"Maintenance Therapy in Multiple Myeloma," SV Rajkumar, The ASCO Post, May 1, 2014, Volume 5, Issue 7.
The article focuses mainly on the results of the U.S. Revlimid maintenance trial and a similar trial done in France. Of those two trials, just one -- the U.S. trial -- has shown an overall survival benefit for post-transplant Revlimid maintenance.
Dr. Rajkumar offers some useful insights into the details of the survival benefit seen in the U.S. trial, noting, for example,
35% of patients in the U.S. trial had received lenalidomide as [initial therapy prior to their stem cell transplant], and these were the patients who contributed to the significant survival benefit. No significant survival differences were seen in patients not receiving lenalidomide induction. How does this affect interpretation?
Since the response and toxicity to lenalidomide use was known a priori in a substantial subset of patients screened for enrollment in the U.S. trial, patients who did not respond and those with undue toxicity with lenalidomide induction were naturally less likely to have been enrolled. On the other hand, patients in whom a clear survival benefit was observed were those who received prior lenalidomide, and were most likely already known to be responsive and tolerating such therapy well at the time of randomization.
The recommendations Dr. Rajkumar makes at the end of the article regarding maintenance mirror those in the Mayo's "MSmart" guidelines that have been discussed frequently here in the forum. They are as follows:
For standard-risk patients, we recommend 2 months of lenalidomide consolidation following autologous stem cell transplantation. ... After 2 months of consolidation, if patients are known to be lenalidomide-responsive and are not in very good partial response or complete response, we recommend lenalidomide maintenance ...
As far as duration of therapy, we recommend capping maintenance at approximately 2 years ...
For intermediate- and high-risk patients, we prefer bortezomib (Velcade)-based maintenance based on the results of several recent trials ...
The most recent update to the Mayo Clinic's "msmart" guidelines are discussed in this recent forum thread.
