Blood Cancer in the Elderly: European Expert Forum, Rome, 19—20 March 2011

Dr Evangelos Terpos (University of Athens, Greece)
Maintenance therapy for multiple myeloma

This is ecancer.tv, reporting here from Rome at the Blood Cancer in the Elderly conference and Evangelos Terpos. Professor Terpos, you’re here from Athens, you’ve got some great data from Greece, I know, and you were an expert commentator at this session on multiple myeloma. We’re looking specifically at older patients, now one of the topics we heard about was maintenance. You listened to Gareth Morgan’s talk, I’m sure, what do you think is the position of maintenance in elderly patients?

I think that during the last years we’ve had a lot of interesting data about maintenance therapy in myeloma. In other haematological malignancies like acute myeloid leukaemia, let’s say, or acute lymphoblastic leukaemia, after induction therapy we have consolidation and maintenance therapies that have increased the survival or even the cure rate in these diseases. So I think that it’s time now for myeloma to change a little bit our managing of our patients.

So we have two major studies in the non-elderly population, meaning patients who are eligible for transplantation, and in these two studies lenalidomide maintenance has increased progression free survival time, something which is very important. In the French study the p-value was incredibly high of the survival difference regarding progression free survival so from that study we are also going to have also overall survival benefit.

Regarding the elderly population we have one study, the MPR, melphalan, prednisone plus lenalidomide and lenalidomide as maintenance. We have seen from this study that the maintenance with lenalidomide, even in the elderly, has produced very encouraging results, meaning that it has prolonged the progression free survival time.

Gareth Morgan was saying that the IMiDs are floating to the top in terms of which agents to use in the maintenance role but he was also talking about ringing the changes, having one IMiD and then maybe another. What do you think about that?

First of all the immunomodulatory drugs, mainly thalidomide and lenalidomide, are oral drugs so it is very convenient to give them as maintenance because the patient has not had to come to the hospital once or twice per week like bortezomib, let’s say. So this one advantage. The second advantage is that the way of action of immunomodulatory drugs, and mainly of lenalidomide which is more potent than thalidomide, is that because of the reduction of tumour load but also because of the immunomodulation that they create, they enhance the immune system against myeloma cells. I think that mainly for this reason lenalidomide seems to be ideal for a maintenance effect. That’s why I’m very much interested, not only in this study which may give the MPR plus maintenance lenalidomide which may give a licence for this drug as the first drug for maintenance use in patients with multiple myeloma, but with MPR as induction. But also I’m very much interested to see what’s going to happen if we use any other induction regimens like MPG with thalidomide, or MPV with bortezomib, and then to have lenalidomide as maintenance. So I think that we have a lot of new information that are going to appear during the next years in order to see what’s the exact role of lenalidomide as a maintenance.

What do you advise, very briefly, in practical terms doctors with patients in front of them right now should think about this maintenance issue then?

I think that we have to think about maintenance very clearly and I strongly believe that after one or two years we are going to have a maintenance licence. Because this is the main problem - all the studies have shown progression free survival benefits regarding lenalidomide maintenance but unfortunately we don’t have the licence yet. So although I strongly believe that the maintenance is going to be very good regarding the progression free survival in myeloma patients, of course we have to wait until the licence from EMEA or FDA in order for doctors to use this drug as maintenance.

Of course, one of the things about the IMiDs is they may be less toxic, relatively low toxicity, so does that make them more suitable for elderly patients with myeloma?

I think that one of the major advantages of IMiDs and mainly of lenalidomide, to be honest. You see that I talk mainly about lenalidomide because for thalidomide the effects are good but not so good like lenalidomide. Of course we don’t have randomised trials comparing thalidomide and lenalidomide maintenance but from the trials that we have until now, the lenalidomide effects are better.

So I believe that first they are oral drugs, second their safety profile is good and with the lower doses that we use for maintenance, I think that they are very suitable, even for the elderly patients.

So just a very brief final word, a practical comment from you, for doctors about toxicity in the elderly then with some of these agents, both in maintenance and induction, very briefly.

I think that with lenalidomide and low dose lenalidomide, like 10-15mg that are used in most of the studies, this type of maintenance is very suitable even for patients who are elderly even above the age of 75.

Evangelos Terpos, it’s a real pleasure to have you again with us here on ecancer.tv.

It’s also a pleasure for me.