Insights From: Rafael Fonseca, MD, Mayo Clinic; Gareth Morgan, MD, PhD, UAMS Myeloma Institute; Thomas G. Martin, MD, UCSF Helen Diller Family Comprehensive Cancer Center
Thomas G. Martin, MD: In regard to maintenance-based therapy, lenalidomide has really changed the way we do maintenance. We now have 3 large randomized trials that show benefit in terms of progression-free survival in patients taking lenalidomide versus not taking maintenance-based therapy. When a meta-analysis of these data was performed, there was a marked advantage in terms of progression-free survival. Also in the meta-analysis, there was an advantage in overall survival, and those who received maintenance in fact had an overall survival advantage of over 2 years. It was more like 2.5 years. And for me, that’s really telling that lenalidomide has become our standard for maintenance-based therapy, especially after transplant. There are also data for lenalidomide as maintenance after primary therapy for those patients who don’t undergo transplant. Now, there are caveats to maintenance therapy and we might treat high-risk patients a little bit differently, but certainly lenalidomide is in the mainstay of maintenance.
Gareth Morgan, MD, PhD: One of the important questions about maintenance is, what is maintenance? How long should maintenance be given for? I think that’s a really important question. At disease relapse, you should clearly continue maintenance, if you can, until the next progression. I think that’s where the data are. In the upfront setting for newly diagnosed patients, we’ve just completed a study and we tried to continue until disease progression. But actually, when you look at that study, only 30% of patients were on it well beyond 3 years. So really, there’s a thing about quality of life, which impacts on how long you can actually deliver maintenance. For us, we continue maintenance for 3 years. The French use it for arguably 1 to 2 years, and a variety of physicians use different timing. But at one level, it all comes down to the same thing: It’s hard to stay on for more than 3 to 4 years, and so you’re driven by the patient experience and toxicity.
Thomas G. Martin, MD: If you have a patient who has undergone therapy, is now in complete remission, and is receiving lenalidomide as maintenance-based therapy, you’re really following them closely for side effects. Patients on maintenance have upwards of a 50% chance of having some cytopenias—either neutropenia or thrombocytopenia—and some other potentially quality-of-life–affecting side effects like fatigue and diarrhea. For patients who have achieved a really good response, like a complete remission, and have some side effects, I have often taken those patients off maintenance-based therapy.
My personal approach in a patient like that is that I take them off for 3 months. And after 3 months of being off maintenance, we revisit the issue. We say, “OK, how was that 3 months versus when you were on maintenance? If your quality of life is really so much better, then we probably should continue off maintenance.” However, if there’s really not much change in the quality of life and we think there’s a benefit to continue maintenance therapy, I continue them on lenalidomide-based therapy.