BACKGROUND: Maintenance therapy following autologous stem cell transplantation (ASCT) can delay disease progression and prolong survival in patients with multiple myeloma. Ixazomib is ideally suited for maintenance therapy given its convenient once-weekly oral dosing and low toxicity profile. In this study, we aimed to determine the safety and efficacy of ixazomib as maintenance therapy following ASCT. METHODS: The phase 3, double-blind, placebo-controlled TOURMALINE-MM3 study took place in 167 clinical or hospital sites in 30 countries in Europe, the Middle East, Africa, Asia, and North and South America. Eligible participants were adults with a confirmed diagnosis of symptomatic multiple myeloma according to International Myeloma Working Group criteria who had achieved at least a partial response after undergoing standard-of-care induction therapy followed by high-dose melphalan (200 mg/m2) conditioning and single ASCT within 12 months of diagnosis. Patients were randomly assigned in a 3:2 ratio to oral ixazomib or matching placebo on days 1, 8, and 15 in 28-day cycles for 2 years following induction, high-dose therapy, and transplantation. The initial 3 mg dose was increased to 4 mg from cycle 5 if tolerated during cycles 1-4. Randomisation was stratified by induction regimen, pre-induction disease stage, and response post-transplantation. The primary endpoint was progression-free survival (PFS) by intention-to-treat analysis. Safety was assessed in all patients who received at least one dose of ixazomib or placebo, according to treatment actually received. This trial is registered with ClinicalTrials.gov, number NCT02181413, and follow-up is ongoing. FINDINGS: Between July 31, 2014, and March 14, 2016, 656 patients were enrolled and randomly assigned to receive ixazomib maintenance therapy (n=395) or placebo (n=261). With a median follow-up of 31 months (IQR 27·3-35·7), we observed a 28% reduction in the risk of progression or death with ixazomib versus placebo (median PFS 26·5 months [95% CI 23·7-33·8] vs 21·3 months [18·0-24·7]; hazard ratio 0·72, 95% CI 0·58-0·89; p=0·0023). No increase in second malignancies was noted with ixazomib therapy (12 [3%] patients) compared with placebo (eight [3%] patients) at the time of this analysis. 108 (27%) of 394 patients in the ixazomib group and 51 (20%) of 259 patients in the placebo group experienced serious adverse events. During the treatment period, one patient died in the ixazomib group and none died in the placebo group. INTERPRETATION: Ixazomib maintenance prolongs PFS and represents an additional option for post-transplant maintenance therapy in patients with newly diagnosed multiple myeloma. FUNDING: Millennium Pharmaceuticals, a wholly owned subsidiary of Takeda Pharmaceutical Company.

4th Department of Medicine Hematology FN and LF UK Hradec Králové Hradec Králové Czech Republic

Department of Haematology Medical University of Lodz Multidisciplinary Provincial Centre of Traumatology and Oncology Nicolas Copernicus in Lodz Lodz Poland

Department of Haematology Oncology National University Cancer Institute National University Health System Singapore and Cancer Science Institute of Singapore National University of Singapore Singapore

Department of Haematology The Royal Marsden Hospital London UK; Division of Molecular Pathology The Institute of Cancer Research ICR London UK

Department of Hematology Amsterdam University Medical Center VU University Amsterdam Cancer Center Amsterdam Netherlands

Department of Hematology and Oncology Nagoya City University Graduate School of Medical Sciences Nagoya Japan

Department of Hematology Ankara University Ankara Turkey

Department of Hematology University Hospital Hôtel Dieu University of Nantes Nantes France

Department of Hematology University Hospital of Salamanca CIC IBMCC Salamanca Spain

Department of Hematooncology University Hospital Ostrava Ostrava Czech Republic

Department of Internal Medicine 2 University of Tuebingen Tuebingen Germany

Department of Internal Medicine 5 University Medical Hospital and National Center of Tumor Diseases University of Heidelberg Heidelberg Germany

Department of Internal Medicine Seoul St Mary's Hospital Seoul South Korea

Department of Oncology and Hematology Azienda Ospedaliero Universitaria City of Health and Science of Turin Turin Italy

Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MN USA

Hematology and Medical Oncology Department of Clinical Therapeutics National and Kapodistrian University of Athens School of Medicine Athens Greece

Malignant Haematology and Stem Cell Transplantation Service Alfred Health Monash University Melbourne VA Australia

Millennium Pharmaceuticals Cambridge MA USA

Millennium Pharmaceuticals Cambridge MA USA; Myeloma Unit Division of Hematology University of Torino Azienda Ospedaliero Universitaria S Giovanni Battista Torino Italy; Center for Hematology and Oncology University Hospital Zürich Zürich Switzerland

Myeloma Institute University of Arkansas for Medical Sciences Little Rock AR USA

Oslo Myeloma Center Oslo University Hospital Oslo Norway; KG Jebsen Center for B cell malignancies University of Oslo Oslo Norway

Comment In

Lancet. 2019 Jan 19;393(10168):204-205. doi: 10.1016/S0140-6736(18)33128-3. PubMed

References provided by Crossref.org

MRD dynamics during maintenance for improved prognostication of 1280 patients with myeloma in the TOURMALINE-MM3 and -MM4 trials

Multiple Myeloma: EHA-ESMO Clinical Practice Guidelines for Diagnosis, Treatment and Follow-up

Ixazomib as Postinduction Maintenance for Patients With Newly Diagnosed Multiple Myeloma Not Undergoing Autologous Stem Cell Transplantation: The Phase III TOURMALINE-MM4 Trial

Adverse event management in the TOURMALINE-MM3 study of post-transplant ixazomib maintenance in multiple myeloma

Lenalidomide Maintenance with or without Prednisone in Newly Diagnosed Myeloma Patients: A Pooled Analysis

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ClinicalTrials.gov
NCT02181413