ASH 2018: Maintenance Therapy in Multiple Myeloma

The ASH conference has started with the early, "unofficial" sessions. Dr. Maria Victoria Mateos spoke at a Friday morning session about the role of maintenance therapy. 

It has become obvious that in general, maintenance therapy is suggested for all patients and extends remission times. Dr. Mateos broadly described the use of maintenance therapy with immunomodulators like lenalidomide or proteasome inhibitors like bortezomib. Overall, she noted that maintenance therapy can be convenient, well tolerated and safe, giving patients an acceptable quality of life. 

What still needs to be considered? She mentioned some important questions such as, what is the optimal length of maintenance therapy? If patients are minimal residual disease (MRD) negative, should they continue maintenance? More will come out on that topic with the Dana Farber / French study of 700 patients who were split into two groups of Revlimid/Velcade/Dex with transplant, then lenalidomide as maintenance for one year vs. until their myeloma progresses. Results aren't out yet. 

Is lenalidomide the best choice as maintenance therapy for high risk patients? In the recent HOVON study, it showed that lenalidomide did improve outcomes, even for high risk patients. But it also suggested that proteasome inhibitor maintenance (bortezomib, carfilzomib or ixazomib) provides better overall survival for patients with deletion 17p. She mentioned that the oral proteasome inixazomib is in further study as maintenance therapy. 

In the elderly or non-transplant eligible patients, she suggested that maintenance is still important. After patients receive their initial treatment (with combinations), they can consider doublets or even triplets as continuing therapy. For example, lenalidomide/dexamethasone/daratumumab has shown to be a good longer term therapy (based on data from the MAIA study). Another potential maintenancde standard could include lenalidomide/bortezomib/dexamethasone.

She concluded by saying that MRD testing will continue to have impact in how, when and for how long maintenance treatment is given and that in the future, immune system profiling may play a role as well.