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Consolidation and Maintenance Therapy for Multiple Myeloma:
Is it the New Standard?
Paul G. Richardson, MD RJ Corman Professor of Medicine,
Harvard Medical School
Jerome Lipper Multiple Myeloma Center,
Dana-Farber Cancer Institute
Boston, Massachusetts, United States
1. True
2. False
True/False: Consolidation post-SCT has been
associated with PFS, RR, but no OS advantage
1. True
2. False
True/False: Maintenance post-SCT has been
associated with PFS, RR, and OS benefit
Current Paradigm of Initial Treatment
Adapted from Ludwig H, et al. Oncologist. 2012;17(5):592-606.
Richardson PG, et al. Br J Haematol. 2011;154(6):755-762.
Transplant
eligibility
Initial therapy
Autotransplant Consolidation
Continue initial therapy
MaintenanceOR
Treatment Goals Following Induction Therapy for Multiple Myeloma
• Improve progression-free survival (PFS) and overall survival (OS)
• Does improved PFS result in improved OS?
• Is a risk adapted approach justified?
• Continued therapy following Induction
– Timing, duration, intensity & toxicity
(to avoid treatment fatigue)
– Easy to deliver, convenient, improves PFS and OS
Mihelic R, et al. Leukemia. 2007;21(6):1150-1157. Richardson PG, et al. Br J Haematol. 2011;154(6):755-762.
ConsolidationMaintenance
Transplant Eligible
ASCT Induction
ASCT Induction
Maintenance until PD
ConsolidationMaintenance
Transplant Eligible
Supportive care
ASCT Induction
ASCT Induction
Maintenance until PD
Consolidation/Maintenance: Deciding Therapy/Risk Factors
• Age
• Performance status/co-morbidities– PS matters more than age
– Renal failure (bortezomib-containing regimen (BCR)
Sonneveld P, et al. J Clin Oncol. 2012;30(24):2946-2955.
• International scoring system– Stage II or III Greipp PR, et al. J Clin Oncol. 2005;23(15):3412-3420.
• Cytogenetics/molecular testing– CD138 selection of marrow aspirate
– Metaphase karyotyping: del(13) (BCR)
Jagannath S, et al, Leukemia. 2007;21(1):151-157.
– FISH: t(4: 14), (14:16) del(1p), +(1q), del(17p) (BCR)
Munshi NC, et al. Blood. 2011;117(18):4696-4700.
– Molecular: GEP 70, EMC-92 (validation and what to do with high risk pts)
Shaughnessy JD Jr, et al. Br J Haematol. 2007;137(6):530-536. Kuiper R, et al. Leukemia. 2012;26(11):2406-2413.
• Other disease features– Extra-medullary disease, plasma cell leukemia, high LDH
Adapted from McCarthy PL, et al. Hematology Am Soc Hematol Educ Program. 2013:496-503.
Adapted from Ludwig H, et al. Oncologist. 2012;17(5):592-606.
Novel Agent-Containing Consolidation Therapy Improves Depth of Response and Prolongs PFS
• Bortezomib monotherapy
(Nordic Myeloma Study Group [NMSG 15/05] trial)1
– Significant improvement in PFS with bortezomib consolidation
compared to control: 27 months vs 20 months, P = .05
• VTD versus TD (GIMEMA trial)2
– VTD consolidation significantly increased CR and CR/nCR
rates versus TD
– Median PFS significantly longer for VTD versus TD:
62 months vs 48 months, P = .001
1. Mellqvist UH, et al. Blood. 2013;121(23):4647-4654. 2. Cavo M, et al. Blood. 2012;120(1):9-19.
Cavo M. Presented at: IMW 2013, oral presentation (S15 consolidation / maintenance)
Straka C, et al. J Clin Oncol. 2015;33(Suppl): Abstract 8511.
• Bortezomib 1.3 mg/m2 16 weekly doses over 20 weeks vs observation
PFS: Consolidation vs Observation
• Median PFS: 33.6 months (bortezomib vs 27.8 months (observation)
Induction treatment = VRD cycles 1,2 and 3 every 21 days
Lenalidomide 25mg/d (days 1 to 14)
Bortezomib 1.3mg/m2 (days 1, 4, 8, 11)
Oral dexamethasone 40mg/d (days 1, 8, 14)
Stem cell collection
ASCT
Consolidation treatment
VRD cycles 4 and 5 every 21 days
Maintenance therapy for 12 months
Lenalidomide 10mg/d for 3 months then 15mg/d if well tolerated
Immunophenotypic analysis
Immunophenotypic analysis
Immunophenotypic analysisResponse assessment
Response assessment
Response assessment
Response assessment
Response assessment
IFM 2008: Phase II Study
in Newly Diagnosed MM Patients <65 Years
Roussel M, et al. J Clin Oncol. 2014;32(25):2712-2717.
IFM 2008: Response Rates (ITT)(VRD x 3 - Transplant - VRD x 2 - Rev 1 year)
After
induction After ASCT
After
consolidation
After
therapy
n (%) n = 31 n = 30 n = 30 n = 31
MRD negative 4/25 (16) 14/26 (54) 15/26 (58) 21/30 (68)
sCR + CR 7 (23) 14 (45) 15 (48) 18 (58)
≥VGPR 18 (58) 21 (68) 26 (84) 26 (84)
Roussel M, et al. J Clin Oncol. 2014;32(25):2712-2717.
IFM 2008: PFS• Median follow up: 39 months (range, 36-42 months), no death
• Estimated 3-year PFS 77% (CI 95%, 57%-88%) and OS 100%
• 10 patients MRD + : 7 relapses
• 21 patients MRD - : No relapse
Roussel M, et al. J Clin Oncol. 2014;32(25):2712-2717.
PFS (ITT) and according to MRD status
IFM, Intergroupe Francophone du Myélome
IFM/DFCI 2009: VGPR Rate During Each Treatment Phase
RVD arm
N = 350
Transplant arm
N = 350P value
Post induction 47% 50% NS
At C4 or post transplant 55% 73% <.0001
Post consolidation 71% 81% <.006
Post maintenance 78% 88% <.001
Attal M. et al. Blood. 2015;126: Abstract 391. IFM, Intergroupe Francophone du Myélome
Maintenance for fixed time
or not if in CR
Maintenance until PD
ASCT
Transplant Eligible
Induction
Maintenance for fixed time
or not if in CR
Maintenance until PD
ASCT
Transplant Eligible
Induction
Supportive Care
Bortezomib and Zoledronate Maintenance Following ASCT
Adapted from: McCarthy PL, et al. J Natl Compr Canc Netw. 2013;11(1):35-42.
Maintenance vs no maintenance
N Initial dose PFS OSBenefit?EFS/OS
Sonneveld P, et al. J Clin Oncol. 2012; 30(24):2946-2955.
827
Bortezomib: 1.3 mg/m2 IV,
every 2 weeks for 2 years
OR
Thalidomide 50 mg daily for
2 years
(V after PAD vs T after VAD)
Med PFS
35 vs 28 months
(P = .002)
Median FU 41 months
OS (MV analysis)
HR 0.77
(95% CI, 0.60-1.00)
P = .049
+/+
Landmark analysis
PFS 45 vs 38% (P = .05)
5-year OS
61 vs 55% (P = .07)+/+
Rosiñol L, et
al Blood.
2012;120(8):
1589-1596.
386
Bort 1.3 mg/m2 IV, d 1, 4, 8, 11 every 3 mo + Thal 100 mg/dOR Thal 100 mg/d aloneORInterferon-α 3 million units SC3 times weekly(VTD vs T vs IFN-α)
2 year PFS
56.2 vs 28.2 vs 35.3
(P = .01)
OS not significantly
different+/NA
Morgan GJ,
et al. Lancet.
2010;376(975
7):1989-1999
1960 (ITT)
Zoledronic acid 4 mg IV every 3-4 weeks ORClodronic acid 1600 mg daily
IT Median PFS
19.5 vs 17.5 months
(P=.07)
Med OS IT
NR vs 62.5 months
P = .0854
NA/trend+
Median OS all pats
50 vs 44.5 mos
P = .04
+
Randomization
MM stage II or III, age 18–65
CAD + GCSF
3 x VAD
CAD + GCSF
3 x PAD
MEL 200 + PBSCT
Depending on local
policy for patients PR
MEL 200 + PBSCT
MEL 200 + PBSCT
Depending on local
policy for patients PR
MEL 200 + PBSCT
Thalidomide
50 mg/day for
2 years
maintenance
Allogeneic
Tx
Bortezomib
1.3 mg/m2 / 2 weeks
for 2 years
maintenance
Phase III: PAD vs VAD induction, High-Dose Melphalan (HDM) and
Bortezomib or Thalidomide Maintenance (HOVON 65 MM / GMMG-HD4 )
Sonneveld P, et al. J Clin Oncol. 2012;30(24):2946-2955.
n = 371n = 373
n = 744, median age 57
VAD: vincristine,
doxorubicin, and
dexamethasone
PAD: bortezomib,
doxorubicin, and
dexamethasone
CAD: cyclophosphamide,
doxorubicin, dexamethasone
Scheid C, et al. Haematologica. 2014;99(1):148-154.
PFS and OS According to Treatment Arm According to Baseline Creatinine and Treatment Arm
PFS OS
Scheid C, et al. Haematologica. 2014;99(1):148-154.
PFS and OS According to Treatment Arm According to Baseline Creatinine and Treatment Arm
PAD B PAD B
PFS OS
Scheid C, et al. Haematologica. 2014;99(1):148-154.
PFS and OS According to Treatment Arm According to Baseline Creatinine and Treatment Arm
VAD T
VAD T
PAD B PAD B
PFS OS
PFS and OS for Thalidomide (Arm A) vs Bortezomib (Arm B) Induction and Maintenance by Cytogenetic Risk
del(17p)
t(4;14)
del(13/13q)
Sonneveld P, et al. J Clin Oncol. 2012;30(24):2946-2955.
PFS and OS for Thalidomide (Arm A) vs Bortezomib (Arm B) Induction and Maintenance by Cytogenetic Risk
del(17p)
t(4;14)
del(13/13q)
PAD B PAD B
Sonneveld P, et al. J Clin Oncol. 2012;30(24):2946-2955.
PFS and OS for Thalidomide (Arm A) vs Bortezomib (Arm B) Induction and Maintenance by Cytogenetic Risk
del(17p)
t(4;14)
del(13/13q)
VAD T
PAD B PAD B
VAD T
Sonneveld P, et al. J Clin Oncol. 2012;30(24):2946-2955.
McCarthy P, et al. N Engl J Med. 2012;366(19):1770-1781.
CALGB 100104 Schema
• Stratification based on registration -2M level and prior thalidomide and lenalidomide
use during Induction.
• Primary Endpoint: Powered to determine a prolongation of TTP from 24 months to
33.6 months (9.6 months)
• The study was un-blinded at a median 18 months and 86/128 placebo patients without
progressive disease chose to cross over to receive lenalidomide.
Lenalidomide
10 mg/d with
↑↓ (5–15 mg)
n = 460
D-S Stage 1-3, ≤70 years
≥2 cycles of induction
Attained SD or better
≤1 year from start of therapy
≥2 x 106 CD34 cells/kg
Placebo
n = 229
Restaging
days 90-100
Registration
CR
PR
SD
Mel 200
ASCT
Randomization
McCarthy P, et al. N Engl J Med. 2012;366(19):1770-1781. Updated: Holstein SA, et al. J Clin Oncol. 2015;22(suppl):
Abstract 8523.
Lenalidomide Improves TTP and OS
Median: 53 vs 26 mos
Hazard ratio 0.54
(P<.001)
Median: NR vs 76 mos
Hazard ratio 0.60
(P = .001)
Holstein SA, et al. J Clin Oncol. 2015;22(suppl): Abstract 8523.Intent-to-treat analysis, data cut-off Nov 2014
Subgroup Analysis of TTP and OS
Holstein SA, et al. J Clin Oncol. 2015;22(suppl): Abstract 8523.
Intent-to-treat analysis, data cut-off Nov 2014
The Cumulative Incidence Risk (CIR) for Progression, Death and Second Primary Malignancy (SPM) During Maintenance Therapy: Placebo Versus Lenalidomide
SPM vs PD/Death SPM vs Death SPM Death vs Death
Holstein SA, et al. J Clin Oncol. 2015;22(Suppl): Abstract 8523.
The Cumulative Incidence Risk (CIR) for Progression, Death and Second Primary Malignancy (SPM) During Maintenance Therapy: Placebo Versus Lenalidomide
The CIR of developing a SPM (p=0.005) or dying from an SPM (p=0.02) is higher with Len
compared with placebo. The CIR of PD (p<0.001) or death (p<0.001) is higher for placebo as
compared with Len.
SPM vs PD/Death SPM vs Death SPM Death vs Death
Holstein SA, et al. J Clin Oncol. 2015;22(Suppl): Abstract 8523.
• ITT Analysis; median follow-up from transplant ~48 months
• Median TTP: 50 months versus 27 months P < .001
• Median OS: Not reached versus 73 months P = .008
McCarthy P, et al, Presented at: IMW 2013.
146/229 events (64%) on placebo
104/231 events (45%) on lenalidomide
CALGB 100104: Updated TTP/OS
Estimated HR=0.51
(95% CI = 0.39 to 0.66)
49% reduction in risk of
progression
69/229 (30%) deaths on placebo
47/231 (20%) deaths on lenalidomide
Estimated HR=0.61
(95% CI = 0.41 to 0.87)
39% reduction in the risk of death
[86 of 128 non-progressing
placebo pts received lenalidomide
at study un-blinding in Jan 2010]
Lenalidomide Maintenance Therapy: CALGB 100104 Update
• Cumulative incidence of second primary cancers greater in lenalidomide group (P = .034)
• Cumulative incidence of risk of PD (P = .004) and death (P<.001) greater in placebo group
Lenalidomide arm Placebo arm P
Median PFS 47 mos 27 months <.001
McCarthy P, et al, Presented at: IMW 2013 and ASH 2013.
Attal M, et al. N Engl J Med. 2012;366(19):1782-1791. Attal M, et al. Blood. 122: Abstract 406.
• PFS benefit: 42 vs 24 months overall; benefit seen in low and high risk
cytogenetic populations
• del17p: 29 vs 14 months; t(4;14): 27 vs 15 months. (Avet L’Oiseau H, et al. Blood. 2010;116: Abstract 1944)
• IMW 2014: PFS for t(4:14) 27 vs 24 mos.
• Maintenance stopped at a median of 2 years (range 1-3) due to SPM concern
IFM 2005-02: PFS and OS From Randomization(Study Unblinded 1/2010)
Maintenance Following ASCT
• 402 patients (younger than 65 years) randomized from 62 centers• Patients: Symptomatic disease, organ damage, measurable disease
Treatment Schedule
*MPR vs MEL 200; R maintenance vs no maintenance; Anti-thrombotic substudy: Aspirin vs Low molecular weight heparin
Rd (R: 25 mg/d, days 1-21; d: 40 mg/d, days 1,8,15,22); MPR (M: 0.18 mg/Kg/d, days 1-4; P: 2 mg/Kg/d, days 1-4; R: 25 mg, d 1-21), MEL 200 (M:
200 mg/m2 day -2); R maint (R: 10 mg/day, days 1-21); # One course MEL 200 if patients achieves VGPR after cycle 1; R: lenalidomide; MEL200:
melphalan 200 mg/m2 and autologous stem cell transplant; MPR: melphalan-prednisone-lenalidomide; NDMM: newly diagnosed multiple myeloma.
Rdfour 28-day courses
MEL 200Two courses#
NO MAINTENANCE
R MAINTENANCE28-day courses until PD
MPRsix 28-day courses
R MAINTENANCE28-day courses until PD
NO MAINTENANCE
*Randomization (2 x 2 design)
MPRsix 28-day courses
MEL 200Two courses#
Palumbo A, et al. N Engl J Med. 2014;371(10):895-905.
MPR, melphalan-prednisone-lenalidomide
0
25
50
75
100
0 10 20 30 40 50 60 70
MEL200-R
MEL200
MPR-R
MPR
Months
100
0 10 20 30 40 50 60 70
0
25
50
75
MEL200-R
MEL200
MPR-R
MPR
Months
Progression-free survival Overall survival
MEL200, melphalan 200 mg/m2; R, lenalidomide maintenance
MPR vs MEL200 vs MPR-R vs MEL200-R
Palumbo A, et al. N Engl J Med. 2014;371(10):895-905.
R maintenance vs No maintenance
Median PFS
R maint. 37 months
No maint. 26 months
5-year OS
R maint. 75%
No maint. 58%
HR 0.52, 95% CI 0.40-0.67, P <.0001
Months
HR 0.62, 95% CI 0.42-0.93, P =.02
Months
0
25
50
75
100
0 10 20 30 40 50 60 70
0
25
50
75
100
0 10 20 30 40 50 60 70
R, lenalidomide
Progression-free survival Overall survival48% reduced risk of progression 38% reduced risk of death
Palumbo A, et al. N Engl J Med. 2014;371(10):895-905.
Lenalidomide Maintenance Therapy Meta-Analysis
Singh M, et al. Blood. 2013;122: Abstract 407.
There was
significant
prolongation of
both PFS (HR 0.49,
95% CI, 0.41–0.58,
P<.001) and OS (HR
0.77, 95% CI, 0.62–
0.95, P = .013) with
LM vs. placebo/no
maintenance
• N=1209, median follow up 6.6 years
• OS benefit with LEN vs control: Not reached vs 86 months
− HR = 0.74; 95% CI, 0.62-0.89; log-rank P = .001
• 5 yr, 6 yr, and 7 yr OS longer with LEN
• LEN maintenance benefited all subgroups after ASCT
Attal M, et al. J Clin Oncol. 2016;34(suppl): Abstract 8001
Lenalidomide Maintenance Therapy Meta-Analysis: Updated OS
Consolidation and Maintenance Therapy Post-Transplant With Lenalidomide, Bortezomib and
Dexamethasone (RVD) in High Risk Patients
1. Stringent CR 51%, 96% VGPR
2. Median PFS 32 months
3. Three-year OS 93%
Nooka AK, et al. Leukemia. 2014;28(3)690-693.
N = 256, all patients received RVD
All received 3 drug maintenance
Minimal exposure to alkylators
Nooka AK, et al. Leukemia. 2014;28(3)690-693.
Early Versus Late Transplant in High Risk MM
P = .044; logrank
RVDx3
RVD x 2
RVD x 5
Revlimid until PD
Melphalan
200mg/m2* +
ASCT
Induction
Consolidation
Maintenance
CY (3g/m2)
MOBILIZATIONGoal: 5 x106 cells/kg
RVDx3
CY (3g/m2)
MOBILIZATIONGoal: 5 x106 cells/kg
Randomize
Collection
Revlimid until PD
SCT at relapse
Calibration
MRD
MRD
MRD
MR
D @
CR
MR
D @
CR
IFM/DFCI 2009; DFCI #10-106; CTN 1304
“The Determination Trial”
Newly Diagnosed MM (N = 1,360)
*Primary objective = 7-color Flow, secondary objective = molecular
P-value : p<0.0001
Negative (<10-6)
PositivePositive
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Patients
without pro
gre
ssio
n (
%)
51 51(0) 51(0) 51(0) 47(3) 36(9) 26(5) 6(9) 3(0)MRD positive
80 80(0) 80(0) 80(0) 80(0) 73(3) 57(3) 33(5) 9(0)MRD neg (<10-6)
N at risk(events)
06
1218
2430
3642
48
Months since randomization
MRD at post-maintenance in CR patients
IFM 2009: 375 CR/sCR, 131 MRD Patients
83%
30%
Avet-Loiseau H, et al. Blood. 2015;126: Abstract 191.
P value: <.0001
Ixazomib Maintenance Following Ixazomib-Lenalidomide-Dexamethasone Induction in Untreated Multiple Myeloma
29 29
48
10
10
19
33
519
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Best response toinduction
Best response overall
sCRCRnCRVGPRPRMRSD
n = 5
n = 2
10 (48%) patients improved their response during maintenance:
2 VGPR to nCR, 5 VGPR to CR, 1 VGPR to sCR, and 2 CR to sCR
n=2
n=1
Kumar SK, et al. Blood. 2011;118.
Conclusions: Post-Transplant ConsolidationEmerging as a Key Component of Initial Treatment
Autotransplant
Initial therapy Maintenance
Consolidation
Conclusions: Post-Transplant ConsolidationEmerging as a Key Component of Initial Treatment
Autotransplant
Initial therapy Maintenance
Consolidation
Bortezomib1
VTD2
Lenalidomide3
RVD4
CTD5
Post-transplant consolidation
improves depths of response
(VGPR and CR)
Mellqvist UH, et al. Haematologica. 2011;96(Suppl1):S31. Cavo M, et al. Blood. 2012;120: Abstract 4210. Attal M, et al.
Haematologica. 2011;96(Suppl1):S23. Roussel M, et al. Blood. 2011;118: Abstract 1872. Sonneveld P, et al. Blood.
2012;120: Abstract 333. Adapted from: Jakubowiak AJ, Poznan 2014. EU /US Perspectives in MM.
Conclusions: Post-Transplant ConsolidationEmerging as a Key Component of Initial Treatment
Autotransplant
Initial therapy Maintenance
Consolidation
Bortezomib1
VTD2
Lenalidomide3
RVD4
CTD5
Post-transplant consolidation
improves depths of response
(VGPR and CR)
Benefits of Consolidation Emerging
Mellqvist UH, et al. Haematologica. 2011;96(Suppl1):S31. Cavo M, et al. Blood. 2012;120: Abstract 4210. Attal M, et al.
Haematologica. 2011;96(Suppl1):S23. Roussel M, et al. Blood. 2011;118: Abstract 1872. Sonneveld P, et al. Blood.
2012;120: Abstract 333. Adapted from: Jakubowiak AJ, Poznan 2014. EU /US Perspectives in MM.
Conclusions: Post-Transplant Maintenance
ThalidomidePFS prolonged (6/6)
OS prolonged (3/6)
LenalidomidePFS prolonged (2/2)
OS prolonged (1/2)
Bortezomib +/- ThalidomideMay contribute to
prolonged PFS (2/2)
prolonged OS (1/2)
Autotransplant
Initial therapy Maintenance
Consolidation
Adapted from Jakubowiak AJ, Poznan 2014; EU/US Perspectives in MM.
Conclusions: Post-Transplant Maintenance
ThalidomidePFS prolonged (6/6)
OS prolonged (3/6)
LenalidomidePFS prolonged (2/2)
OS prolonged (1/2)
Bortezomib +/- ThalidomideMay contribute to
prolonged PFS (2/2)
prolonged OS (1/2)
Autotransplant
Initial therapy Maintenance
Consolidation
Lenalidomide associated with increased SPM post SCT/HD Mel but OS benefit seen
USA: lenalidomide most commonly used agent based on favorable risk/benefit ratio
Updated TTP Updated OSIncludes pts crossing over
McCarthy, IMW 2013
Adapted from Jakubowiak AJ, Poznan 2014; EU/US Perspectives in MM.
Conclusions/Future Directions• New directions in prognostication / risk adapted therapy:
– Minimal residual disease measurements
PCR, Flow Cytometry, NGS
– Cytogenetic testing
CD138 selection with cytogenetic analysis
– Molecular gene expression profiling
• Disease control with less toxicity will likely result in improved
PFS and OS
• Addition of next generation novel agents
– Carfilzomib
– Anti-CD38 antibodies (DARA, ISA), anti-CS-1/SLAM F7 (ELO)
– Ixazomib
– Vaccines
– HDACIs
Conclusions/Future Directions
• Transplant eligible
– Bortezomib for 2 years following ASCT is a standard primarily
for those presenting in renal failure and those patients with
chromosome del(17p)
– Lenalidomide until PD is a standard of care following ASCT
– Second primary cancer risks is increased with lenalidomide
maintenance after HD MEL, but cumulative incidence risk of
relapse and death are worse without lenalidomide
maintenance
• Consolidation/maintenance for transplant eligible multiple
myeloma patients as part of clinical trials a key priority
• Identify target pathways for testing new agents with curative
intent (eg, checkpoint inhibition)
Thank You!!
Slide Courtesy of Phil McCarthy, MD