Lenalidomide Maintenance Therapy In Multiple Myeloma: A Meta-Analysis Of Randomized Trials

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 407-407 ◽  
Author(s):  
Preet Paul Singh ◽  
Shaji K Kumar ◽  
Betsy R. LaPlant ◽  
Morie A Gertz ◽  
Angela Dispenzieri ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Maintenance Therapy ◽  
Research Funding ◽  
Meta Analysis ◽  
Phase Iii ◽  
Controlled Trials ◽  
Cell Transplant ◽  
Grade 3 ◽  
Substantial Heterogeneity

Abstract Background Conflicting results have emerged, especially with respect to the impact on overall survival (OS), from trials evaluating lenalidomide maintenance (LM) therapy after induction therapy alone or post-autologous stem cell transplant (ASCT) in multiple myeloma (MM). We performed a systematic review and meta-analysis of existing outcome data from LM trials to evaluate role of lenalidomide as maintenance strategy in MM. Patients and methods A comprehensive search of electronic databases and abstracts through June 2013 was performed to identify randomized controlled trials (RCTs) that compared LM vs. placebo/no maintenance. Single arm studies were excluded. Pooled hazard ratio (HR) or odds ratio (OR) estimates with 95% confidence intervals (CIs) were calculated using the random-effects model for clinical endpoints of progression free survival (PFS), OS, response rate (RR) and adverse events (AEs), including second primary malignancies (SPMs). Analyses were performed using Comprehensive Meta-Analysis Software Version 2. We assessed between-study heterogeneity with the Cochran Q test and quantified its extent with the I2 statistic. Results Overall, five RCTs, with data extractable from four phase III trials (3 publications and 1 abstract) were identified (n= 1935). All studies were RCTs with an adequate randomization. MRC MM XI study was excluded from analyses as survival data are not available. Two placebo controlled trials (IFM 05-02, CALGB 100104) addressed the role of LM post-ASCT, one placebo-controlled trial (MM-015) studied LM therapy in the non-transplant setting and the remaining trial (RV-MM-PI209) had a 2 X 2 design comprising of both ASCT and non-transplant randomized arms followed by a second randomization of LM versus no maintenance. There was no heterogeneity for estimate of PFS results (Cochran Q, p=0.68; I2=0%), but considerable heterogeneity for estimate of OS (Cochran Q, p=0.09; I2= 55%), among the studies. There was significant prolongation of both PFS (HR 0.49, 95% CI, 0.41–0.58, p<0.001) and OS (HR 0.77, 95% CI, 0.62–0.95, p=0.013) with LM vs. placebo/no maintenance (Figure 1). Best response during maintenance was reported only in 2 studies and odds of responding (very good partial response or better) were not significantly different with LM (OR 1.28, p=0.3). Grade 3-4 AEs data were available from 3 trials for calculation of pooled OR with LM compared with placebo. We observed a nearly two-fold increase in the risk of SPMs with LM (OR 1.99; 95% CI, 1.31–3.04; p=0.001). Patients on LM were more likely to have grade 3-4 AEs than placebo: neutropenia (OR 4.9, p<0.001), thrombocytopenia (OR 2.7, p<0.001), fatigue (OR 2.3, p=0.01) and venous thromboembolism (OR 3.2, p=0.02). Odds of discontinuing treatment were also significantly higher in patients on lenalidomide (OR 2.9, p<0.001). Conclusions Meta-analysis of RCTs demonstrates significant improvement in PFS and modest improvement in OS with LM. There is an increased risk of grade 3-4 adverse effects, including SPMs with LM. Substantial heterogeneity for estimate of OS among protocols is a limitation of this analysis. Lack of uniform access to lenalidomide upon disease progression in the placebo/no maintenance arms of the constituent studies should be taken into account while interpreting aggregate effect estimates for OS in this meta-analysis. OS: Cochran Q p=0.09, I2=55%, substantial heterogeneity PFS: Cochran Q p=0.68, I2=0%, minimal heterogeneity Disclosures: Off Label Use: Lenalidomide for maintenance therapy in multiple myeloma. Kumar:Merck: Consultancy, Honoraria; Celgene: Consultancy, Research Funding; Millennium: The Takeda Oncology Company: Research Funding; Novartis: Research Funding; Genzyme: Research Funding. Dispenzieri:Celgene, Millenium, Jansenn, Pfizer: Research Funding. Bergsagel:Onyx: Consultancy. Lacy:Celgene Corporation: Research Funding.

Phase III Intergroup Study of Lenalidomide (CC-5013) Versus Placebo Maintenance Therapy Following Single Autologous Stem Cell Transplant for Multiple Myeloma (CALGB 100104): Initial Report of Patient Accrual and Adverse Events.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 3416-3416 ◽  
Author(s):  
Philip L. McCarthy ◽  
Kouros Owzar ◽  
Edward A. Stadtmauer ◽  
Sergio Giralt ◽  
David D Hurd ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Stem Cell ◽  
Maintenance Therapy ◽  
Research Funding ◽  
Progressive Disease ◽  
Study Drug ◽  
Phase Iii ◽  
Cell Transplant ◽  
Grade 5 ◽  
Grade 3

Abstract Abstract 3416 Poster Board III-304 Relapse and/or progression of disease are the primary causes of treatment failure after autologous hematopoietic stem cell transplant (ASCT) for multiple myeloma (MM). The primary objective of CALGB 100104 was to investigate whether adding maintenance therapy would improve the time to progression (TTP). The study was powered to detect an improvement of 9.6 months (prolongation of TTP from 24 months to 33.6 months) in MM patients undergoing a single ASCT. Secondary objectives were the Complete Response conversion rate following maintenance initiation, the Overall Survival and the feasibility of long term lenalidomide maintenance therapy. Eligible MM patients were Durie-Salmon Stage I-III patients within 1 year of diagnosis, receiving at least 2 months of any induction therapy with response (Stable Disease (SD) or better) and ≤ 70 years of age. Patients with progressive disease prior to ASCT were not eligible for study. Patients underwent stem cell mobilization followed by Melphalan 200 mg/m2 and ASCT with a minimum of 2 × 106 CD34 cells/kg for stem cell infusion. Responding patients with SD or better were randomized at day 100 to 110 post ASCT to study drug versus placebo. Patients with progressive disease were not randomized. Randomized patients were stratified by elevated β2 microglobulin at diagnosis and prior thalidomide or lenalidomide use during induction therapy. The starting dose was 10 mg daily with an escalation at 3 months to 15 mg if tolerated. Study drug could be de-escalated by 5 mg daily if not tolerated. Patients could be maintained at 5, 10 or 15 mg as tolerated and were followed with monthly complete blood counts. Drug was held for neutropenia (Absolute Neutrophil Count (ANC) < 500/μl or thrombocytopenia (<30,000/ μl) and restarted after resolution of cytopenia(s). Patients were re-staged by blood and urine testing every 3 months, by skeletal survey and bone marrow testing yearly and remained on maintenance therapy until progression. A total of 568 pts were registered at centers from the following cooperative groups: CALGB (n=377), ECOG (n=132), and BMT-CTN (n=59). The study opened in 12/2004 with increasing annual accrual: 2005, n=33, (6%); 2006, n=62, (11%); 2007, n=137, (24%); 2008, n=214, (38%); 2009, n=122, (21%) and study closure on 07/03/09. The drop out rate before randomization at day 100 to 110 was projected to be 10-15% with an expected randomization of 462 patients. Among the 568 registered patients, 424 have been randomized, 81 have dropped out pre-randomization and 63 are pending randomization as of 08/06/09. Projected final randomization is approximately 475. Pooled Hematologic and Non-Hematologic Adverse Events (AEs) are available from 275 patients in both arms. Individual patients experiencing Hematologic AEs are as follows: Grade 3 (severe) n=43 (16%); Grade 4 (life-threatening) n=26 (9%); and no Grade 5 (lethal). Individual patients experiencing Non-Hematologic AEs are as follows: Grade 3 n=74 (27%); Grade 4 n=9 (3%); Grade 5 n=5 (2%). The most common Non-Hematologic AEs were infection, fever, rash and fatigue. The Data Safety and Monitoring Board (DSMB) will continue to monitor the study for AEs and determination of progression. This large Phase III study has successfully completed patient registration and is nearing completion of patient randomization at day 100 to 110 post ASCT through the cooperation of the Intergroup oncology and transplant clinical research groups. Further analysis will determine if maintenance therapy with lenalidomide (CC-5013) is of benefit for MM patients following single ASCT. Disclosures McCarthy: Celgene: Speakers Bureau. Off Label Use: Lenalidomide for maintenance therapy following autotransplant for multiple myeloma. Stadtmauer:Celgene: Speakers Bureau. Richardson:Millenium (Research Funding and Advisory Board), Celgene, Keryx, BMS, Merck, Johnson and Johnson (All Advisory Board): Membership on an entity's Board of Directors or advisory committees, Research Funding. Anderson:Millenium: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding.

scholarly journals Safety Analysis of Intra-Patient Dose- Study of Crenolanib Maintenance Therapy in Patients with FLT3 Mutant AML Following Allogeneic Hematopoietic Stem Cell Transplant

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3426-3426 ◽  
Author(s):  
Betul Oran ◽  
Stefan O. Ciurea ◽  
David Marin ◽  
Jessica M McCarty ◽  
Qaiser Bashir ◽  
...  
Keyword(s):  
Stem Cell ◽  
Side Effects ◽  
Maintenance Therapy ◽  
Dose Escalation ◽  
Research Funding ◽  
Patient Dose ◽  
Phase Iii ◽  
Cell Transplant ◽  
Grade 3 ◽  
Active Disease

Abstract Background: FLT3 inhibitors (like sorafenib and midostaurin) have been administered as maintenance therapy post allogeneic stem cell transplantation (SCT) to reduce persistent relapse risks in FLT3-mutant AML patients. Reduced doses of both sorafenib and midostaurin have been found to be tolerable in the post-HSCT setting. Crenolanib is a highly potent and selective FLT3-targeted TKI that has activity as a single-agent and combined with chemotherapy in patients with FLT3-ITD and/or FLT3-TKD mutations. We here report the outcomes of safety and tolerability of crenolanib maintenance in FLT3 mutant AML patients after allo-HSCT (NCT02400255). Methods: To assess the tolerability of crenolanib maintenance in post-SCT AML patients and evaluate the appropriate dose for such patient population, a clinical trial of crenolanib maintenance therapy was performed in patients (age ≥ 18) with FLT3 mutant AML who had undergone SCT. Enrollment criteria included patients with FLT3-ITD, or FLT3-TKD positive disease at any point prior to SCT, having first SCT, with ≥ 50% T cell donor chimerism, adequate engraftment with complete remission (CR) at post-SCT evaluations. Patients needed to enroll between 42 and 90 days post-transplant without uncontrolled infection and graft versus host disease (GvHD). Initially, the study was designed for patients to be treated with crenolanib 80 mg TID (240 mg daily. Due to initial tolerability in the first patients (n=4), the design was changed to an intra-patient dose-escalation, in which patients received crenolanib starting at a dose of 60 mg BID for a month and then escalated to 80 mg BID and finally 80 mg TID as tolerated. As of July 2018, 24 patients, median age 53.5 years (range 31-74) have been enrolled and received crenolanib maintenance therapy. Disease status at SCT was CR (n=10, 42%), CR without count recovery (CRi, n=12, 50%), and active disease (n=2, 8%). The minimal residual disease (MRD) by multicolor flow cytometry was evaluable in 22 CR/CRi patients at SCT and was deemed to positive in 5 (23%). Conditioning regimen was myeloablative (20, 83%) or reduced intensity (4, 17%). Donors were matched related (n=11, 46%), matched unrelated (n=11, 46%) or haploidentical (n=2, 8%). After 4 patients enrolled, the trial design was altered to allow for intra-patient dose escalation. Ten patients were never able to escalate above 60mg BID, one patient stayed at 60 mg TID, 12 patients escalated to 80 mg BID, of those 12, 7 were able to escalate to 80 mg TID. The median days on crenolanib was 474 days (4-728 days) and median number of cycles was 17.5 cycles (1-26 cycles). Of the 21 patients no longer on study, 6 were due to relapse with median time to progression of 17 days (7-76 days) after first dose of crenolanib. Of the 6 relapses, four patients were positive for MRD prior to transplant and two had active disease. Two patients came off study due to noncompliance with study procedures, two were due to withdrawal of consent, 7 were patient decision due to side effects, one was due to suicidal ideation, and one was for insurance non-payment. Only one patient completed the planned 24 cycles of treatment with crenolanib 60 mg BID. Currently, four patients remain on study. Observed side effects were predominantly grade 1 and 2 with the most common (regardless of attribution) being nausea (62%), vomiting (38%), and diarrhea (33%), 13 adverse events that were grade 3 were reported likely attributable to crenolanib, no grade 4 side effects reported. There were two grade 2 GVHD-AEs, one grade 1 and one ungraded GVHD-AEs reported. One patient had a grade 3 rash that was confirmed as GVHD. Conclusion: These interim results suggest that crenolanib can be safely given at a dose of 160 mg to 240 mg total daily in the post-SCT setting. Two randomized phase III trials have been initiated to investigate the efficacy of crenolanib with chemotherapy vs chemotherapy alone in R/R FLT3 mutated AML as well as crenolanib vs midostaurin following chemotherapy in newly diagnosed FLT3 mutated AML (NCT03250338, EudraCT 2017-001600-29; NCT03258931). Post HSCT crenolanib maintenance will be offered at 100 mg BID (200 mg daily) in both trials. Disclosures Oran: AROG pharmaceuticals: Research Funding; ASTEX: Research Funding; Celgene: Consultancy, Research Funding. Shpall:Affirmed GmbH: Research Funding. Agrawal:Arog: Employment. Champlin:Sanofi: Research Funding; Otsuka: Research Funding.

The Improved Efficacy of Bortezomib Containing Induction Regimens (BCIR) Versus Non-Bortezomib Containing Induction Regimens (NBCIR) in Transplant-Eligible Patients with Multiple Myeloma (MM): Meta-Analysis of Phase III Randomized Controlled Trials (RCTs),

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 3994-3994
Author(s):  
Ajay K. Nooka ◽  
Jonathan L. Kaufman ◽  
Madhusmita Behera ◽  
Charise Gleason ◽  
Amelia Langston ◽  
...  
Keyword(s):  
Research Funding ◽  
Mixed Model ◽  
Meta Analysis ◽  
Progression Free Survival ◽  
Response Rates ◽  
Phase Iii ◽  
P Value ◽  
Cell Transplant ◽  
Odds Ratios ◽  
Grade 3

Abstract Abstract 3994 Introduction: Patients with MM undergoing autologous stem cell transplant (ASCT) achieving complete response (CR) or very good partial response (VGPR) have prolonged progression free survival (PFS) and overall survival (OS) compared to the patients that achieve <VGPR prior to ASCT (Lahuerta JJ et al., 2008; Moreau P et al., 2011). Therefore it is of profound significance to attain the best response with induction therapies to obtain the better long-term outcomes. The response rates have significantly improved since the introduction of bortezomib, a proteasome inhibitor, in the induction therapies for myeloma. We performed a meta-analysis to evaluate the efficacy of the addition of bortezomib to the existing regimens used in induction therapy. Methods: We searched Medline, Embase, Cochrane databases and ASH, ASCO conference proceedings from 01/2000 through 08/2011 for publications and abstracts to identify the phase III RCTs comparing BCIR vs. NBCIR in transplant-eligible patients with myeloma. A meta-analysis was performed using both the fixed (Mantel-Haenszel) and random (DerSimonain and Laird) models to calculate the risk difference with the comparator arm to evaluate the rates of CR, ≥VGPR, ORR, PFS, OS and toxicities. Altogether, we identified 4 RCTs (two published articles and unpublished data from two RCTs including 2086 patients). The consistency of results (effect sizes) among studies was investigated by means of two heterogeneity tests, the χ 2-based Cochran's Q test, and the I2 Statistic. We considered that heterogeneity was present when the P value of the Cochran's Q test was <.1 and I 2 statistic was > 50%. Results: Q-statistic for ORR (P =0.338; df =3; I2 = 11.1); ≥VGPR (P =0.175; df =3; I2 = 39.53); CR (P =0.677; df =3; I2 = 0) suggests homogeneity across studies. Pooled odds ratios of overall response rates (ORR), ≥VGPR, CR with BCIR vs. NBCIR were 2.619 (P <0.000; 95% CI: 2.103–3.261); 3.558 (P <0.000; 95% CI: 2.908–4.354); 2.739 (P <0.000; 95% CI: 2.072–3.621) respectively indicating BCIR result in improved efficacy. Similar results were translated post-ASCT demonstrating the superiority of BCIR over NBCIR. Post-ASCT ORR (p =0.141; df =3; I2 = 45.03); ≥VGPR (P =0.442; df =3; I2 = 0); CR (P =1.00; df =3; I2 = 0) suggest homogeneity. Pooled odds ratios of ORR, ≥VGPR, CR post-ASCT for BCIR vs. NBCIR were 1.907 (P <0.000; 95% CI: 1.431–2.639); 2.43 (P <0.000; 95% CI: 2.025–2.914); 2.406 (P <0.000; 95% CI: 1.966–2.945) respectively. The pooled hazard ratios (HR) for 3 year PFS and OS were HR 0.723 (95% CI 0.620–0.844; P =0.000); 3 year OS HR 0.789 (95% CI 0.651–0.957; P =0.016) respectively in favor of BCIR. The relative risk (RR) of selected ≥grade 3 toxicities was higher with BCIR. RR of peripheral neuropathy (PN) was 2.469 (95% CI 1.848–3.297; P =0.000) and infection with herpes-zoster virus (HZV) was 2.197 (95% CI 1.368–3.529; P =0.001). The RR of a thromboembolic event (TEE) with BCIR was 0.8 (95% CI 0.56–1.15; P =0.206). Conclusion: Our mixed model meta-analysis demonstrates that the addition of bortezomib to the induction regimens in the transplant-eligible patients with MM results in improved ORR, ≥VGPR, CR, PFS and OS compared with the NBCIR. Known bortezomib related grade 3 toxicities are higher with BCIR recommending appropriate PN monitoring and HZV prophylaxis. The pooled estimates of response and survival strongly favor inclusion of bortezomib in the induction regimens. Disclosures: Kaufman: Millenium, Onyx, Novartis, Keryx: Consultancy; Merck, Celgene: Research Funding. Gleason:Celgene, Merck, Millenium: Consultancy. Flowers:Genentech/Roche (unpaid): Consultancy; Celgene: Consultancy; Millennium/Takeda: Research Funding; Wyeth: Research Funding; Novartis: Research Funding. Lonial:Millennium: Consultancy; Novartis: Consultancy; Celgene: Consultancy; BMS: Consultancy; Onyx: Consultancy; Merck: Consultancy.

Maintenance Therapies for Multiple Myeloma (MM): A Direct Meta-Analysis

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 4271-4271
Author(s):  
Helen Mahony ◽  
Ambuj Kumar ◽  
Rahul Mhaskar ◽  
Branko Miladinovic ◽  
Keith Wheatley ◽  
...  
Keyword(s):  
Maintenance Therapy ◽  
Meta Analysis ◽  
Phase Iii ◽  
Novel Agents ◽  
Controlled Trials ◽  
Cochrane Central Register ◽  
The Novel ◽  
Significant Difference ◽  
American Society

Abstract Abstract 4271 Background: The role of various maintenance therapies in the management of MM is unclear and evidence on the efficacy of these regimens is conflicting. In order to provide the totality of available randomized evidence on the role of maintenance therapy in MM, we conduct a comprehensive systematic review and meta-analysis of all RCTs studying maintenance therapy. Here, we report the pooled results of trials which directly examined the novel agents of bortezomib, lenalidomide, or thalidomide and reported the outcomes of overall survival (OS) and/or progression-free survival (PFS). Methods: A comprehensive literature search of MEDLINE (PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL), and meetings abstracts from American Society of Hematology, American Society of Clinical Oncology, European Society for Medical Oncology and European Hematology Association was undertaken to identify all phase III randomized controlled trials (RCTs) of maintenance therapy published until July 2012. We extracted data on OS and PFS. Time to event data were pooled under the random effects model as hazard ratios (HR) and its corresponding 95% confidence interval (CI). Heterogeneity was assessed using the chi square test and I2statistic. All analyses were done in Review Manager 5.1. Results: Twenty-two RCTs met the inclusion criteria. (Figure 1) However, only data from the following RCTs were able to be pooled for the direct head-to-head comparison: 2 RCTs of bortezomib maintenance therapy enrolling 792 patients, 5 RCTs of lenalidomide maintenance therapy enrolling 1776 patients, 11 RCTs of thalidomide maintenance therapy enrolling 3952 patients. The pooled HR and 95% CI, number of RCTs, and number of patients for each comparison are presented in Figure 2. Only two trials compared the novel agents of bortezomib and thalidomide head-to-head. There was no significant different in terms of PFS. For the novel agent of lenalidomide, there was no significant difference is OS compared to placebo. The pooled PFS was in favor of lenalidomide maintenance compared to placebo. For thalidomide, OS was significantly in favor of the intervention when compared to placebo or prednisone/dexamethasone. There was no significant difference in OS between thalidomide maintenance when compared to interferon control. For the outcome of PFS, the pooled results favored thalidomide when compared to prednisone/dexamethasone or interferon control. There was no significant difference between thalidomide and placebo. Conclusion: To date, the largest number of trials has been among thalidomide as maintenance therapy. In our meta-analysis, thalidomide is the only agent which improves survival compared to no treatment. Other novel agents have been evaluated in a smaller number of trials and current data does not allow for firm conclusions that any agent is superior to the other. An indirect, network meta-analysis is called for to provide additional insights regarding comparative efficacy of the novel agents as the maintenance treatment for MM. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Bortezomib-Based Consolidation/Maintenance Therapy for Multiple Myeloma: A Meta-Analysis of Randomized Controlled Trials

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3293-3293
Author(s):  
Shijia Zhang ◽  
Yucai Wang ◽  
Yvonne Datta ◽  
Veronika Bachanova ◽  
Sarah Cooley
Keyword(s):  
Multiple Myeloma ◽  
Maintenance Therapy ◽  
Randomized Controlled Trials ◽  
Induction Therapy ◽  
Meta Analysis ◽  
Sensory Neuropathy ◽  
Progression Free Survival ◽  
Controlled Trials ◽  
Randomized Controlled ◽  
Grade 3

Abstract Background: Bortezomib is a proteasome inhibitor that can lead to cell-cycle arrest and apoptosis. Bortezomib-based regimens are widely used as induction therapy of multiple myeloma (MM). Unlike lenalidomide (an immunomodulatory drug), the role of bortezomib in the consolidation and maintenance therapy of multiple myeloma is less clear. This study aims to examine the efficacy and safety of bortezomib-based regimens as consolidation/maintenance therapy in MM patients following induction therapy with or without autologous stem cell transplantation (ASCT). Methods: PubMed, ASH, and ASCO databases were searched for randomized controlled trials (RTC) of bortezomib-based regimens (either single-agent or combination) as consolidation/maintenance therapy for MM patients through July 2018. Study endpoints included overall survival (OS), progression-free survival (PFS), and adverse events (AE). Pooled hazard ratios (HR) for survival outcomes and relative risks (RR) for dichotomous data with 95% confidence interval (CI) were calculated with a random effect model using MedCalc (MedCalc Software, Ostend, Belgium). For studies that did not report HRs for survival outcomes but provided graphical survival curves, the log HRs and variances were estimated based on the method by Parmar et al (Stat Med 1998; 17: 2815-2834). Heterogeneity was assessed using the I2 statistic of inconsistency, with statistically significant heterogeneity defined as I2 > 50% or p-value < 0.1. Results: Eight randomized controlled trials (7 phase III, 1 phase II; 2 were published in a single article) were identified. Bortezomib-based regimens were administered as consolidation treatment in 5 RTCs and maintenance therapy in 3 RTCs, following induction therapy +/- ASCT. A total of 2439 patients were included: 1154 patients received bortezomib-based regimens, and 1285 patients received non-bortezomib-based regimens or observation. Two RCTs (1 for consolidation, 1 for maintenance) did not provide HRs, which were estimated as described as above. Pooled data from the 8 RCTs showed that bortezomib-based consolidation/maintenance therapy improved progression-free survival (HR 0.71, 95% CI 0.64-0.79, P < 0.001; I2 = 6.61%) and overall survival (HR 0.80, 95% CI 0.68-0.94, P = 0.005; I2 = 0%) compared to observation or regimens without bortezomib. When the 2 RCTs that did not report HRs were excluded from the meta-analysis, it did not alter the favorable outcome of bortezomib-based consolidation/maintenance therapy: PFS (HR 0.70, 95% CI 0.60-0.82, P < 0.001; I2 = 40.54%) and OS (HR 0.76, 95% CI 0.64-0.91, P = 0.002; I2 = 0%). The PFS benefit was maintained in a subgroup analysis by the setting of treatment (consolidation, HR 0.73, 95% CI 0.63-0.85, P < 0.001; I2 = 0%, maintenance, HR 0.70, 95% CI 0.56-0.0.86, P = 0.001; I2 = 55.63%). Bortezomib-based therapy prolonged OS in the maintenance setting (HR 0.71, 95% CI 0.58-0.86, P < 0.001; I2 = 0%) but not in the consolidation setting (HR 1.01, 95% CI 0.77-1.33, P = 0.935; I2 = 0%). Regarding safety, bortezomib-based consolidation/maintenance therapy significantly increased the risk of grade 3 or 4 peripheral sensory neuropathy and neuralgia (RR 2.09, 95% CI 1.11-3.95, p = 0.022; I2 = 52.64%) compared to observation or regimens without bortezomib. There was a trend toward increased rates of grade 3 or 4 thrombocytopenia (RR 1.54, 95% CI 0.95-2.52, p = 0.08; I2 = 21.67%), GI symptoms (RR 2.54, 95% CI 0.63-10.25, p = 0.19; I2 = 76.72%), vascular events (RR 1.90, 95% CI 0.80-4.53, p = 0.15; I2 = 0.00%), and fatigue (RR 2.10, 95% CI 0.83-5.30, p = 0.12; I2 = 0.00%) with bortezomib-based consolidation/maintenance, but these did not reach statistical significance. Conclusions: Bortezomib-based consolidation/maintenance significantly improves PFS and OS in MM patients following induction therapy +/- ASCT. The OS benefit appears to be limited to the maintenance setting based on a subgroup analysis. Bortezomib-based regimen increases the risk of grade 3 or 4 peripheral sensory neuropathy and neuralgia. Disclosures Bachanova: Gamida Cell: Research Funding; GT Biopharma: Research Funding; Kite Pharma: Membership on an entity's Board of Directors or advisory committees.

scholarly journals Immunomodulatory drug and dexamethasone-containing triple versus doublet combination treatments for relapsed or refractory multiple myeloma: a meta-analysis of phase III randomized controlled trials

2020 ◽  
Author(s):  
Minjie Gao ◽  
Xiao Yan ◽  
Fei Li ◽  
Kaihong Xu ◽  
Qitian Mu ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Randomized Controlled Trials ◽  
Meta Analysis ◽  
Phase Iii ◽  
Controlled Trials ◽  
Efficacy And Safety ◽  
Refractory Multiple Myeloma ◽  
Randomized Controlled ◽  
Immunomodulatory Drug ◽  
Grade 3

Abstract Background Triplet therapy has become the standard of care for relapsed or refractory multiple myeloma (RRMM) over the past few years. Prior to that, doublet therapy including dexamethasone and an immunomodulatory were standard. Several systematic studies have been conducted and many combinations with variable triplet therapies but have not always used the former standard therapy as a benchmark. The objective of this meta-analysis was to evaluate the efficacy and safety of triplet combinations that included dexamethasone and an immunomodulatory drug versus a doublet combination of just dexamethasone and an immunomodulatory for the treatment of RRMM. Methods A comprehensive literature search (PubMed, EMBASE, Cochrane Library) for phase III randomized controlled trials for efficacy and safety of triplet versus doublet combinations that specifically included dexamethasone and an immunomodulatory drug for treatment of RRMM. Efficacy (ORR, PFS, OS) and adverse events (≥ grade 3) were assessed using traditional statistical measures for aggregate data. Results Of 235 potential reports, 6 met the inclusion criteria (N = 115–792 participants). The methodological quality was ≥ 4 Jadad score for each. Triplet treatment had higher ORR (HR = 0.74, 95%CI: 0.65–0.84, P ≤ 0.001), PFS (HR = 0.63, 95%CI: 0.52–0.75, P ≤ 0.001), and OS (HR = 0.74, 95%CI: 0.65–0.84, P ≤ 0.001). The incidence of ≥ grade 3 diarrhea and fatigue were significantly higher in the triplet combination group. There was a trend toward increased incidence of ≥ grade 3 neutropenia, thrombocytopenia, thromboembolism, and peripheral neuropathy in the triplet therapy group. Notably, triplet therapy had a significantly lower rate of anemia compared to doublet therapy. Conclusions This study reinforces current guidelines and recommendations for triplet combinations containing dexamethasone and an immunomodulatory drug.

Phase III Intergroup Study of Lenalidomide Versus Placebo Maintenance Therapy Following Single Autologous Hematopoietic Stem Cell Transplantation (AHSCT) for Multiple Myeloma: CALGB 100104

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 37-37 ◽  
Author(s):  
Philip L. McCarthy ◽  
Kouros Owzar ◽  
Kenneth C. Anderson ◽  
Craig C. Hofmeister ◽  
David Duane Hurd ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Maintenance Therapy ◽  
Disease Progression ◽  
Board Of Directors ◽  
Stable Disease ◽  
Interim Analysis ◽  
Research Funding ◽  
Phase Iii ◽  
Cell Transplant ◽  
Advisory Committees

Abstract Abstract 37 The primary objective of CALGB 100104 was to determine if maintenance lenalidomide would prolong time to progression (TTP) after single AHSCT for multiple myeloma. Eligibility included: Stage I-III multiple myeloma, ≤ 1 year from diagnosis, ≥ 2 months of induction with stable disease or better and age < 70 years. AHSCT regimen was melphalan 200 mg/m2. Patients (pts) with stable disease or better were randomized double-blinded at day 100–110 post-AHSCT to lenalidomide or placebo, after stratification by diagnostic β2-microglobulin (β2M) level and prior thalidomide or lenalidomide therapy. Starting dose was 10 mg/day, escalated to 15 mg/day after 3 months and continued until disease progression. Drug was stopped and dose reduced according to the development of toxicity. Drug was held for ≥ Gr 3 toxicity, restarted at resolution to ≤ Gr 2 and de-escalated by 5 mg or maintained as tolerated at 15, 10, 5 mg daily or 5 mg daily for 21 of 28 days per month. All pts required some form of anticoagulation including aspirin, warfarin or heparin compounds. There was no consolidation therapy. Results: 568 pts were enrolled before AHSCT (04/15/05-07/03/09) from 47 centers. Of 108 pts (19%) not randomized, reasons were: progressive disease/no response 16%, adverse events (AEs) 5%, died during therapy 2%, refusal 26 %, other disease 1%, other therapy 4 %, other reasons 33%, unknown 14%. Pt characteristics in the lenalidomide arm and placebo arm respectively were: median age (range) 58 (29-70) and 57 (39-70); male gender 48% and 52%; β2M >2.5 mg/L, 28% and 27%. For 554 pts with complete data, induction regimens were thalidomide based (27%), lenalidomide based (22%), bortezomib based (20%), bortezomib and thalidomide based (12%), bortezomib and lenalidomide based (9%), dexamethasone based (4%), lenalidomide and thalidomide (3%), lenalidomide, thalidomide and bortezomib (1%), other (1%) and missing (1%); hence 74% of pts received either lenalidomide or thalidomide prior to enrollment. The primary endpoint of the study, TTP was met in a planned protocol interim analysis in the 3rd quarter of 2009 and the study results were released on 12/17/09. This updated 3rd interim analysis for TTP includes further events up until 12/17/09 after which study pts were un-blinded. This interim analysis is based on 460 randomized pts with approximately 33% of the required number of events (progression or death before progression) observed. The median follow-up is 17.5 months from ASHCT. The number of events among 231 pts randomized to lenalidomide was 44 compared to 91 among 229 pts randomized to placebo. The one-sided unadjusted P-value was <0.0001. Pts receiving lenalidomide experienced a 61% reduction in the risk of disease progression or death when compared to pts receiving placebo. The estimated hazard ratio was 0.39 (95% CI,0.27-0.56 p < 0.0001). The preliminary estimated median TTP is 42.3 months for the lenalidomide arm and the estimated median TTP is 21.8 months for the placebo arm. Deaths in the lenalidomide and placebo arms were 19 and 28 respectively (p=0.13) and as of this analysis, there is no difference between these two arms. Significant improvements in TTP were observed in the lenalidomide maintenance arm regardless of β2M level or prior thalidomide or lenalidomide induction therapy. For 389 reported pts, the post-randomization, hematologic AEs were Gr 3 (32%), Gr 4 (13%) and Gr 5 (0) for the lenalidomide arm and Gr 3 (6%) Gr 4 (4%) and Gr 5 (0) for placebo (p=0.0001). The non-hematologic AEs were Gr 3 (30%), Gr 4 (3%) and Gr 5 (1%) for the lenalidomide arm and Gr 3 (19%), Gr 4 (3%), and Gr 5 (2%) for placebo (p=0.0048). Comparing lenalidomide versus placebo post-randomization pooled Gr 3–5 AEs, there were significantly more episodes of thrombocytopenia (11% versus 3%, p=0.01), neutropenia (44% vs 8%, p<0.0001) anemia (5% vs 1%, p=0.0082) and all infections (16% vs 3%, p<0.0001) with lenalidomide. There were no significant differences in incidence of fatigue, neuropathy, rash and thromboembolism. A minority of patients discontinued therapy due to AEs (12%, 28 of 231 on lenalidomide vs 2%, 5 of 229 on placebo) and for other reasons (13%, 29 of 231 on lenalidomide vs 6%, 14 of 231 on placebo). Conclusions: Long term administration of lenalidomide is feasible. When compared to placebo controls, lenalidomide initiated at day 100–110 post-AHSCT in multiple myeloma patients significantly delays TTP. Disclosures: McCarthy: Celgene: Honoraria, Research Funding. Off Label Use: Lenalidomide maintenance therapy for myeloma following autologous hematopoietic cell transplant. Anderson:Millenium: Consultancy, Honoraria; Celgene: Consultancy; Novartis: Consultancy; Onyx: Consultancy; Merck: Consultancy; Bristol Myers Squibb: Consultancy; Acetylon: Equity Ownership, Membership on an entity's Board of Directors or advisory committees. Hurd:Celgene: Research Funding. Giralt:Celgene: Honoraria, Speakers Bureau; Millenium: Honoraria, Speakers Bureau. Stadtmauer:Celgene: Speakers Bureau. Richardson:Celgene: Membership on an entity's Board of Directors or advisory committees; Millenium: Membership on an entity's Board of Directors or advisory committees. Vij:Celgene: Honoraria, Speakers Bureau. Callander:Millenium: Research Funding. Maziarz:Millenium: Speakers Bureau; Genzyme: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Landau:Millenium: Membership on an entity's Board of Directors or advisory committees. Martin:Celgene: Speakers Bureau; Millenium: Speakers Bureau; Novartis: Speakers Bureau. Qazilbash:Celgene: Speakers Bureau. Shea:Millenium: Consultancy, Research Funding.

scholarly journals Phase 2 Trial of LDE225 and Lenalidomide Maintenance Post Autologous Stem Cell Transplant for Multiple Myeloma

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 1905-1905
Author(s):  
Francis K. Buadi ◽  
Martha Q. Lacy ◽  
Angela Dispenzieri ◽  
Gabriela Perez ◽  
Morie A. Gertz ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Overall Survival ◽  
Stem Cell ◽  
Maintenance Therapy ◽  
Research Funding ◽  
Stem Cell Transplant ◽  
Autologous Stem Cell Transplant ◽  
High Dose ◽  
Cell Transplant ◽  
Grade 3

Background: Lenalidomide maintenance therapy post-autologous stem cell transplantation (ASCT) is associated with improved progression-free survival (PFS) and possibly overall survival in multiple myeloma (MM). However, almost all patients do relapse as a result of residual multiple myeloma cells that remain after the high-dose chemotherapy. In the myeloma setting it has been found that the hedgehog (Hh) pathway is essential for maintaining a subset of tumor causing stem cells. LDE 225 (Sonidegib) is a potent selective oral bioavailable antagonist of Smoothened (SMO), a component of the Hh signaling pathway. In in vitro experiments, LDE225 treatment of myeloma cell lines resulted in a modest inhibition of cell proliferation at increasing doses. When LDE225 was combined with lenalidomide, a more than additive effect was observed in terms of cell proliferation, an effect that was more pronounced in the context of myeloma cell lines growing in co-culture with marrow derived stromal cells. These findings form the basis of evaluation of LDE 225 as a strategy to enhance the activity of lenalidomide in the post-transplant maintenance setting. The minimal residual state post SCT provides the most optimal situation for evaluation of a drug that is likely to work by inhibiting the tumor cells that escaped high dose therapy. Methods: Multiple myeloma patients without evidence of progression, who were 60 - 120 days after a single autologous stem cell transplant (SCT), performed within 1 year of diagnosis were eligible for the study. Maintenance therapy was started approximately 3 months after SCT. Treatment consisted of lenalidomide 10 mg days 1-21 and LDE225 400 mg days 1-28 in 28-day cycles for a total of 18 cycles. The goal of the study was to assess toxicity of this combination, complete response rate (CR) progression free survival (PFS) at 1 and 2 year and overall survival (OS). CR and PFS were estimated using an exact binomial distribution and Kaplan Meier curves respectively. Results: A total of 28 patients were accrued from Jan 2014 to Aug 2016, 1 patient canceled prior to treatment and 1 patient was deemed ineligible resulting in 26 evaluable pts for CR and PFS. The median age of all pts (n=26) was 60 years (range 43-69) and 50% were males. Seventy-three percent of patients reported one treatment regimen prior to SCT, while 27% reported 2 or more prior regimens. The other characteristics of the patient are summarized in Table 1. Twenty seven pts received at least one cycle of treatment and are evaluable for toxicities (AE). Patients were treated for a median of 12.5 (range 1-18) cycles. While 10 pts (38.5%) completed protocol treatment (18 cycles), the remaining 16 pts went off treatment due to AEs (6, 23%), disease progression (3, 11.5%), refusal of further treatment (3, 11.5%) and other reasons (4, 15.4%). A grade 3 or higher AE at least possibly attributed to either drug was seen in 63%. Grade 3+ hematologic toxicities were noted in 30%, with 7% neutropenia and 4% thrombocytopenia. Notable grade 2+ non-hematologic toxicities with more than 5% incidence were dysgeusia 22%, alopecia 11%, and anorexia 7%. Grade 3+ non-hematologic toxicities were fatigue, myalgia and arthralgia each at 7%. The CR rate in evaluable patients was 46% (5 CRs and 7 sCRs) with a 95% CI of 27% - 66%. CR rate improved from 31% to 46%. VGPR or better improved from 42% to 85%. The 24-month PFS (time from SCT to progression or death due to any cause) was 73% (95% CI: 57.9 - 92.3%) with a median time to censoring of 38 months. Conclusion: Lenalidomide in combination with LDE225 as posttransplant maintenance therapy was associated with some toxicity but manageable. The combination improved the depth of response after autologous stem cell transplant. Long-term follow-up is needed to determine overall survival. Disclosures Lacy: Celgene: Research Funding. Dispenzieri:Celgene: Research Funding; Takeda: Research Funding; Pfizer: Research Funding; Janssen: Consultancy; Intellia: Consultancy; Akcea: Consultancy; Alnylam: Research Funding. Gertz:Ionis: Honoraria; Alnylam: Honoraria; Prothena: Honoraria; Celgene: Honoraria; Spectrum: Honoraria, Research Funding; Janssen: Honoraria. Kapoor:Glaxo Smith Kline: Research Funding; Amgen: Research Funding; Janssen: Research Funding; Cellectar: Consultancy; Takeda: Honoraria, Research Funding; Celgene: Honoraria; Sanofi: Consultancy, Research Funding. Dingli:alexion: Consultancy; Janssen: Consultancy; Millenium: Consultancy; Rigel: Consultancy; Karyopharm: Research Funding. Russell:Imanis: Equity Ownership. Kumar:Janssen: Consultancy, Research Funding; Takeda: Research Funding; Celgene: Consultancy, Research Funding. OffLabel Disclosure: Sonidegib (LDE 225) is a selective oral bioavailable antagonist of Smoothened (SMO), a component of the hedgehog signaling pathway.

scholarly journals Long Term Outcome of Lenalidomide-Dexamethasone (Rd) Vs Melphalan-Lenalidomide-Prednisone (MPR) Vs Cyclophosphamide-Prednisone-Lenalidomide (CPR) As Induction Followed By Lenalidomide-Prednisone (RP) Vs Lenalidomide (R) As Maintenance in a Community-Based Newly Diagnosed Myeloma Population: Updated Analysis of EMN01 Phase III Study

Blood ◽  
2017 ◽  
Vol 130 (Suppl_1) ◽  
pp. 901-901
Author(s):  
Sara Bringhen ◽  
Massimo Offidani ◽  
Pellegrino Musto ◽  
Anna Marina Liberati ◽  
Giulia Benevolo ◽  
...  
Keyword(s):  
Board Of Directors ◽  
Research Funding ◽  
Phase Iii ◽  
Cell Transplant ◽  
Newly Diagnosed ◽  
Community Based ◽  
Advisory Committees ◽  
Risk Of Death ◽  
Grade 3 ◽  
To Receive

Abstract Introduction : Rd and MPR showed to be effective combinations in elderly newly diagnosed multiple myeloma (NDMM) patients (pts). Cyclophosphamide is a less toxic alkylating alternative agent. EMN01 is the first trial to formally compare these three different Lenalidomide-based combinations. Maintenance with Lenalidomide has been recently approved in patients eligible for autologous stem cell transplant (ASCT). Few data are available about the best combination as maintenance in patients not eligible for ASCT. Methods : 662 pts with NDMM were randomized to receive 9 28-day cycles of Rd (lenalidomide 25 mg/day for 21 days; dexamethasone 40 mg on days 1,8,15 and 22 in pts 65-75 years old and 20 mg in those &gt;75 years), MPR (lenalidomide 10 mg/day for 21 days; melphalan orally 0.18 mg/Kg for 4 days in pts 65-75 years old and 0.13 mg/Kg in &gt;75 years pts; prednisone 1.5 mg/Kg for 4 days) or CPR (lenalidomide 25 mg/day for 21 days; cyclophosphamide orally 50 mg/day for 21 days in pts 65-75 years old and 50 mg every other day in &gt;75 years pts; prednisone 25 mg every other day). After induction, pts were randomized to receive maintenance with lenalidomide alone (R; 10 mg/day for 21 days) or with prednisone (RP; R, 10 mg/day for 21 days and P, 25 mg every other day), until disease progression. Results : Pts characteristics were well balanced in all groups; 217 pts in Rd, 217 in MPR and 220 in CPR arms could be evaluated. After a median follow-up of 63.7 months, median PFS was 23.2 months in MPR, 18.9 months in CPR and 18.6 months in Rd (MPR vs CPR p=0.02; MPR vs Rd p=0.08). Median overall survival (OS) was 79.9 months in MPR, 69.4 months in CPR and 68.1 months in Rd (MPR vs CPR p=0.98; MPR vs Rd p=0.64). The most common grade ≥3 adverse event (AEs) was neutropenia: 64% in MPR, 29% in CPR and 25% in Rd pts (p&lt;0.0001). Grade ≥3 non hematologic AEs were similar among arms. At the end of induction, 402 pts were eligible for maintenance, 198 in the RP and 204 in the R groups. PFS from start of maintenance was 22.2 months in the RP group and 17.6 in the R group, with 20% reduced the risk of death/progression for pts receiving RP maintenance (HR 0.81, p=0.07; Figure 1). A subgroup analysis was performed to determine the consistency of RP vs R treatment effect in different subgroups using interaction terms between treatment and cytogenetic abnormalities, ISS, age, sex, induction treatment and response before maintenance (Figure 1). No difference in OS was observed (HR 1.02, p=0.93) but the OS analysis was limited by the low number of events. Median duration of maintenance was 23.0 months in RP pts and 20.5 months in R pts, 14% and 13% of pts discontinued due to AEs, in RP and R groups, respectively. Conclusion : This phase III trial compared 2 different Lenalidomide-containing induction regimens and 2 different Lenalidomide-containing maintenance regimens in an elderly community-based NDMM population. MPR prolonged PFS by approximately 5 months, yet the higher incidence of hematologic toxicity should be carefully considered. The addition of low-dose prednisone to standard lenalidomide maintenance reduced the risk of death/progression by 20%, with a good safety profile. Updated results will be presented at the meeting. Disclosures Bringhen: Mundipharma: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria; Celgene: Honoraria; Bristol Myers Squibb: Honoraria; Karyipharm: Membership on an entity's Board of Directors or advisory committees. Offidani: celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees. Musto: Celgene: Honoraria; Janssen: Honoraria. Gaidano: Gilead: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Roche: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria. De Sabbata: Celgene: Membership on an entity's Board of Directors or advisory committees. Palumbo: Sanofi: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria, Research Funding; Binding Site: Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Merck: Consultancy, Honoraria, Research Funding; Genmab A/S: Consultancy, Honoraria, Research Funding; Janssen-Cilag: Consultancy, Honoraria, Research Funding; Bristol-Myers Squibb: Consultancy, Honoraria, Research Funding, Speakers Bureau; Takeda: Consultancy, Employment, Equity Ownership, Honoraria, Research Funding. Hájek: Amgen, Takeda, BMS, Celgene, Novartis, Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Abbvie: Consultancy, Honoraria; Pharma MAR: Consultancy, Honoraria. Boccadoro: Novartis: Honoraria, Research Funding; Bristol-Myers Squibb: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; AbbVie: Honoraria; Mundipharma: Research Funding; Sanofi: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Janssen: Honoraria, Research Funding.

Sign in / Sign up

Export Citation Format

Share Document