lenalidomide/dexamethasone). But the addition of other classes of agents to the one that we talked a bit about in the activity was daratumumab, an anti-CD38 monoclonal antibody. I find that agent or combinations with that class of agents pretty darn exciting because of their ability to increase overall response rates and also to increase the depth of response. It's something we'll focus a little bit on in the activity, just trying to achieve minimal residual disease negativity. In terms that, some of our listeners will be more familiar with it in leukemia or lymphoma or other hematologic disorder spaces. I think it's really starting to come into the primetime in myeloma. If we can get a great response or a very deep response in somebody's early stages of treatment, I think that portends very, very well for how their future treatments and sequences might go.

Keira Smith: Definitely. As far as what's coming down the pipeline, what are you looking forward to seeing in the next few years or so?

Dr. Kalis: That's a very loaded question and I appreciate that. I think back to grandpa's double barrel 12-gauge, but if I'm going to stick with that 12-gauge analogy, you've got one side that's the chimeric antigen receptor (CAR) T cells. We've got some commercially available CAR T cells right now that are targeting BCMA, and some very exciting and encouraging data from those agents has come out now. I think there's a lot more to be learned about how to best utilize those drugs, probably saving it for fourth-, fifth-, sixth-line therapy in our relapse patients. There are some ongoing trials that I'm following pretty closely, looking at using CAR T cells earlier in treatment, first-line, back in line. Coming back to that shotgun analogy, you go back to the other barrel, we've got bispecific antibodies offering us the opportunity to take an off-the-shelf drug, and we're not re-engineering a patient's own cells.

We have an off-the-shelf product that can be utilized rather quickly, targeting some of the same things—BCMA with teclistamab. There are other agents out there; talquetamab is one that comes to mind with GPRC5D as a target. But I think it'll be very interesting to see just how these agents are sequenced. We're starting to get some more mature data emerging for how to use them, what the results are, and what we're seeing in terms of symptoms and side effects, things like cytokine release syndrome or different neurologic toxicities. Can you use one and then the other? What will we combine them with? That's a big thing I think we've all seen in myeloma. One drug is good, so let's try three or four with different mechanisms of action and see where that gets us. There's a lot still to come.

Keira Smith: To pivot a little bit, in the activity you covered treatment advances in multiple myeloma, and the other aspect of it was the managed care provider perspective that Dr. Cannon shared his insights on. Is there anything about this other perspective that you see in your practice that you'd like to talk about?

Dr. Kalis: Oh, definitely, definitely. In pharmacy, we're uniquely positioned to not only ensure that the right drugs are reaching the right patient at the right time—It's that old tried-and-true cliche, but it still stands because it's so accurate—but I think in today's landscape, we've also taken on more of a role in making sure that the agents we're using are among some of the more cost-effective. We've got a very complex landscape of payers, whether it's private insurances or government programs or other things.

One thing that my institutions focus a lot on is how are we getting reimbursed for these? As we talk about some of these exciting advances in myeloma—daratumumab, isatuximab, elotuzumab, CAR T cells, and others—one of the questions we're getting a lot from administrators is, well, you've got some really high price tags on these drugs, so how do we know we're going to get reimbursed? Or what are the criteria we need to focus on? Are we following guideline or labeling indications?

One of my favorite things to teach students is you start with the on-label stuff on oncology and then it very quickly becomes off-label as the science advances, until the labels and regulatory aspects catch up. I've seen some numbers in the literature for CAR T cells looking at around $400,000-$500,000 for the drug, and then you have to add the cost of hospitalization and supportive agents such as tocilizumab in there. We're seeing many of these same questions come up with the bispecific antibodies. I think it's very apropos for pharmacists to stay involved, even just peripherally, with some of the costs associated with our therapies in managed care. We can achieve similar outcomes with a less expensive agent and have patients reach the same end point. Maybe we need to be taking a closer look at that.

Keira Smith: Definitely. All right, Todd, I will turn it over back to you.

Todd Eury: I like the fact that i3 Health has built out this two-part module. Joe, you've led it along with Dr. Cannon in discussing this for our pharmacists to access, and we're going to have links in our show notes driving people to the place where you can actually take this course and understand: Aligning Treatment Goals in Value-Based Care in Newly Diagnosed Multiple Myeloma. Joe, it is always amazing and great to listen to you and learn from you. You've helped so many other pharmacists really advance their knowledge and create curiosity in order to dig in, and that's the domino effect.

I want to see pharmacists empowering pharmacists to push further in order to get this data back to our physicians, our researchers, and really to adjust treatment along the way. Like we all said, when things morph, we want to stay ahead of it. I think pharmacists are the key. I'm a fan, as you know, Joe, and I hope to have you back on a future podcast. We're so excited about i3 Health, and Keira, we have to have you back as well. I want to thank you both.

Dr. Kalis: Thank you, Todd. It was a pleasure to be here. I'd like to thank all those folks out there in the past who kind of set me on this course or help me come up with some of the analogies. Robert Mancini, Ryan Zimmerly, you're out there. I'll see you guys when I see you.

Todd Eury: Right. Thank you so much. Thank you to the i3 Health team for helping us put this together. Be on the lookout for our promotion of this educational event, and we'll be promoting this throughout all of our social media. If you have ideas for future education through podcasting, maybe you'd like to participate in what you're passionate about, please reach out to Keira and the i3 Health team. You can go to i3Health.com. Once again, that's i3Health.com.

Pharmacists, you are our heroes. Thank you for everything that you're doing for patients out there who are suffering with serious chronic diseases. We look to you to bring us future education, so we thank you. And listeners, anything that you can provide us in helping to make these presentations better, please let us know.

About Dr. Kalis

Joseph Kalis, PharmD, BCOP, is an Ambulatory Oncology Clinical Pharmacy Specialist at the University of Colorado Health. In this position, he educates patients about their chemotherapy and immunotherapy treatments, reviews treatment plans and dose adjustments, and assists with supportive care. Dr. Kalis is a member of the Hematology/Oncology Pharmacy Association's Oncology Core Competency Certificate Program, and he has published several peer-reviewed papers on oncology and pharmacy.

Transcript edited for clarity. Any views expressed above are the speakers' own and do not necessarily reflect those of Oncology Data Advisor.