What is the role of maintenance therapy after an ASCT? Why is maintenance therapy needed if yo are in a complete remission or MRD negative?

What is the role of maintenance therapy after an ASCT?

So let's talk a little bit about the role of maintenance therapy after stem cell transplant. Then questions that will come up are, do I need maintenance if I'm already in complete remission?

So a little bit of background. Why did we start doing maintenance? If you go back 15 and 20 years ago when we completed transplant, many patients still had evidence of residual disease after transplant. So the logical next question is can we make it better by keeping some treatment going on?

For our patient audience, obviously, just remember that we will use the words, but we're just describing whether it's more or less treatment. And maintenance may be perceived as a little bit of a lower dose, but effectively it's just more treatment for the person.

So there were a number of studies that were done, but particularly those studies that used a drug called lenalidomide, commercially known as REVLIMID, which showed that if a patient received that medication after stem cell transplant, the ability to keep the disease under control was longer. It was estimated to be about 53 months. That's, you know, close to 2 to 5 years. And there were three studies that showed that as opposed to doing nothing.

So the prevailing notion has been let's do something afterwards. Do I still need maintenance therapy if I am in a complete response (CR)? A common question that comes up is should I do maintenance but some not complete response? And two thoughts come to mind.

First of all, it sounds like a cliche, but when you need to build on progress, when someone is doing great, that's an opportunity to make them even do better. So those are the good ones who do the best in a way.

Why do I say this? If you have a transplant and you're in a complete remission, can someone tell you for sure that there's no cells in the background? The answer is no. And you're so close to getting this under control that maintenance would make sense.

Now, the second thought is as follows, which is a little bit of a counter opinion, but it's important to go into the details. When the maintenance studies were done, the rate of very deep responses, particularly MRD negative responses, particularly MRD negative responses, was much lower than what we have nowadays. Many of those patients were treated with doublets as induction therapy in those clinical trials.

So one could say, well, there's no surprise. Obviously more treatment was important and the outcomes were better. There could be a future where we understand better that if someone has not only a complete response, but if they're MRD negative, and perhaps they receive a great regimen for induction, there might be a future where they may not need maintenance.

We're not there yet to really say we should hold back on maintenance. But I ask myself, if you were to complete a stem cell transplant after a four drug combination today and you get maintenance, how much benefit is there for you doing that? It's probably smaller than what it was ten years ago.

So my hope is that there is a future that, like people treat breast cancer. Some people will complete the first phase of treatment, maybe with transplant, and we may have enough information to say you may or may not need maintenance.

So maintenance therapy is important. There are lots of studies that have now shown that continuous therapy in myeloma can lead to prolonged periods of remission and probably improved survival.

But it's not for everybody. Everybody has a little bit different myeloma. We have to risk stratify patients. I have patients who do not want to take a drug every day and they have very low risk disease. And after they've undergone a transplant, their disease is at such a low burden that we're not worried about what's going to happen to them for years.

I have other patients where that's not the case, where their disease is more aggressive and even if their disease burden is very low, there is a good chance that their myeloma is going to come back sooner. And for those patients, we definitely encourage maintenance.

So I definitely talk about maintenance to every single one of my patients, but there is a small minority that choose not to do it for various reasons.

Is there a scenario where a patient does not do maintenance therapy? I talk about maintenance with every patient, but sometimes the patients don't want to do maintenance. Sometimes it has to do with cost of drugs. Sometimes it has to do with side effects of the pills.

So we make an assessment of the risk of their disease and how much more benefit that they will get with maintenance. Some patients, the magnitude of the benefit is much higher than others. So we make a calculated decision at that point, along with their physician, about whether it's the right decision for them.

To determine the effect of maintenance therapy on the progression free survival and overall survival of multiple myeloma patients. Researchers combined data from 22 randomized controlled trials, which involved almost 10,000 myeloma patients using 15 different regimens.

Data from this study showed that lenalidomide maintenance extended a patient's progression free survival and overall survival, compared to patients that received no maintenance therapy. It also showed that whether you are high risk or low risk, maintenance therapy improves your progression free and overall survival compared to groups that did not do any maintenance therapy.

To learn more about maintenance therapy, watch the HealthTree lessons on this subject in starting myeloma treatment.