Expert hematologist-oncologists consider the role of maintenance and consolidation following the completion of transplant in patients with newly diagnosed multiple myeloma.
Sundar Jagannath, MD: Now coming back to the post-transplant maintenance and consolidation, where are you on the post-transplant maintenance and consolidation, Dr Richard?
Shambavi Richard, MD: The evidence for consolidation has always been highly debated. I think there is no absolute standard for consolidation. I in general tend to not use consolidation. I try to maximize my induction. In terms of consolidation, I might use it in a couple of specific situations. I might use it for instance if there’s a high-risk patient who is still MRD [minimal residual disease]-positive post-transplant, so we’re almost there but not quite. We all know the predictive power of getting to MRD-negative, especially post-transplant. And so I might try a few cycles of consolidation or intensification to get them to that prior to going to maintenance. So that’s one situation where I might use consolidation. Interestingly, the StaMINA trial, which was really an extension of the BMT CTN 0702 [trial], if you remember, initially they had patients who had a single transplant [who] were then randomized to either directly going to maintenance, a second transplant, a tandem transplant and then maintenance, or 4 cycles of VRd [bortezomib (Velcade), lenalidomide (Revlimid) plus dexamethasone], consolidation and then maintenance. And at the 3-year mark, they really didn’t have too much of a difference in terms of PFS [progression-free survival], overall survival, or any of the various parameters that were looked at. However, on an extended follow-up, especially when teasing out the high-risk patients, there was actually a difference with the tandem transplant. And so, the tandem transplant was best off, followed by the people who got the consolidation and then the maintenance. And then the ones who were least well off were the ones who actually went directly to maintenance. I think that there’s probably room for consolidation someplace, but I wouldn’t generalize it and use it on everybody. In general, so if I have a standard-risk patient who easily went into MRD-negative post-transplant, I don’t use consolidation in patients like that.
Transcript edited for clarity.