Evaluating lenalidomide-based regimens for elderly patients with multiple myeloma

This study compared different treatment combinations for first-line and maintenance therapies in elderly patients with multiple myeloma (MM). The authors found that first-line MPR was most effective for fit elderly patients, while all patients benefitted from RP maintenance therapy.

MM is a complex disease, and treatment options depend on a patient’s age and fitness level. Treatment is typically given in two stages. First-line treatment, also called induction therapy, aims to kill the cancer. This stage of treatment can include a combination of chemotherapy, targeted therapy, and steroid therapy. Then, maintenance therapy is given to help prevent the cancer from coming back (relapse). 

However, because elderly patients can differ in their fitness levels, which treatment combinations are most effective is unclear. This study evaluated the effectiveness and safety of different induction and maintenance therapies for elderly patients with MM.

This study had 654 patients age 65 or older. Patients received one of three induction therapies containing lenalidomide (Revlimid; R). 217 patients had Rd (lenalidomide, dexamethasone). 217 patients had MPR (melphalan, prednisone, lenalidomide). 220 patients had CPR (cyclophosphamide, prednisone, lenalidomide). 

After induction therapy, 402 patients received maintenance therapy. Of these, 204 patients had R (lenalidomide only), and 198 patients had RP (lenalidomide, prednisone). Patients were followed for an average of 71 months.

Overall, MPR was the most effective induction therapy. The average time without tumor growth or spread was 18.6 months after Rd, 22.2 months after MPR, and 18.9 months after CPR.  The average survival time was 61.5 months after Rd, 65.2 months after MPR, and 66.4 months after CPR.

In fit patients, MPR was the most beneficial induction therapy.  Patients were 28% more likely to survive longer without tumor growth or spread with MPR compared to CPR or Rd. In intermediate-fit and frail patients, there was no difference between any of the treatment combinations.

During induction therapy, 68% (MPR) and 13% (RP) of patients experienced serious blood-related side effects. 32% (CPR), 29% (Rd), and 23% (R) of patients also had serious blood-related side effects. Serious infections occurred 11% (MPR), 6.5% (CPR), and 9% (Rd) of patients.

Overall, RP was the most effective maintenance therapy. The average time without tumor growth or spread was 22.2 months after RP and 18.6 months after R. Patients were 15% more likely to survive longer without tumor growth or spread with RP compared to R. 

During maintenance therapy, most side effects were mild. However, 10% (RP) and 21% (R) of patients had seriously low white blood cell counts.

The authors concluded that MPR was the most effective induction treatment in fit elderly patients with MM. RP was the most effective maintenance therapy for all patients.

The manufacturer of lenalidomide, Celgene, funded this study. More studies are needed to confirm these results, particularly for frail patients.