The U.S. Food and Drug Administration (FDA) has expanded the approved use of two CAR-T cell therapies, Abecma and Carvykti, for the treatment of multiple myeloma, offering new hope for patients at earlier stages of the disease. These approvals mark a significant advancement in the treatment paradigm for relapsed or refractory multiple myeloma, providing options that can potentially lead to treatment-free periods and improved overall survival.
Abecma Approved for Earlier Lines of Therapy
On April 4, 2024, the FDA approved Bristol Myers Squibb's Abecma (idecabtagene vicleucel) for adult patients with relapsed or refractory multiple myeloma after two or more prior lines of therapy. This expands the previous indication, which was limited to patients who had received four or more prior lines of treatment. Abecma is a CAR-T cell therapy that targets B-cell maturation antigen (BCMA) on multiple myeloma cells, leading to their destruction.
The approval was based on the Phase 3 KarMMa-3 trial, which demonstrated a 51% reduction in the risk of disease progression or death compared to standard regimens. This trial included patients who had received two to four prior lines of treatment and were refractory to the last treatment regimen, which included an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 antibody.
Carvykti Approved for Use After First Relapse
On April 5, 2024, Johnson & Johnson announced that the FDA approved Carvykti (ciltacabtagene autoleucel) for adult patients with relapsed or refractory multiple myeloma who have received at least one prior line of therapy, including a proteasome inhibitor and an immunomodulatory agent, and are refractory to lenalidomide. This approval makes Carvykti the first and only BCMA-targeted CAR-T cell therapy approved for use as early as the first relapse.
The approval was based on the Phase 3 CARTITUDE-4 trial, which showed that Carvykti reduced the risk of disease progression or death by 59% compared to standard therapies. In this study, the median progression-free survival (PFS) was not reached with Carvykti, compared to 11.8 months with standard regimens (HR, 0.26; 95% CI, 0.18-0.38; P <.001).
Clinical Impact and Considerations
"Carvykti demonstrated remarkable efficacy as a personalized, one-time infusion in the earlier treatment of relapsed/refractory multiple myeloma as shown through the CARTITUDE-4 study results," said Binod Dhakal, MD, associate professor in Division of Hematology and Oncology at Medical College of Wisconsin. "With this approval, I'm excited for patients who may have the opportunity for a treatment-free period for their multiple myeloma as early as first relapse, with the hope of eliminating the burden of having to be on continuous treatment while living with this challenging disease."
While these approvals represent a significant step forward, logistical barriers and patient preferences must be considered. As Saad Z. Usmani, MD, MBA, FACP, FASCO, chief of the Myeloma Service at Memorial Sloan Kettering Cancer Center, noted, "Cilta-cel will play an important role for patients with functional, high-risk and/or lenalidomide-refractory multiple myeloma who experience early relapse within the first 2 years of diagnosis."
Both Abecma and Carvykti carry boxed warnings for cytokine release syndrome (CRS), neurologic toxicities, hemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS), prolonged cytopenia, and secondary hematological malignancies. Careful monitoring and management of potential adverse events are crucial for patients receiving these therapies.
These expanded approvals offer new hope for patients with multiple myeloma, providing options for earlier intervention and the potential for improved outcomes and a better quality of life.
