More flexibility for people living with myeloma as Scotland approves two treatments at second line and beyond

Two patient-centred treatments have been approved for use in Scotland at second line and beyond.  

Pomalidomide (Imnovid®) in combination with dexamethasone (PD) and pomalidomide in combination with bortezomib (Velcade®) and dexamethasone (PVD) have both been approved by the National Cancer Medicines Advisory Group (NCMAG). 

These decisions add flexibility to the treatment pathway in Scotland. They bring much needed options for patients for whom currently accepted second line treatments are not suitable either due to frailty, co-morbidities or challenges with the burden of treatment, including travel to cancer services due to geographical remoteness, the need for carer support or mobility. 

NCMAG supported the use of PD for people who have received at least one prior treatment including lenalidomide (Revlimid®) and where existing treatments are not suitable due to frailty, co-morbidities or unacceptable treatment burden This is an off-label and off-patent use. 

Until now, PD was only available to people at third line and beyond in Scotland, and this approval gives patients access to this effective oral regimen earlier in the treatment pathway. 

NCMAG supported the use of PVD for people who have had at least one prior treatment, have become resistant to lenalidomide and for whom an anti-CD38 monoclonal antibody like daratumumab (Darzalex®) is not a viable option. This is an on-label and off-patent use. 

Scotland is the first UK nation to support the use of PVD, which is already available in other countries, on the NHS. PVD gives patients with co-morbidities like cardiac issues access to an effective triplet at second line and beyond. PVD may also be a good option for patients in rural locations because it can, in some cases, be given at home or in a community setting. 

Scott Purdon, Head of Patient Advocacy at Myeloma UK, said:

“It’s fantastic to see these new treatments approved. We know that people want options to be able to take treatments at home where possible and avoid travelling to hospital. We worked hard alongside clinicians to make the case for PD and PVD to be available on the NHS. This is down to clinicians listening to people living with myeloma and putting their needs front and centre. We are so grateful that NCMAG have taken a flexible approach and we will be taking our learnings from this process to see what is possible for the rest of the UK.”

Moira, a myeloma patient who sits on the Myeloma UK Advocacy Partner Panel, welcomed the news. She said:

“From Day 1 of my diagnosis, I have been told treatments for myeloma are being developed at a great rate of knots. It is incredibly reassuring when drugs successfully go through the approval process. The hope now is to have newer, better drugs with fewer side-effects made available even sooner to all patients regardless of where they live in the UK. It is heartening Myeloma UK have campaigned for PD and PVD to be given the green light here in Scotland at second line. Hopefully the rest of the UK will follow suit soon. As always, grateful thanks to all at Myeloma UK for their tireless efforts.” 

NCMAG is a committee set up to review off-patent or off-label uses of cancer medicines to make a national decision about whether their use is supported on the NHS in Scotland. 

Unlike the Scottish Medicines Consortium (SMC) and the National Institute for Health and Care Excellence (NICE), which assess treatments put forward by pharmaceutical companies, NCMAG reviews applications submitted directly by clinicians.  

This clinician-led process puts patients’ needs first and helps to address gaps in treatment pathways.

Dr Jennifer Travers, a clinician at The Beatson West of Scotland Cancer Centre, one of the proposers for the application for PD and PVD to NCMAG. She said:

“Every patient with myeloma is different and one size does not fit all.  By having more options for treatment at each line of therapy, then we can tailor things to best meet the need of an individual.  We are delighted with the work done by the NCMAG in order to improve the care for myeloma patients in Scotland.”

Myeloma UK worked directly with Dr Travers and NCMAG as part of the application, ensuring that the voices of the myeloma community were heard throughout the process.

Q&A

What do these decisions mean for patients? 

These decisions mean that in Scotland: 

• Pomalidomide and dexamethasone can now be used earlier in the treatment pathway and can be given to eligible patients from first relapse. It gives patients whose myeloma is refractory to lenalidomide access to an all-oral treatment option that can be easily taken at home. 

• Pomalidomide, bortezomib and dexamethasone can be used to treat eligible myeloma patients at first relapse and beyond. It gives patients in Scotland access to a new triplet combination, widening treatment options for people with additional health conditions (e.g. cardiac issues).  

Both these decisions add much needed flexibility to the myeloma treatment pathway in Scotland. This means clinicians will now have more options to tailor treatments to patients based on their overall health and quality of life. 

What’s NCMAG?

The National Cancer Medicines Advisory Group (NCMAG) advises NHS Scotland on the use of certain cancer medicines. They review the clinical and cost-effectiveness of cancer medicines that the Scottish Medicines Consortium (SMC) wouldn’t assess and provide national advice on their use in Scotland. This includes looking at alternative dosing schedules and treatment combinations as well as looking at new uses for generic medicines. 

NCMAG’s advice helps to improve patient access to cancer medicines, and to make decisions about cancer treatments more efficient.  

How does NCMAG work?

A NCMAG review is a clinician-initiated process. It starts when a clinician submits a proposal for national advice on a new or alternative use of a cancer medicine that could benefit their patients.  

If the proposal meets the criteria for NCMAG, it is reviewed by the NCMAG Council.  

NCMAG conducts a full review of evidence, including evidence from patients and patient representatives, and assesses the clinical and cost-effectiveness of the new use of the cancer treatment before coming to a decision on whether they are supportive of its use within NHS Scotland. 

What about England, Wales and Northern Ireland? 

NCMAG only makes recommendations about the use of cancer treatments in Scotland. Therefore, this decision only effects myeloma patients in Scotland. 

There are similar processes for clinician-led treatment reviews in England, Wales and Northern Ireland. Myeloma UK is working with the UK Myeloma Society to seek approvals for clinician-led proposals including PD and PVD across the UK.