Comparing first-line treatments for multiple myeloma

This review compared initial treatments for patients with multiple myeloma (MM) that cannot be treated with a transplant. This study found that drug regimens which included the targeted treatments bortezomib or daratumumab had better outcomes.

MM is a cancer involving abnormal white blood cells called myeloma cells. Myeloma cells build up in the bone marrow. This can cause bone pain and weakness. Myeloma cells also create large amounts of antibodies that can damage the kidneys. MM affects patients in different ways. This makes diagnosing and treating the disease more complicated.

MM is typically treated with multiple drug regimens. One type of medication is chemotherapy, which prevents the division and growth of cells. Chemotherapy medications include thalidomide (T; Thalomid), lenalidomide (R; Revlimid), and melphalan (M; Alkeran). Corticosteroids are steroid medications that act like the stress hormone cortisol. Steroids can reduce the side effects of chemotherapy and reduce tumor size. Steroid medications include prednisone (P; Deltasone) and dexamethasone (Decadron). There are also targeted therapies that act on certain molecules on cancer cells. These include bortezomib (V; Velcade) or daratumumab (Da; Darzalex).

Because there are many drug regimens used for MM, it is unclear what the most effective options are.

This study analyzed the results of 10 studies of patients with newly diagnosed MM. Each study compared two treatments. Both induction and maintenance regimens were used. Induction is the first treatment given for a disease. Maintenance treatment is given to keep the cancer from coming back after successful first treatment). Statistical analysis was used to compare the results of different trials. 

There were 11 drug regimens included in the analysis. These were VMP (bortezomib, melphalan, prednisone), Da_VMP_Da (daratumumab and VMP induction with daratumumab maintenance), MPT (melphalan, prednisone, thalidomide), MPT_T (MPT induction with thalidomide maintenance), RD (lenalidomide, dexamethasone), VRD (bortezomib, lenalidomide, dexamethasone), VRD_RD (VRD induction with RD maintenance), MRP_R (melphalan, lenalidomide, prednisone with lenalidomide maintenance), CRP_R (cyclophosphamide, lenalidomide, prednisone with lenalidomide maintenance), CTD (cyclophosphamide, thalidomide, dexamethasone), Da_RD_Da (daratumumab and RD induction with daratumumab maintenance), and RD18 (18 cycles of RD).

Da_VMP_Da, Da_RD_Da, and VRD_RD were the most effective treatments. Other treatments had a higher risk of the cancer progressing (becoming worse). Patients taking CPR_R had 2.2 times higher risk of the cancer progressing compared to Da_VMP_Da. For MPT, the risk was 3.0 times higher than Da_VMP_Da.

This study found that regimens containing daratumumab and bortezomib were more effective than other drug regimens for the initial treatment of MM.

One of the authors has done advisory work for Janssen Pharmaceuticals, the manufacturer of daratumumab and bortezomib.