ASH 2021: The Seemingly Eternal Question in Myeloma Treatment

Do myeloma patients still need autologous stem cell transplants (ASCTs) given all the progress in other treatments?  That was the unspoken question I kept hearing when Dr. Susan Dol from the University of Alabama at Birmingham presented MASTER study trial data at the annual American Society of Hematology meeting.

After all, Dr. Bol reported that initiating treatment for newly diagnosed multiple myeloma (NDMM) with four drug combination induction of daratumumab, carfilzomib (Kyprolis), lenalidomide (Revlimid), and dexamethasone (dara-KRd) resulted in an unprecedented depth of response regardless of risk status with ultra high-risk seeing the greatest improvement.

Was ASCT still needed?  The answer was still a resounding YES.

Not only that, it could add benefit to any risk group, concluding it should remain an integral part of therapy, especially in those with high-risk disease and those that remain minimal residual disease (MRD) positive following induction therapy.

On the other hand, the researchers seemed to agree it was worth exploring if ASCT deferral for patients who achieve MRD negativity at 10 after induction.

MASTER examined the depths of response in patients receiving induction of daratumumab, carfilzomib (Kyprolis), lenalidomide (Revlimid), and dexamethasone (dara-KRd), a proven induction combination.  The extent of MRD change that occurred as a result of subsequent ASCT was measured and analyzed.

Patients in the study were classified as standard-risk, high-risk, and ultra high-risk. Every group demonstrated improvement in depth of response as measured by MRD testing to depths of 10^-5 to 10^-6 sensitivity.  The following table breaks down the increased depth of response by level of risk.

Studies are underway to find relief from burdensome ASCT and those results can’t come soon enough.  It will be a great day, especially for those that respond very deeply to induction.  But that day isn’t here yet.