ohio state's ash review 2017 - update in myeloma
TRANSCRIPT
Update in Myeloma: ASH 2016
Don M Benson Jr, MD PhD, FACPAssociate Professor of Medicine | Head of Translational Research
Division of HematologyThe Ohio State University Comprehensive Cancer Center
Objectives
• 1. Review new data with approved therapies• Daratumumab• Role of stem cell transplantation
• 2. Review data on investigational agents• Venatoclax• Nelfinavir• Selinexor
• 3. Integrate new evidence to practice guidelines
Daratumumab
DemographicsPOLLUX (n=569)Len/dex ± dara
CASTOR (n=498)Bort/dex ± dara
Patient information:
Median age (years) 65 64
ISS stage 3 (%) 20 22
High risk cyto/FISH (%) 20 27
Treatment history:
1 prior line (%) 52 47
> 3 prior lines (%) 6 10
‐ Prior SCT (%) 63 61
‐ Prior PI & IMID 44 50
‐ Refractory to IMID (%) n/a 33
‐ Refractory to bortezomib (%) 21 n/a
POLLUX New Eng J Med 2016; 375: 1319‐31 & CASTOR New Eng J Med 2016; 375: 754‐66
Daratumumab
ASH 2016 Abstracts 489, 1150, 1151
Daratumumab
ASH 2016 Abstracts 489, 1150, 1151
Daratumumab
ASH 2016 Abstracts 489, 1150, 1151
Daratumumab
ASH 2016 Abstracts 489, 1150, 1151
Daratumumab
Abstract 489
POLLUX (New Eng J Med 2016; 375: 1319‐31)‐ len / dex vs. len / dex / daratumumab‐ 1‐3 prior lines
lenalidomide‐naïve results (n=219 v 226)
Outcome Len/dex + dara p value
PFS (mo) 18.4 N/R < 0.0001
1‐yr PFS (%) 59 83
ORR (%) 79 96 < 0.0001
≥ VGPR (%) 47 76 < 0.0001
≥ CR (%) 21 44 < 0.0001
Prior lenalidomide results (n=45 v 46)Outcome Len/dex + dara p value
PFS (mo) N/R N/R
1‐yr PFS (%) 63 81
ORR (%) 71 87 0.0729
≥ VGPR (%) 38 78 0.0001
≥ CR (%) 12 44 0.0011
bortezomib‐naïve results (n=45 v 44)
Outcome Len/dex + dara p value
PFS (mo) 15.8 N/R 0.017
1‐yr PFS (%) 69.2 85.4
ORR (%) 82 98 0.0158
≥ VGPR (%) 55 74 0.0544
≥ CR (%) 23 42 0.0576
Bortezomib‐refractory results (n=49 v 54)Outcome Len/dex + dara p value
PFS (mo) 10.3 N/R 0.0117
1‐yr PFS (%) 44.4 70.8
ORR (%) 68 92 0.0024
≥ VGPR (%) 36 75 0.0001
≥ CR (%) 13 46 0.0003
Daratumumab
Abstract 1149
“PAVO”: Phase 1b study of SQ daratumumab with rHuPH20‐ co‐formulate approved in Europe for trastuzumab and rituximab
• Eligibility:– ≥ 3 prior lines
• PI & IMID
• 1200mg (n=8)– In 60mL / 20min
• 1800mg (n=45)– In 90mL / 30 min
TEAE 1200mg 1800mg
AE profile of DARA‐PH20 consistent with IV daratumumab
Any drug‐related (%) 63 62
Anemia (%) 13 13
Low platelets (%) 13 7
Neutropenia (%) 13 7
Hypertension (%) 25 4
Fatigue (%) 25 2
Device‐related infection (%)
0 4
Infusion related (%) 13 24 (all Gr 1 or 2)
Daratumumab
Abstract 1149
“PAVO”: Phase 1b study of SQ daratumumab with rHuPH20‐ co‐formulate approved in Europe for trastuzumab and rituximab
STaMINA trial
Abstract LBA‐1
MelphalanautoSCT
Len maintenance
VRD x 4 cycles Len
maintenance
Mel autoSCTLen
maintenancen=754:‐ SOC n = 257‐ VRD n = 254‐ tandem n= 247
High risk cyto/FISH = 24%
STaMINA trial
Abstract LBA‐1
MelphalanautoSCT
Len maintenance
VRD x 4 cycles Len
maintenance
Mel autoSCTLen
maintenancen=754:‐ SOC n = 257‐ VRD n = 254‐ tandem n= 247
High risk cyto/FISH = 24%
Adherence: 95%
Adherence: 88%
Adherence: 68%
STaMINA trial
Abstract LBA‐1
MelphalanautoSCT
Len maintenance
VRD x 4 cycles Len
maintenance
Mel autoSCTLen
maintenancen=754:‐ SOC n = 257‐ VRD n = 254‐ tandem n= 247
High risk cyto/FISH = 24%
PFS (%) HR PFS OS SPM
52 40 83 4
PFS (%) HR PFS OS SPM
56 38 82 5.9
All p‐values = n/s
PFS (%) HR PFS OS SPM
57 48 86 6
Median follow up 38 months
Investigational agents
• Venetoclax
• Nelfinavir
• Selinexor
Venetoclax
Abstract 488
Patients N=66
Cytogenetics/FISH (n):‐ t(11;14)‐ Other: t(4;14), del17p, del13q
3036
Prior lines: median (range) 5 (1‐15)
Prior SCT (%) 75
Bort and len refractory (%) 61
Refractory to last line (%) 79
Venetoclax
Abstract 488
Venetoclax + bortezomib/dex
Abstract 975
Nelfinavir
Nelfinavir – SAKK 39/13 trial
Patient population (n=34)
Age, med 67 (42‐82)
Prior therapy, med 5 (2‐10)
Prior SCT (%) 76
Poor risk cyto (%) 38
Bort refractory (%) 100
Len refractory (%) 79
Pom refractory (%) 44
Abstract 487
Response rates: (%)
Overall RR (≥ PR) 65
‐ high risk FISH 77
‐ bort + len refractory 70
‐ bort + len + pom ref 60
A phase II study of Bort/Dex + Nelfinavir in Bort‐refractory myeloma
Selinexor• “STORM” trial: phase II of CRM1/XPO1 SINE
– n=79 patients enrolled:• Quad‐refractory (len, pom, bort, carfil) n=48• Penta‐refractory (quad + anti‐CD38) n=31
– Median prior lines of therapy = 7
– Baseline ≥ grade 3 anemia 13%, thrombocytopenia 8%
– Common TRAE’s: cytopenias (21‐58%), GI (3‐5%), fatigue
Abstract 491
Selinexor
Abstract 491
Outcomes
• Median OS = 9.3 months– Responders = N/R (> 11 months)– Non responders = 5.7 months
• DOR 5 months
• High risk FISH = 33% ORR– Responses observed despite:
• Del17p, t(14;16), t (4;14)
Standard risk Intermediate risk High risk
Trisomies t(4;14) del17p
t(11;14) 1q gain t(14;16)
t(6;14) t(14;20)
All others GEP signature
Updated practice guidelines
Standard risk Intermediate risk High risk
Transplant ineligibleVRD x ~ 12 months(len/dex if ≥ 75 / frail)
VRD x ~ 12 months VRD x ~ 12 months
Len/dex x 1 year or to progression
Bortezomib maintenancex 1 year
Bortezomib maintenance x 1 year
Transplant eligibleVRD x 4 cycles VRD x 4 cycles KRD x 4 cycles
SCT Collect cells SCT SCT (tandem?)
Len x at least 2 years
Len/dex to progression
Bortezomib maintenance x 2 years
Bortezomib or Carfilzomib maintenancex 2 years
First line
First relapseOn maintenance Off therapy*
Fit patient* Indolent relapse* or frail patient
Fit patient* Indolent relapse* or frail patient
Len:‐ KPD ‐ Dara/bort/dex
Bort:‐ Dara/len/dex
Len:‐Dara/bort/dex‐Ixa/cytox/dex
Bort:‐Dara/len/dex‐Ixa/len/dex
‐ KRD‐ Dara/len/dex
‐Ixa/len/dex‐Elo/len/dex
* SCT if not already performed; 2nd SCT if > 18 months PFS or > 36 months PFS
Second or later relapseNo plasma cell leukemia / extramedullary disease
Single refractory* Dual refractory* Triple refractory* Triple refractory*
Refractory to IMID:‐ Dara/bort/dex
Refractory to PI:‐ Dara/len/dex**
Refractory to lenand bort/ixa:
‐ KPD / KRD
‐ Pom‐based regimen + dara**
Refractory to len, bort/ixa, carfil:
‐Pom‐based + dara**
Refractory to len, pom, bort/ixa:
‐dara‐based**
‐Alkylator‐based
‐Bort/dex/pano
* SCT if not already performed; 2nd SCT if > 18 months PFS or > 36 months PFS** if daratumumab‐refractory, use elotuzumab
Quadruple refractory (len, pom, bort/ixa, carfil) ORSecondary plasma cell leukemia / extramedullary disease
VDT‐PACE x 2 cycles (or CVAD if older / poor PS)‐‐‐‐SCT (if candidate), other options include: dara‐based, pano‐containing, alkylator combination, anthracycline combination
Summary • Daratumumabcombinations
• SCT len
• On the radar:– Venetoclax for t(11;14)– Nelfinavir– Selinexor
• Guideline updates:• VRD induction• Class switching at relapse• Daratumumab combinations