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Question 1 of 2
According to recent studies, approximately what percentage of patients with multiple myeloma are unable to continue treatment beyond the third line of therapy?
A
B
C
D
Ciltacabtagene autoleucel (cilta-cel) is a B-cell maturation antigen (BCMA)-targeting chimeric antigen receptor (CAR) T-cell therapy, which is one of only two U.S. Food and Drug Administration (FDA)-approved CAR T-cell therapies for the treatment of relapsed/refractory multiple myeloma (RRMM). Both approved CAR T-cell agents are indicated in the heavily pre-treated setting after four or more prior lines of therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.1
However, in February 2024, the European Medicines Agency (EMA) Committee for Medicinal Products for Human Use (CHMP) recommended the approval of cilta-cel after at least one prior line of therapy, including an immunomodulatory agent or proteasome inhibitor, for those who have progressed on the last therapy and are refractory to lenalidomide.1
The Multiple Myeloma Hub is pleased to summarize the rationale for and latest data from clinical trials of cilta-cel after one to three lines of therapy for the treatment of MM.
Listen to this article as a podcast here:
Integrating cilta-cel into earlier lines of therapy: Rationale and latest data from CARTITUDE-2 and CARTITUDE-4
There are multiple justifications for the implementation of CAR T-cell therapies into earlier lines of therapy, including the potential to minimize mechanisms of resistance to CAR T-cell therapies (Figure 1).2
Figure 1. Mechanisms of resistance to CAR T-cells*
CAR, chimeric antigen receptor; MM, multiple myeloma.
*Adapted from D’Agostino and Raje.3 Created with BioRender.com.
Additional justifications for the implementation of CAR T-cells in earlier lines include the following:
Figure 2. PFS rates in patients treated with CAR T-cells by prior treatment*
ADC, antibody–drug conjugate; BCMA-TT, B-cell maturation antigen targeted therapy; CAR, chimeric antigen receptor; PFS, progression-free survival.
*Adapted from Einsele.2
Additionally, there is an argument for implementing the treatments with the highest response rates in the earlier lines due to the lower documented attrition rates for therapy in the later lines (Figure 3). Notably, in Austria, 85% of patients with MM were unable to receive treatment beyond the third line of therapy, with similar data observed in the US, France, and Australia, highlighting the need for effective therapies in early lines where attrition rates remain high.2
Figure 3. Attrition rates for multiple myeloma therapies by line*
1L, first-line treatment; 2L, second-line treatment; 3L, third-line treatment; 4L, fourth-line treatment; 5L, fifth-line treatment.
*Adapted from Einsele.2
CARTITUDE-2 (NCT04133636) is a phase II, multicohort clinical trial evaluating the safety and efficacy of cilta-cel for the treatment of MM. Cohorts A and B included patients with one to three prior lines of therapy who are lenalidomide-refractory and those with early relapse at ≤12-months after autologous stem cell transplant or treatment initiation, respectively.
The trial design of CARTITUDE-2, including primary and secondary endpoints, has been reported previously by the Multiple Myeloma Hub here.
At a median follow up of 29.9 months in cohort A and 27.0 months in cohort B:
Figure 4. Response rates in Cohorts A and B from CARTITUDE-2*
CR, complete response; ORR, overall response rate; PR, partial response; sCR, stringent complete response; VGPR, very good partial response.
*Data from Hillengrass, et al.4
At 24 months, median overall survival, PFS, and duration of response were not reached in either cohort (Figure 5).
Figure 5. 24-month OS, PFS, and DOR from CARTITUDE-2*
DOR, duration of response; OS, overall survival; PFS, progression-free survival.
*Data from Hillengrass, et al.4
Table 1. Cytopenias and adverse events of special interest from CARTITUDE-2*
AE, adverse event; CAR, chimeric antigen receptor; CRS, cytokine release syndrome; ICANS, immune effector cell-associated neurotoxicity syndrome; MNT, movement/neurocognitive treatment-emergent adverse event. |
||||
Adverse events, % |
Cohort A |
Cohort B |
||
---|---|---|---|---|
Any grade |
Grade 3/4 |
Any grade |
Grade 3/4 |
|
Treatment-emergent cytopenias |
|
|
|
|
Neutropenia |
95 |
95 |
94.7 |
89.5 |
Lymphopenia |
80 |
80 |
47.4 |
47.4 |
Thrombocytopenia |
80 |
40 |
57.9 |
26.3 |
Anemia |
75 |
45 |
57.9 |
47.4 |
Leukopenia |
60 |
60 |
31.6 |
31.6 |
AEs of special interest |
|
|
|
|
CRS |
95 |
10 |
84.2 |
5.3 |
CAR T-cell neurotoxicity |
30 |
5 |
31.6 |
5.3 |
ICANS |
15 |
0 |
5.3 |
0 |
Other neurotoxicities |
15 |
5 |
26.3 |
5.3 |
MNT |
0 |
0 |
5.3 |
5.3 |
SPM |
0 |
0 |
10.5 |
5.3 |
CARTITUDE-4 (NCT04181827) is a phase III, randomized trial evaluating the safety and efficacy of cilta-cel in patients with lenalidomide-refractory MM after one to three prior lines of therapy. The control group was standard-of-care treatment consisting of pomalidomide, bortezomib, and dexamethasone or daratumumab, pomalidomide, and dexamethasone.
The trial design of CARTITUDE-4, including primary and secondary endpoints, has been reported previously by the Multiple Myeloma Hub here.
High rates of overall response were observed in the 176 patients enrolled in CARTITUDE-4, with a majority (86.4%) reaching a complete response or higher (Figure 6).
Figure 6. Response rates from CARTITUDE-4*
CR, complete response; ORR, overall response rate; PR, partial response; sCR, stringent complete response; VGPR, very good partial response.
*Adapted from Einsele.2
As compared with CARTITUDE-1, a trial of cilta-cel in RRMM four or more prior lines of therapy, a lower incidence and severity of CRS, ICANS, and MNTs was observed in CARTITUDE-4, highlighting the potentially increased tolerability of CAR T-cell therapies in earlier lines. However, these data are likely confounded by differences in patient populations and treatment regimens, requiring further direct clinical trial comparisons to draw any conclusion.
Common adverse events included CRS and neurotoxicity, consistent with CAR T-cell use in later lines. However, the majority of these adverse events were Grade 1 or 2, with most cases of CRS resolved after 3 days (Table 2).
Table 2. Adverse events from CARTITUDE-4*
CRS, cytokine release syndrome; ICANS, immune effector cell-associated neurotoxicity syndrome; MNT, movement/neurocognitive treatment-emergent adverse event. |
|||||
Adverse event, % unless otherwise specified |
As-treated patients (n = 176) |
||||
---|---|---|---|---|---|
Any grade |
Grade 3/4 |
Median time to onset, days |
Median duration, days |
Resolved, n |
|
CRS |
76.1 |
1.1 |
8 |
3 |
134 |
Neurotoxicity |
20.5 |
2.8 |
- |
- |
- |
ICANS |
4.5 |
0 |
10 |
2 |
8 |
Other |
17 |
2.3 |
- |
- |
- |
Cranial nerve palsy |
9.1 |
1.1 |
21 |
77 |
14 |
Peripheral neuropathy |
2.8 |
0.6 |
63 |
201 |
3 |
MNT |
0.6 |
0 |
85 |
- |
0 |
Multiple trials investigating the safety and efficacy of CAR T-cell therapies in the first line setting in newly diagnosed MM are ongoing; including:
A multitude of data support the investigation of cilta-cel in earlier lines of therapy, particularly highlighting the reduced likelihood of prior exposure to BCMA-directed therapies and lower incidence of toxicities, which have the potential to improve quality of life. Increased attrition rates paired with this reduction in toxicities highlight where CAR T-cell therapy may become appropriate and tolerable to a higher proportion of patients with MM. Data from CARTITUDE-2 and CARTITUDE-4 provide evidence for the efficacy of cilta-cel in this setting, although in relatively small cohorts.
This educational resource is independently supported by Johnson & Johnson. All content is developed by SES in collaboration with an expert steering committee; funders are allowed no influence on the content of this resource.
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