Relapsed/refractory patients

Long-term follow-up from POLLUX | Daratumumab in combination with lenalidomide and dexamethasone for relapsed or refractory multiple myeloma

The phase III POLLUX (NCT02076009) study, comparing the efficacy of lenalidomide and dexamethasone (Rd) to that of Rd combined with daratumumab (DRd), has uncovered the promising clinical activity of DRd in patients with relapsed or refractory (R/R) multiple myeloma (MM; RRMM). Combination of the anti-CD38 monoclonal antibody, daratumumab, with the Rd regimen demonstrated favorable progression free survival (PFS) and overall response rates (ORR) in RRMM.1 In September 2018, the MM Hub reported the interim results from POLLUX study, which highlighted the potential of DRd. Nizar J Bahlis, Charbonneau Cancer Research Institute, University of Calgary, Calgary, CA, and colleagues recently published results from a long-term efficacy and safety analysis of POLLUX after a median follow-up of more than 3.5 years.2

Study overview2
  • Adult patients with RRMM (N = 569) were randomly assigned (1:1) to receive:
    • Rd (n = 286)
      • Lenalidomide (orally): 25 mg on Days 1–21 of each 28-day cycle
      • Dexamethasone (orally): 40 mg weekly
    • DRd (n = 283)
      • Rd, as above
      • Daratumumab (intravenously): 16 mg/kg weekly for 8 weeks, every 2 weeks for 16 weeks, and every 4 weeks thereafter until progression
    • Values are henceforth given as DRd vs Rd
    • Patient characteristics1:
      • Median age: 65 years in both arms
      • Median time from diagnosis: 3.48 years vs 3.95 years
      • Patients who were refractory to last line of therapy: 28.0% vs 26.9%
      • Patients who had received prior autologous stem cell transplantation: 62.9% vs 63.6%
      • 52% of patients had received one prior therapy, 18% had received prior lenalidomide, and 21% were refractory to bortezomib (in both arms)
    • Primary endpoint: PFS
    • Secondary endpoints: ORR, rates of ≥ very good partial response (VGPR) and ≥ complete response (CR), minimal residual disease (MRD), time to response, duration of response (DoR), and overall survival (OS)
    • Exploratory endpoint: PFS on subsequent line of therapy (PFS2)
    • Subgroup analysis was conducted by prior lines of therapy (1 and 1–3), prior lenalidomide treatment, refractoriness to bortezomib, and achievement of ≥ CR
Results2

Efficacy

  • The median follow-up time was 44.3 (0–50.9) months
  • DRd led to improved median PFS rates compared to Rd in the intention to treat (ITT) population and in subgroup analysis, as shown in Table 1
  • Median ORR in the response evaluable population (n: 281 vs 276): 92.9% vs 76.4% (p < 0.0001)
    • ≥ VGPR: 80.4% vs 49.3% (p < 0.0001)
    • ≥ CR: 56.6% vs 23.2% (p < 0.0001)
  • Median DoR: not reached (NR) vs 25.2 (95% CI, 19.3–29.7) months
  • Median time to next therapy: 50.6 months vs 23.1 months (hazard ratio [HR] = 0.39; 95% CI, 0.31–0.50; p < 0.0001)
  • Median PFS2: NR vs 31.7 months (HR = 0.53; 95% CI, 0.42–0.68; p< 0.0001)
  • Deaths (n): 104 vs 121
  • Median OS: NR in either arm
    • Forty-two-month OS rates: 65% vs 57%
  • Patients in the ITT population who were MRD negative at a threshold of 10-5 (p < 0.0001): 30.4% vs 5.3%

Table 1. Median PFS by subgroup2

Median PFS, months

DRd

Rd

HR (95% CI)

p value

ITT population

n: 286 vs 283

44.5

17.5

0.44 (0.35–0.55)

< 0.0001

One prior therapy

n: 149 vs 146

NR

19.6

0.42 (0.30–0.58)

< 0.0001

One–three prior therapies

n: 272 vs 264

44.5

17.5

0.43 (0.34–0.54)

< 0.0001

Prior lenalidomide therapy

n: 50 vs 50

38.8

18.6

0.38 (0.21–0.66)

0.0004

Refractory to bortezomib

n: 59 vs 58

34.3

11.3

0.40 (0.24–0.67)

0.0003

MRD negative

NR

42.0

0.46 (0.19–1.08)

0.0667

MRD positive

29.4

16.0

0.60 (0.48–0.76)

< 0.0001

HR, hazard ratio; ITT, intention to treat; MRD, minimal residual disease; NE, not estimable; NR, not reached; PFS, progression-free survival

  • Subgroup analysis:
    • Forty-two-month PFS rates in patients that had received one prior line of therapy: 57.3% vs 27.8%
    • PFS was prolonged in 159 vs 64 patients who achieved ≥ CR
      • Forty-two-month PFS rates: 73.6% vs 59.6%
    • Among patients receiving prior lenalidomide therapy, ORR: 84.0% vs 64.0% (p = 0.0233)
      • ≥ VGPR: 80.0% vs 36.0% (p < 0.0001)
      • ≥ CR: 54.0% vs 12.0% (p < 0.0001)
Safety2
  • No new safety concerns were reported at this long-term follow-up
  • Neutropenia was the most frequent treatment-emergent adverse event (TEAE) and was more common in the DRd arm: 63.3% vs 48.0%
  • Patients who experienced TEAEs leading to treatment discontinuation: 14.8% vs 14.5%.
  • Second primary malignancies occurred in 8.5% vs 8.9% of patients
Conclusion2

DRd significantly prolonged PFS compared to Rd in all patient subgroups, while demonstrating a 56% reduction in the risk of disease progression or death at the 3.5-year follow-up. The greatest clinical benefit of DRd was observed in patients that had received one prior line of therapy, supporting the use of DRd in patients with RRMM after first relapse. The safety profile of DRd remains as described in the 2018 analysis with no additional concerns, and DRd continues to produce favorable clinical outcomes in patients with RRMM.

Whilst the POLLUX study is comparing the Rd regimen to DRd, the phase III CASTOR study is comparing bortezomib and dexamethasone (Vd) to daratumumab and Vd (DVd). The MM Hub recently covered an age subgroup analysis from both trials, which is available here.

References
  1. Dimopoulos M.A. et al. Daratumumab plus lenalidomide and dexamethasone versus lenalidomide and dexamethasone in relapsed or refractory multiple myeloma: Updated analysis of POLLUX. Haematologica. 2018 Dec; 103(12):2088–2096. DOI: 10.3324/haematol.2018.194282
  2. Bahlis N.J. et al. Daratumumab plus lenalidomide and dexamethasone in relapsed/refractory multiple myeloma: extended follow-up of POLLUX, a randomized, open-label, phase 3 study. Leukemia. 2020 Jan 30. DOI: 10.1038/s41375-020-0711-6
Download this article:

You can now download this article in Adobe PDF® format.

Download as PDF
Was this article informative? Thank you for your feedback!