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Expert Explains Shifting Myeloma Paradigm

Angelica Welch
Published: Friday, Apr 27, 2018

Dr. Keith Stewart, MB ChB
Keith Stewart, MB ChB
In the shifting treatment landscape of multiple myeloma, experts are beginning to question previously established methods as new agents and techniques emerge.

State of the Science Summit™ on Multiple Myeloma and Myeloproliferative Neoplasms, Keith Stewart, MB, ChB, professor of medicine, consultant, Division of Hematology/Oncology, Department of Internal Medicine, Mayo Clinic, discussed the role of stem cell transplant, minimal residual disease (MRD) testing, and maintenance therapy in the treatment of patients with multiple myeloma.

Transplant

Agents such as the immunomodulatory drug lenalidomide (Revlimid) and the proteasome inhibitor bortezomib (Velcade) have entered the myeloma space, potentially changing the progression of treatment for these patients. Specifically, the role of transplant has come under question—a therapy that Stewart says is often intolerable for patients.

Specifically, the addition of lenalidomide, bortezomib, and dexamethasone consolidation or a second autologous hematopoietic stem cell transplant (ASCT) was not superior to a single ASCT, followed by lenalidomide maintenance, in the upfront treatment of multiple myeloma.

Maintenance

In the posttransplant setting, maintenance therapy with lenalidomide has become a favored therapeutic approach in the United States. Maintenance therapy with lenalidomide, specifically, has shown a significant benefit in PFS, as well as OS. In a meta-analysis published in 2017, patients with multiple myeloma posttransplant assigned to lenalidomide had superior PFS (52.8 vs 23.5 months) compared with those given placebo or observation (HR, 0.48; 95% CI, 0.41-0.55).2 At a median follow-up of 79.5 months, the median OS was 86.0 months for the placebo or observation group and had not been reached for the lenalidomide maintenance group (HR, 0.75; 95% CI, 0.63-0.90; P = .001).

These claims of benefit were cemented in place by the large Myeloma XI trial out of the United Kingdom, Stewart said, which looked at the role of maintenance therapy in more than 1000 patients. The study showed that patients with myeloma had deeper responses after induction and after allogeneic stem cell transplantation with outpatient-delivered quadruplet therapy than with sequential immunomodulatory triplet combinations.3 Although lenalidomide has shown benefit in patients following stem cell transplant, investigators are looking into combinations to see if the addition of more drugs may prove better.

“Based on those 2 recent updates, lenalidomide maintenance also seems to be here to stay,” Stewart said. “The question that arises is, ‘Is that enough, or should other drugs be added?’ We don't have a lot of data on that.”

Additionally, ixazomib (Ninlaro) has shown potential in the maintenance setting, and the question of whether monoclonal antibodies such as daratumumab (Darzalex) might be useful in that setting is still unresolved. Stewart says that some experts suspect that that class of agents may show some benefit.

MRD Testing

A potentially paradigm-shifting advance is the use of MRD testing in patients with multiple myeloma.

"We have pretty powerful evidence at this point that MRD measurement is important. Patients who obtain MRD-negative states live longer free of disease and probably have a longer OS,” said Stewart.


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