ASCT in Myeloma: Will It Be Transplanted by Other Treatments?
Posted: Friday, October 11, 2019
Although the field has evolved greatly with the introduction of new agents, for now, autologous stem cell transplantation (ASCT) remains part of the standard of care for every newly diagnosed patient with multiple myeloma who is eligible for ASCT. Currently, as high-dose therapy (HDT)-ASCT, it is delivered after induction with a three-drug regimen, described María-Victoria Mateos, MD, PhD, of Spain’s University Hospital of Salamanca, and colleagues, in Clinical Lymphoma, Myeloma & Leukemia. Their overview of several ASCT-related trials and topics was also presented at the 2019 Society of Hematologic Oncology Annual Meeting in Houston (Abstract EXABS-MM-455).
The induction regimen of bortezomib plus thalidomide and dexamethasone, followed by HDT-ASCT, was examined in two European phase III randomized trials, Dr. Mateos and co-investigators reported. After a median follow-up of about 10 years in each, an Italian group reported a 60% overall survival rate and a 34% progression-free survival rate, whereas a Spanish team found a median overall survival of 123 months and a median progression-free survival of 52 months.
In two other trials, CALGB 100104 and IFM 2005, the use of lenalidomide as maintenance after HDT-ASCT resulted in a new standard of care. Now, ways to potentially improve the conditioning regimen are under investigation, with, for example, busulfan plus melphalan pitted against melphalan alone. So far, in a phase III randomized trial with 202 patients, the mean progression-free survival was 64.7 months with the combination versus 43.5 months with melphalan alone (P = .022).
“ASCT has been recently challenged by first, the introduction of proteasome inhibitors and immunomodulatory drugs, and, second, the possibility of achieving deep responses that may make it possible to reserve ASCT following relapse,” noted Dr. Mateos and her team. “In the future, new trials will evaluate the role of HDT-ASCT and will be challenged by the new immunotherapeutic strategies, like CAR [chimeric antigen receptor] T cells.” Right now, an ongoing Italian Myeloma Group trial has one group of patients receiving four cycles of carfilzomib, lenalidomide, and dexamethasone, then HDT-ASCT, then consolidation with four additional cycles of the three drugs, whereas the second group’s regimen is 12 cycles of the same three-drug combination without HDT-ASCT. So far, complete response and negative minimal residual disease rates are similar in both arms.
Disclosure: The study authors’ disclosure information can be found at clinical-lymphoma-myeloma-leukemia.com.
