Dr Fenske on the Omission of ASCT in Mantle Cell Lymphoma After First CR and uMRD

“Considering that the median age for patients with mantle cell lymphoma is somewhere in the range of 60 to 70 [years, for] a lot of these patients, ASCT is a very difficult procedure for them to get through. It has a significant amount of toxicity.”

Timothy S. Fenske, MD, MS, medical oncologist, professor of medicine, the Medical College of Wisconsin, discusses implications for the mantle cell lymphoma (MCL) treatment landscape following the readout of data regarding the omission of consolidative autologous stem cell transplant (ASCT) from the phase 3 ECOG-ACRIN EA4151 trial (NCT03267433).

At the 2024 ASH Annual Meeting, Fenske presented initial data of an analysis from ECOG-ACRIN EA4151, which investigated rituximab (Rituxan) with or without consolidative ASCT in patients with MCL in their first complete remission (CR) with undetectable minimal residual disease (uMRD).

The study’s findings—along with data from the phase 3 TRIANGLE trial (NCT02858258) from Europe evaluating ibrutinib (Imbruvica) plus immunochemotherapy with or without ASCT— showed that ASCT could be omitted in first-line therapy in patients with MCL who achieve uMRD, Fenske says. Data from ECOG-ACRIN EA4151s showed that at a median follow-up of 2.7 years, the futility boundary for overall survival (OS) was crossed for ASCT plus rituximab vs rituximab alone in all randomly assigned patients (n = 516; HR, 1.11; 95% CI, 0.71-1.74; P = .66) and in all patients treated as assigned (n = 375; HR, 1.00; 95% CI, 0.58-1.74; P = .99).

However, Fenske notes that offering ASCT may still be appropriate for patients who have detectable MRD after first CR, which was determined by the 3-year OS and progression-free survival rates from other arms in the ECOG-ACRIN EA4151 trial.

The findings regarding the omission of ASCT in patients with uMRD in first CR are significant, especially because patients with MCL are generally older, Fenske emphasizes, explaining that ASCT can be a difficult procedure for those in this age group because of the level of toxicity. The outcomes from the ECOG-ACRIN EA4151 and TRIANGLE trials have established that safely omitting ASCT in patients with undetectable MRD is a notable advancement, he concludes.