The talk is about what are we currently using and where are we going in the post-transplant setting. Still induction and transplant is standard. Consolidation is more ambiguous and maintenance is also a clear standard but it’s a question about what drugs and how to do it. So, first, when it comes to consolidation, which you repeat the same regimens as induction after transplant, I don’t think it matters whether you call them consolidation or you put them like in the German HD7 trial where you put all cycles before and no consolidation. But it’s important probably how many cycles you have to get the best possible response and the highest number of MRD negative patients.

There was a study until today, actually, trying to use a CAR T, ide-cel, in this situation as a consolidation to improve benefit for the patients. That study was terminated today actually. That was a study for those not getting into CR, so the bad responders, but it was difficult to include because results are very good these days. So that study actually stopped today. But still consolidation is a standard – in almost all trials the standard arm contains induction and consolidation, usually 4+2 cycles, it varies a little bit, and it will probably be like that for the foreseeable future.

When it comes to maintenance it’s a bit different. There we have a clear standard, lenalidomide maintenance. At least it was the clear standard until last week where the EMA, Europe, approved daratumumab and lenalidomide maintenance until progression. This is based on the PERSEUS trial. The FDA evaluated that some weeks ago and decided not to approve the maintenance. The CASSIOPEIA trial, which was presented this spring, has shown that daratumumab monotherapy maintenance also is better than observation but lenalidomide is the standard. So at least for now in Europe daratumumab and lenalidomide maintenance is the standard of care. Of course, there is still some process to have this reimbursed in the different countries but that will be the standard in Europe.

Hopefully the FDA will approve that later. They will probably wait for a couple of studies that are randomising to double maintenance or not which will hopefully convince them then. But we don’t know the data yet so let’s expect that and hope that.

So that’s where we’re at now: daratumumab lenalidomide maintenance. I think this will also change in the future. So the most exciting ongoing studies in this space, there are actually a couple, but the most exciting is maybe the bispecifics. They are being used in randomised trials versus lenalidomide maintenance. There are no results, it will still take a couple of years before we see the results, but we know the efficacy of the bispecifics, so it’s really high. So probably it will be superior to lenalidomide maintenance alone.

However, lenalidomide maintenance, even with some tolerance issues, doesn’t have the large infection problems that some of the bispecifics have. So it will be exciting to see how these infection rates are in patients that are with a low tumour load, in a good situation, early in their disease. It’s also a possibility to maybe eradicate myeloma in a fraction of the patients with this treatment. So that’s a potential that bispecifics have that probably daratumumab lenalidomide doesn’t have.

There’s also a more conventional way moving forward, it’s iberdomide which is a next generation IMiD, now called a CELMoD, which is more active than both lenalidomide and pomalidomide, which has also been explored in the maintenance setting versus lenalidomide. So it’s a more easy drug to handle than bispecifics, it’s an oral. Side effects are very low, it’s easily tolerable. So maybe in the future there will be some intensive way of using maintenance with bispecifics and maybe some more manageable, or easier manageable, way with oral drugs and still better than lenalidomide.

So, to sum it up, lenalidomide is still the standard in the US. In Europe now it’s daratumumab lenalidomide, usually it’s the other way around but that’s the situation here now. It will develop into daratumumab lenalidomide in both places and elsewhere also. Then we’re waiting for the results of the newer drugs, iberdomide and the bispecifics.