Expert Point of View: Sagar Lonial, MD

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Commenting on Dr. Palumbo’s presentation at the ASH meeting, Sagar Lonial, MD, Professor of Hematology and Medical Oncology at the Winship Cancer Center at Emory University, Atlanta, noted that while a survival benefit has been associated with maintenance lenalidomide (Revlimid) after transplant, the value of maintenance for transplant-ineligible patients has been “an open question.”

“Most trials have shown improvements in progression-free survival but not in overall survival,” he noted. “What Dr. Palumbo showed at ASH is that the response rate and depth of response for the group receiving maintenance therapy not only improved progression-free survival but, for the first time, was actually associated with an overall survival benefit,” Dr. Lonial emphasized.

“One could argue that the four-drug induction regimen (bortezomib [Velcade], melphalan, prednisone, thalidomide [Thalomid]) may have been better than VMP (bortezomib, melphalan, and prednisone), or it may have been that the maintenance therapy (bortezomib and thalidomide) provided the benefit. But I think there is enough writing on the wall,” he concluded, “to suggest that visiting the question of maintenance therapy, particularly for high-risk myeloma patients, might be important for older patients as well as younger ones.”

Dr. Lonial added that the availability of subcutaneous bortezomib should ameliorate concerns over peripheral neuropathy with maintenance bortezomib. “When we tend to dose in the maintenance setting, we give it weekly or every other week, and I think those approaches offer the opportunity for much less toxicity,” he said. ■

Disclosure: Dr. Lonial has served as a consultant or on the scientific advisory board for Millennium, Celgene, Novartis, Onyx, Bristol-Myers Squibb, and Sanofi-Aventis.

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