What is the efficacy of maintenance therapy in the treatment of multiple myeloma (MM)?

Updated: May 11, 2021
  • Author: Dhaval Shah, MD; Chief Editor: Emmanuel C Besa, MD  more...
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A meta-analysis shows the benefit of maintenance lenalidomide, with a 51% reduction in the risk of recurrence. [81] This benefit outweighs the risk of SPM seen in the trials of lenalidomide maintenance.

Bortezomib has also been shown to be effective for maintenance therapy in the  HOVON-65/GMMG-HD4 trial. [82] In this trial, patients were randomized to either PAD (bortezomib, doxorubicin [Adriamycin], and dexamethasone) induction followed by bortezomib maintenance or to VAD induction followed by thalidomide maintenance. PFS in the PAD arm was significantly better than in the VAD arm (35 vs 28 months). Patients with high-risk cytogenetics, especially del(17p13) and t(4;14) abnormalities, seemed to benefit more with bortezomib maintenance.

Although several trials have shown the benefit of maintenance therapy after ASCT, the risk of SPM and the need for continuous treatment should be kept in mind. Individual patient characteristics should be taken in consideration before recommending maintenance therapy.

Maintenance therapy has also been evaluated in non–transplant eligible patients. Thalidomide has been studied as maintenance in a number of trials; most of the trials have shown only advantage in PFS, with no advantage in OS. The main problem with thalidomide has been the high incidence of neuropathy in these patients.

A trial of lenalidomide as maintenance therapy after induction with melphalan, prednisone, and lenalidomide showed a significant improvement in PFS (26 vs 7 months) but similar 4-year OS. Patients in the lenalidomide arm had more hematologic toxicity, including neutropenia, thrombocytopenia, and higher risk of second primary malignancy. However, given its overall tolerability, lenalidomide is a good option for induction and maintenance therapy in transplant-ineligible patients. [83]

A number of trials have also evaluated bortezomib in maintenance therapy. All of them have showed benefit in PFS but no clear OS benefit. Bortezomib given once a week in maintenance seems to be better tolerated and associated with lesser neuropathy. [84]

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