Patients are enrolled to screening (Reg Step 1) prior to or after ASCT but prior to Reg Step
2. Patients are followed until they will begin Maintenance and then registered to Reg Step 2
(first randomization). Patients are randomized between Lenalidomide for 2 years and
Lenalidomide + Daratumumab/rHuPH20. After 2 years of Maintenance, MRD is assessed to guide
further therapy. MRD-positive patients will continue with the assigned treatment.
MRD-negative patients will be further randomized (Reg Step 3) to either continue or
discontinue the assigned treatment. Patients are treated for up to 7 years from Step 2 reg
and followed for up to 15 years.
Registration Step 1 Except where otherwise indicated below that test is required in a
shorter timeframe, all tests for establishing baseline disease status must be completed
within 60 days prior to registration. All test results must be documented on the Baseline
Tumor Assessment Form for Multiple Myeloma and the Onstudy Form.
Inclusion Criteria
- Patients must have had a confirmed diagnosis of symptomatic multiple myeloma (See
Section 4.1) that required systemic induction therapy prior to autologous stem cell
transplantation (ASCT).
- Patients with disease measurable by serum light chain assay alone are eligible
(defined as >/= 100 mg/L on involved light chain).
- Patients must be registered to Step 1 prior to registration to Step 2. Registration to
Step 1 may take place prior to or after autologous stem cell transplant (ASCT), but
after completion of induction therapy.
- Patients must have initiated induction therapy within 12 months prior to registration
Step 1 and have received at least two cycles of induction therapy.
- Patients must be willing and able to take DVT prophylaxis (aspirin, low molecular
weight heparin, warfarin, or equivalent oral anticoagulation).
- Patients must be >/= 18 and </= 75 years of age at time of registration to Step 1.
- Patients must have history and physical exam within 28 days prior to registration.
- Patients must have Zubrod Performance Status </= 2.
- Patients must have evidence of adequate renal function, as defined by (1) creatinine
clearance (CrCl) >/= 30 mL/min., as measured by a 24-hour urine collection, or
estimated by the Cockcroft and Gault formula, or (2) serum creatinine < 2.5 mg/dL.
Values must be obtained within 28 days prior to registration.
- Patients must have adequate hepatic function defined by the following within 42 days
prior to registration:
- Total bilirubin </=1.5 x IULN (institutional upper limit of the norm) AND
- AST and ALT </=3.0 x IULN
- Patients must meet one of the following criteria:
- Be acceptable for transplant per institutional guidelines and the criteria
evidencing this must be documented on the S1803 Onstudy Form. (See Appendix 18.3
for standard transplant eligibility guidelines. Note that these are guidelines
and not required criteria.) OR
- Have completed autologous stem cell transplant within 180 days prior to
registration (see also Section 5.2a).
- Patient's with human immunodeficiency virus (HIV) are eligible providing they are on
effective antiretroviral therapy and have undetectable viral load at their most
previous viral load test and within 6 months prior to registration.
- Patients must be able to take and swallow oral medication (capsules) whole. Patients
may not have any known impairment of gastrointestinal function or gastrointestinal
disease that may significantly alter the absorption of study drug (e.g. ulcerative
disease, uncontrolled nausea, vomiting, diarrhea, malabsorption syndrome, or small
bowel resection).
- For patients who have not yet received transplant: Patients must be willing and able
to return to the transplant center for their assigned treatment after randomization.
Note that patients need not have a direct relationship with the transplant center in
order to register.
- Patients must submit specimens for MRD as outlined in Section 15.1. See Section 15.1
for further information, including specimen submission timepoints. Note that patients
are not ineligible based solely on archival specimens being unavailable.
- Patients must be offered participation in specimen banking for future research. With
patient's consent, specimens must be submitted as outlined in Section 15.2.
- Patients must be informed of the investigational nature of this study and must sign
and give written informed consent in accordance with institutional and federal
guidelines.
- As a part of the OPEN registration process (see Section 13.3 for OPEN access
instructions) the treating institution's identity is provided in order to ensure that
the current (within 365 days) date of institutional review board approval for this
study has been entered in the system.
Exclusion Criteria
- Patients with smoldering myeloma are not eligible. Patients with purely non-secretory
MM as measured by electrophoresis and immunofixation and the absence of Bence Jones
proteins in the urine are not eligible. Patients must have measurable M protein in the
serum (defined as >/= 0.5g/dL) or urine (defined as >/= 200 mg/24h). Patients with
plasma cell leukemia are not eligible.
- Patients must not have any organ involvement by amyloidosis or evidence of amyloidosis
related organ dysfunction.
- Patients must not have progressive disease at any time prior to registration.
- Patients must not be refractory to either lenalidomide or daratumumab/rHuPH20.
- Patients must not be intolerant to either lenalidomide or daratumumab/rHuPH20.
- Patients must not have received any investigational agents within 14 days prior to
registration.
- Patients must not have chronic obstructive pulmonary disease with a forced expiratory
volume in 1 second (FEV1) < 50% of predicted normal. FEV1 is required for patients
suspected of having chronic obstructive pulmonary disease and are not eligible if FEV1
is < 50% of predicted normal.
- Patients must not have moderate or severe persistent asthma within the past 2 years
and must not have currently uncontrolled asthma of any classification.
- Patients must not have had prior autograft or allograft, or prior organ transplant
requiring immunosuppressive therapy.
- Patients must not have known allergy to any of the study drugs.
- Patients with uncontrolled bacterial, viral or fungal infections (currently taking
medication and with progression or no clinical improvement) at time of enrollment are
not eligible.
- Patients must not have known central nervous system (CNS) involvement with multiple
myeloma, defined as CSF positivity for plasma cells at any time or a parenchymal CNS
plasmacytoma at time of enrollment. Lumbar puncture is not required.
- Patients must not be seropositive for hepatitis C (except in the setting of sustained
virologic response, defined as undetectable viral load at least 12 weeks after
completion of antiviral therapy). HCV testing is only required if clinically indicated
or if the patient has a history of HCV.
- No other prior malignancy is allowed except for the following: adequately treated
basal cell or squamous cell skin cancer, in situ cervical cancer, adequately treated
Stage I or II cancer from which the patient is currently in complete remission, or any
other cancer from which the patient has been disease free for three years.
- Patients must not have any uncontrolled intercurrent illness including (not limited
to): Symptomatic CHF (NYHA III/IV), unstable angina pectoris or coronary angioplasty,
or stenting within 6 months prior to registration, Unstable cardiac arrhythmia
(ongoing cardiac dysrhythmias of NCI CTCAE v5.0 Grade >/= 2), intra-cardiac
defibrillators, known cardiac metastases, or abnormal cardiac valve morphology (>/=
Grade 3), or known psychiatric illness that would limit study compliance.
Registration Step 2 - First Randomization (Post-ASCT, Pre-Maintenance)
Inclusion Criteria:
- Patients must have completed ASCT within 180 days prior to registering to Step 2.
- Patients must have one of the following performed within 60 days prior to registration
for disease assessment: diagnostic quality skeletal survey, whole body CT scan, MRI,
or PET.
- Patients must have Zubrod Performance Status </= 2
- Patients must have adequate bone marrow function as evidenced by platelets >/=
75,000/mm3 and ANC >/= 1,000/mm3 within 28 days prior to first randomization:
- Patients must have adequate hepatic function defined by the following within 28 days
prior to first randomization:
- Total bilirubin </=1.5 x IULN (institutional upper limit of the norm) AND AST and ALT
</=3.0 x IULN
- Patients must have evidence of adequate renal function, as defined by creatinine
clearance (CrCl) >/= 30 mL/min., as measured by a 24-hour urine collection, or
estimated by the Cockcroft and Gault formula, or have a serum creatinine < 2.5 mg/dL
within 28 days prior to first randomization.
- All ASCT-related toxicities must have recovered to </=Grade 1 (except for alopecia,
fatigue and amenorrhea) prior to first randomization.
- Mucositis and gastrointestinal symptoms must have resolved to </=Grade 1.
- Females of childbearing potential (FCBP) must have a negative serum or urine pregnancy
test with a sensitivity of at least 25 mIU/mL within 10-14 days prior to registration.
- FCBP must agree to have a second pregnancy test within 24 hours prior to starting
Cycle 1. Further, FCBP must either commit to continued abstinence from heterosexual
intercourse or begin TWO acceptable methods of birth control: one highly effective
method and one additional effective method AT THE SAME TIME, at least 28 days before
starting lenalidomide. FCBP must also agree to ongoing pregnancy testing and must
agree to not become pregnant for at least 3 months after the last dose of study
treatment.
- Men must agree to use a latex condom during sexual contact with a FCBP, even if they
have had a successful vasectomy, during the study treatment and for 3 months after the
last dose of study treatment.
- Patients must be informed of the investigational nature of this study and must sign
and give written informed consent in accordance with institutional and federal
guidelines.
Exclusion Criteria:
- Patients must not have received any other maintenance therapy post-ASCT and prior to
Step 2 registration.
- Patients must not have had progressive disease between induction and registration to
Registration Step 2. (See Section 10.1b).
Registration Step 3 - Second Randomization (Post 24 Months Maintenance)
Inclusion Criteria:
- Patients must have completed 24 cycles of protocol maintenance with either
lenalidomide or lenalidomide + daratumumab/rHuPH20.
- Patients must have 24-month MRD by NGS test results available and must be MRD
negative. Patients whose PCR results are indeterminable will be considered to have
positive results.
- Patients must be in very good partial remission (VGPR) or better by IMWG response
criteria (see Section 10.1b).
