Subscribe

Delaying Transplant in Patients with Newly Diagnosed Multiple Myeloma

Value-Based Care in Myeloma - Multiple Myeloma
Caroline Helwick

“In the era of novel agents, one size does not fit all” in terms of induction and autologous stem-cell transplant (ASCT), said Paul G. Richardson, MD, Director of Clinical Research, Dana-Farber Cancer Institute, Boston, who spoke at a special session on transplantation in multiple myeloma at the American Society of Hematology annual meeting.

“For 20 years, high-dose therapy with ASCT has been considered a standard frontline treatment for younger patients with adequate organ function. But with the introduction of novel agents, the role of ASCT has changed in several ways,” Dr Richardson noted.

Advances in treatment mean that a subset of newly diagnosed patients may be safely treated without immediate ASCT. “We may be able to achieve the same things without the dramatic impact of high-dose alkylating agents,” Dr Richardson suggested.

Delaying transplantation, or never needing it at all, would spare patients the acute toxicities and long-term complications that are inherent to high-dose alkylation and, in particular, exposure to melphalan, Dr Richardson added.

Novel Agents, Robust Responses

Dr Richardson noted that the efficacy of novel agents, including bortezomib (Velcade), lenalidomide (Revlimid), and thalidomide (Thalomid), has led to their investigation in the upfront setting, without the immediate application of ASCT.

At this point, 3-drug regimens that combine a proteasome inhibitor and an immunomodulatory drug are considered the best standard induction for ASCT-eligible patients, but the question now is whether these responses may be sufficient for patients to forego early ASCT.

These 3-drug platforms can produce deep, high-quality, and durable responses. Recent retrospective studies have suggested that outcomes with these drugs alone are as good as those achieved by patients who undergo early ASCT after induction treatment with these regimens, Dr Richardson noted.

In phase 2 clinical trial populations, response rates are 100% with the combination of lenalidomide, bortezomib, and dexamethasone (Decadron), and complete and near-complete remission rates exceed 50%. The combination of carfilzomib (Kyprolis), lenalidomide, and dexamethasone has shown complete response rates of more than 60%, he pointed out.

Now, monoclonal antibodies are poised to “revolutionize the field,” Dr Richardson added, because they are producing “unprecedented qualities of response” and are capable of overdriving poor cytogenetic characteristics of disease.

In addition, other next-generation agents, such as ixazomib, and novel agents in development (eg, monoclonal antibodies and histone deacetylase inhibitors) will offer potent salvage regimens for patients who progress after frontline initial induction treatment without early ASCT. “These offer reliable rates and durations of response that make the ability to then move to a delayed ASCT more feasible,” he suggested.

Who May Avoid Transplant?

“Now and increasingly in the future, early ASCT is not required in all transplant-eligible patients,” Dr Richardson concluded.

This subset potentially includes patients with low disease stage (International Staging System stage I vs stages II-III), low-risk cytogenetic profile, absence of extramedullary disease, deep response to induction therapy, and negative minimal residual disease after induction, he indicated.

To truly establish delayed ASCT as a standard of care, randomized clinical trial data evaluating early ASCT versus delayed ASCT will be critical. Dr Richardson noted that a large study is ongoing, and its results are eagerly awaited.

Related Items
Can Some Patients with Multiple Sclerosis Stop Treatment?
Caroline Helwick
Web Exclusives published on August 30, 2017 in Multiple Sclerosis
Oral Ozanimod: A Safer Sphingosine-1-Phosphate Receptor Modulator?
Caroline Helwick
Web Exclusives published on June 26, 2017 in Multiple Sclerosis
Vitamin D Supplementation Shows Benefits in Multiple Sclerosis, but Questions Remain
Caroline Helwick
Web Exclusives published on March 31, 2017 in Multiple Sclerosis
Ocrelizumab Receives Breakthrough Therapy for Progressive Multiple Sclerosis
Caroline Helwick
VBCN - April 2016 Volume 3, No 1 published on May 3, 2016 in Multiple Sclerosis
Ozanimod Achieves Very Low Relapse Rate in MS
Caroline Helwick
VBCN - April 2016 Volume 3, No 1 published on May 3, 2016 in Multiple Sclerosis
Stem-Cell Transplantation Shows Promise in Multiple Sclerosis, but Major Concerns Remain
Caroline Helwick
VBCN - April 2016 Volume 3, No 1 published on May 3, 2016 in Multiple Sclerosis
Multiple Myeloma Therapy in 2015: “An Extraordinary Moment in Oncology”
Dana Taylor
VBCC - February 2016, Vol 7, No 1 published on February 16, 2016 in Multiple Myeloma
All-Oral Regimen May Become a New Standard of Care in Advanced Multiple Myeloma
Dana Taylor
VBCC - February 2016, Vol 7, No 1 published on February 16, 2016 in Multiple Myeloma
Consistent Benefit Over Time in Elotuzumab Studies
Dana Taylor
VBCC - February 2016, Vol 7, No 1 published on February 16, 2016 in Multiple Myeloma
Daratumumab Improves Overall Survival in Multiple Myeloma
Dana Taylor
VBCC - February 2016, Vol 7, No 1 published on February 16, 2016 in Multiple Myeloma
Last modified: May 20, 2015
  • Rheumatology Practice Management
  • American Health & Drug Benefits
  • Value-Based Cancer Care
  • Value-Based Care in Myeloma
  • Value-Based Care in Neurology