Maintenance therapy in newly diagnosed multiple myeloma: current recommendations

Abstract

The recent availability of novel agents has substantially improved the outcomes of patients with Multiple Myeloma (MM). Achieving the deepest level of complete response and maintaining a sustained remission are important steps towards MM cure. To achieve this goal, consolidation and maintenance therapies are currently incorporated into the modern therapeutic paradigm. The excellent activity shown by new drugs has led to their investigational use as maintenance therapy. However, despite promising results of continuous treatment with the novel agents, consensus regarding maintenance therapy still lacks. This review will focus on maintenance therapy, offering an overview of the different strategies available in MM. The issue of continuous treatment in the light of new biological discoveries, including intra-clonal heterogeneity, will also be addressed.

Keywords::

• bortezomib
• lenalidomide
• maintenance
• multiple myeloma
• thalidomide

Financial & competing interests disclosure

A Brioli has received honoraria from Celgene; M Cavo has received honoraria and has been a member of the advisory board for Celgene, Janssen and Millennium. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• None of the novel agents is currently approved as maintenance therapy for newly diagnosed multiple myeloma patients.

• Thalidomide maintenance may be an effective option in patients with biologically low-risk disease.

• Thalidomide should be given at the minimal effective dose and possibly for no longer than 1 year.

• Lenalidomide maintenance dramatically improves progression-free survival and, although to a lesser extent and without consistency in all the studies reported so far, overall survival.

• Which patients mostly benefit from lenalidomide maintenance according to biological characteristics of the disease at baseline and the quality of response to induction therapy is not well defined.

• More mature data are needed to define the optimal duration of lenalidomide maintenance and the impact of prolonged exposure to lenalidomide on patients' quality of life.

• Physicians and patients must carefully outweigh pros and cons of a maintenance strategy with lenalidomide.

• The role of single agent bortezomib as maintenance therapy is not defined.

• More mature data are needed to confirm whether incorporation of bortezomib into induction and maintenance treatment improves the poor prognosis associated with adverse genetic lesions, including t(4;14) and del(17p).