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FDAApprovesLenalidomideasMaintenanceTherapyforPatientsWithMultipleMyelomaFollowingAutologousStemCellTransplant
OnFebruary22,theU.S.FoodandDrugAdmiNISTration(FDA)expandedtheexistingindicationforlenalidomide(Revlimid)10mgcapsulestoincludeuseforpatientswithmultiplemyelomaasmaintenancetherapyfollowingautologoushematopoieticstemcelltransplant.TheexpandedindicationmakeslenalidomidethefirstandonlytreatmenttoreceiveFDAapprovalformaintenanceusefollowingautologoushematopoieticstemcelltransplant.
“Autologousstemcelltransplantafterinductiontherapyispartofthecontinuumofcarefortransplant-eligIBLe[patientswith]multiplemyeloma.However,mostpatientswillstillseetheirdiseaserecurorprogressafterthistreatment,”saidPhilipMcCarthy,MD,Director,BloodandMarrowTransplantCenter,DepartmentofMedicineatRoswellParkCancerInstitute.“Lenalidomidemaintenancetherapy,whichhasbeenshowntoincreaseprogression-freesurvivalfollowingautologousstemcelltransplantinclinicaltrials,canbeconsideredastandardofcareforthesepatients.”
ClinicalTrialFindings
Theapprovalwasbasedontwolargestudies—CALGB100104andIFM2005-02—includingmorethan1,000patientscomparinglenalidomidemaintenancetherapygivenuntildiseaseprogressionorunacceptabletoxicityafterautologoushematopoieticstemcelltransplantvsnomaintenance.Inbothstudies,theprimaryefficacyendpointwasprogression-freesurvival.
Inthemostcurrentprogression-freesurvivalanalysis,Study1(CALGB100104)demonstratedamedianprogression-freesurvivalof5.7years(95%confidenceinterval[CI]=4.4–notestimable)vs1.9years(95%CI=1.6–2.5)fornomaintenance,adifferenceof3.8years(hazardratio[HR]=0.38;95%CI=0.28–0.50).
Study2(IFM2005-02)alsoshowedabenefitwithamedianprogression-freesurvivalof3.9years(95%CI=3.3–4.7)vs2years(95%CI=1.8–2.3)fornomaintenance,adifferenceof1.9years(HR=0.53;95%CI=0.44–0.64).
Individualstudieswerenotpoweredforanoverallsurvivalendpoint.
AdescriptiveanalysisshowedthemedianoverallsurvivalinStudy1was9.3years(95%CI=8.5–notestimable)forpatientswhoreceivedlenalidomidevs7years(95%CI=5.9–8.6)fornomaintenance(HR=0.59;95%CI=0.4–0.78).InStudy2,medianoverallsurvivalwas8.8years(95%CI=7.4–notestimable)forpatientswhoreceivedlenalidomidevs7.3years(95%CI=6.7–9.0)fornomaintenance(HR=0.90;95%CI=0.72–1.13).
AdverseEvents
Themostfrequentlyreportedadversereactionsin≥20%(lenalidomidearm)acrossbothmaintenancestudies(Study1,Study2respectively)wereneutropenia(79%,61%);thrombocytopenia(72%,24%);leukopenia(23%,32%);anemia(21%,9%);upperrespiratorytractinfection(27%,11%);bronchitis(5%,47%);nasopharyngitis(2%,35%);cough(10%,27%);gastroenteritis(0%,23%);diarrhea(55%,39%);rash(32%,8%);fatigue(23%,11%);asthenia(0%,30%);musclespasm(0%,33%);andpyrexia(8%,21%).ThemostfrequentlyreportedGrade3or4reactions(morethan20%inthelenalidomidearm)includedneutropenia,thrombocytopenia,andleukopenia.
Thefrequenciesofonsetofadversereactionsweregenerallyhighestinthefirst6monthsoftreatmentandthenthefrequenciesdecreasedovertimeorremainedstablethroughouttreatment.
Inpatientsreceivinglenalidomidemaintenancetherapy,hematologicsecondprimarymalignanciesoccurredin7.5%ofpatientscomparedto3.3%inpatientsreceivingplacebo.Theincidenceofhematologicplussolidtumor(excludingsquamouscellcarcinomaandbasalcellcarcinoma)secondprimarymalignancieswas14.9%,comparedto8.8%inpatientsreceivingplacebowithamedianfollow-upof91.5months.Nonmelanomaskincancersecondprimarymalignancies,includingsquamouscellcarcinomaandbasalcellcarcinoma,occurredin3.9%ofpatientsreceivinglenalidomidemaintenance,comparedto2.6%intheplaceboarm.