How do you utilize lenalidomide maintenance in non-transplant eligible myeloma?

Maintenance is a standard of care management for both transplant eligible and transplant ineligible, regardless of type of induction regimen. Studies have shown benefit for both groups. Time to progression (PFS) almost twice as long for both groups with maintenance compared to no maintenance.

- For transplant ineligible: would do 8-10 cycles of induction treatment (Velcade/lenalidomide/dex first line treatment), then maintenance lenalidomide (or beotezomib if did not tolerate Lenalidomide).

- In the US, length of maintenance is until progression or toxicity or pt decides to stop. Most of the clinical trials are being performed this way.

- We are looking at ways we can modify this. Does everyone need to be on maintenance "forever" or can we ...

This is an important question with very recent potentially practice-changing data.

TLDR: For a patient with standard-risk myeloma who is not tolerating lenalidomide well and/or is keen to get off therapy, 2 years of lenalidomide maintenance is justified and should reflect a new standard of care.

The second randomization of the ENDURANCE trial (Kumar et al., PMID 42456135) compared indefinite duration vs. fixed-duration (2 years) of lenalidomide maintenance for patients with standard-risk newly diagnosed multiple myeloma treated with either VRD or KRD induction and not undergoing upfront autologous stem cell transplant.

The results of the 2nd randomization showed that patients with fixed-duration lenalidomide achieved comparable overall surviva...

First-line treatment for most myeloma patients in the US is 4-drug therapy with CD38Ab+RVd using lower cumulative exposure dosing in more frail patients, based in part on results from IMROZ, CEPHEUS, and BENEFIT trials. These all are expected to generate 80+% 2-year PFS and slightly better than 5-year median PFS.

Many of these standard-risk patients stay on CD38Ab+lenalidomide until progression. I don't know if we can extrapolate the defined period maintenance results from ENDURANCE (Kumar et al., PMID 42456135) to this patient population and stop CD38Ab+lenalidomide after 2 years.

For patients with intermediate and IMS/IMWG defined high risk disease, these patients still don't have access to a BsAb or CART as part of first-line therapy, so m...