The Current Standard of Care in the Post-Transplant Setting | Fredrik Schjesvold, MD, PhD | IMS 2024

Hello, I'm Fredrik Kjessvård from Oslo Myeloma Center and the Nordic Myeloma Study Group. So I'm here at Rio and today I will participate in a symposium arranged by BMS where I'm going to discuss what the current standard of care is in post-transplant setting. So this is a bit complicated. You have consolidation, you have maintenance, you have new ways of approaching this. Today the standard is, I would say in most places, consolidation after transplant. Consolidation is when you give sort of more cycles, so the same drug regiments that was used in the induction. Consolidation by itself has actually never been proven to give any survival benefit, but still it gives PFS benefit, it increases the response rates and it's common, I would say. So in almost all trials performed recently and being performed now, consolidation, more treatment cycles after transplant is the common way to do it. There's also another way of doing it. So one German trial coming close to maturation soon, instead of having consolidation afterwards, which is usually two more cycles, they put all in front. They give six cycles in front of transplant. I don't think it really matters. I think the total amount of treatment matters. So you get all these cycles. Then you have a BMS trial called CARMA-9, which is trying to give either cell as consolidation in a randomized trial. This was only for patients not responding very well. Actually I learned this morning, it's now open, that this study has closed down. The reason for this is actually quite good news for patients, because they are struggling to find enough patients with a bad response after transplant and consolidation. So that study is now terminated. Now it's still the standard of consolidation and then there's maintenance. Maintenance is also complicated. As many of you know, lenalidomide maintenance is the standard and has been that for some years both in Europe and the US and elsewhere. There's still a big discussion about duration of treatment. The American trial determination compared to the European trial, IFM 2009, which had maintenance until progression versus maintenance just for a fixed period, shows a much longer progression-free survival until progression. There are some English data suggesting maybe that after five years you can maybe stop without losing benefit, but that's not very clear. So I would say still, len maintenance is the standard. Then there's DARA, DARA-2-MAP maintenance, which has been an issue lately. The Perseus data showing benefit of adding DARA in induction, consolidation and in maintenance. So this fall, FDA has chosen not to approve DARA maintenance in addition to LEN, while Europe last week approved DARA maintenance. So in Europe now, DARA-LEN is the standard, but not in the US as of now. We also have seen recently this spring that in the Cassiopeia study that DARA-2-MAP alone as maintenance also give a better progression-free survival compared to no maintenance. So more and more we also see that in the newest studies. DARA-LEN is the scientific standard, but as of today not approved in the US actually. It usually is the other way around, but that's the situation now. So that's the situation now. I think the next steps will be based on several trials being performed today, and that is maintenance usually for a fixed duration with the bispecific antibodies. So they are challenging LEN now in their pure maintenance randomized setting, and hopefully, expectedly at some time they will prove that bispecific is better than LEN alone. And how to compare that to DARA-LEN is of course very difficult. We will just have to sort of compare data when we have them. And the only other thing about this maintenance with bispecific is that LEN is not always tolerated, but it doesn't give many dangerous problems. But bispecific you can have more infections. It depends a bit on the type. I'm not going to go into details about that. I think this data that will come in a couple of years will tell us how the future will look like. But for now, consolidation is standard after transplant. Maintenance is standard. LEN is standard. It's sort of a standard, but not everywhere. And in the future, maybe bispecifics will add to this.