Data suggest that indefinite maintenance treatment results in better outcomes for patients compared to shorter treatment for 18 months. That’s why I’m in favor of a longer duration of maintenance therapy. I would continue maintenance until disease progression or severe toxicities for patients with standard- and high-risk MM.

I consider the concerns of my patients, and we come up with the best strategy. Most of my patients stay on maintenance at the best-tolerated dose. I believe that toxicities that are more than Grade 1 or mild in severity are not acceptable during maintenance. If Grade 2 side effects emerged, I would definitely reduce the dose or even discontinue the drug. Any concerns for MDS, cytopenias or other serious side effects would potentially lead to discontinuation, especially for patients in complete response.

I would continue therapy until the patient developed progressive disease, regardless of whether the patient was at standard or high risk. My recommendation is based on my clinical experience and data that suggest that when you stop therapy, you develop recurrent disease.

My approach would be the same for patients with both standard- and high-risk disease, and I would continue maintenance until disease progression. The data show an improvement in time to disease progression with maintenance.

The IFM 2005-02 study was initially designed to continue lenalidomide maintenance until disease progression, but due to the occurrence of second primary malignancies they stopped therapy at a median of 2 years. In the CALGB 100104 study, we didn’t stop lenalidomide maintenance. We still have some patients who are receiving lenalidomide almost 10 years out. We observed a benefit both in terms of time to disease progression and overall survival. The MM-015 study by Palumbo and colleagues of continuous lenalidomide was underpowered to determine if a benefit existed in overall survival with lenalidomide maintenance.

I believe there is a benefit to maintenance, both in standard- and high-risk disease. There is a risk of second primary malignancies, but the risk is early and dissipates over time. The risk of disease progression and death is higher in patients who do not receive maintenance.

I recommend continuing maintenance therapy until disease progression irrespective of the patient’s risk status. I’m not convinced that 2 years is sufficient. So unless the treatment is not being tolerated, I would continue until disease progression.

I do not recommend maintenance because it is not recommended in France off protocol. Trials are ongoing with lenalidomide maintenance for different durations that are investigating this question. I consider that continuing lenalidomide maintenance until disease progression may be too long and not cost effective. There is also an impairment of quality of life and significant toxicities, such as secondary malignancies, associated with it. I would like to see more data on 1- or 3-year maintenance duration.

For all patients, regardless of the results of FISH and the response achieved, we administer lenalidomide until disease progression. Provided all toxicities are Grade 1 or less, we continue until disease progression. Otherwise, we further reduce the dose or continue with 1 month on and 1 month off. If the side effects are Grade 2 or higher, we stop maintenance. For us, it is important that patients have a good quality of life while receiving maintenance therapy.

I would continue maintenance therapy until disease progression for patients with standard-risk and high-risk disease.

I would recommend continuing maintenance until disease progression for patients with both standard- and high-risk disease based on the data from the CALGB-100104 study and the Italian study by Palumbo and colleagues published recently in the New England Journal of Medicine showing a benefit for maintenance therapy.