How long should a multiple myeloma patient receive lenalidomide maintenance therapy?

Chair and Professor, Department of Hematology and Medical Oncology and Chief Medical Officer of Winship Cancer Institute at Emory University School of Medicine

This month, Sagar Lonial, MD, addresses a question about duration of maintenance therapy in a patient diagnosed with multiple myeloma.

CLINICAL DILEMMA

I have a young patient who was diagnosed with IgG lambda multiple myeloma in 1997. He was induced with vincristine, doxorubicin, and dexamethasone (VAD) followed by an autologous transplant in 1998. He relapsed six years later. At this point (in 2004) he was started on thalidomide and dexamethasone and intermittently switched to thalidomide alone. In 2013, he was switched to lenalidomide; he has been on 10 mg a day. His labs show no monoclonal protein. All of his other parameters suggest that he is in complete remission. How long should he continue taking lenalidomide? If we decide to discontinue, what will guide us in decision making?

EXPERTS MAKE THE CALL

All of the trials that give lenalidomide in the relapse setting continue until disease progression or there are signs of adverse events. If lenalidomide is well tolerated, I would continue as long as the two criteria above are met, that is, the patient tolerates treatment well and does not have signs of progression. If the patient is still on dexamethasone, I would definitely stop that, but continue the lenalidomide for as long as possible. While there are early signs that the use of minimal residual disease (MRD) testing with either next-generation sequencing or flow cytometry may be able to identify patients who are MRD-negative, there are no trials that incorporate these tests to decide when or if to stop treatment. Thus, current standard of care is to continue until progression.

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