Evaluation of the effect of nivolumab and daratumumab with or without low-dose cyclophosphamide in patients with relapsed/refractory multiple myeloma.
Myeloma patients who develop bortezomib and lenalidomide-resistant disease have a very poor survival of only a median of 9 months, indicating that new agents are urgently needed. Recent studies have shown that daratumumab as a single agent is effective and well tolerated in these heavily pretreated MM patients. However, approximately 60% of patients do not achieve a partial response, and ultimately all patients will develop progressive disease during daratumumab therapy. In less pretreated patients daratumumab-based combinations (daratumumab plus lenalidomide-dexamethasone or daratumumab plus bortezomib-dexamethasone) were very effective and well tolerated. Therefore, in this study, the investigators will combine daratumumab with other agents to improve survival of heavily pretreated MM patients. The PD-1 blocker nivolumab, as single agent, does not induce objective responses but induces stable disease in approximately 67% of relapsed/refractory MM patients. We have recently shown that daratumumab treatment results in increased T cell frequencies by eliminating CD38-positive immune suppressor cells, which probably contributes to the durable responses observed with daratumumab. Cyclophosphamide, at a dose substantially lower than the maximum tolerated dose, has next to its direct anti-tumor activity serveral other effects including anti-angiogenic effects, induction of changes in the micro-environment, and also improvement of the anti-tumor immune response. In this study, the investigators will combine two or three immune modulating agents with different mechanisms of action in order to improve the outcome of relapsed/refractory MM patients. The investigators will evaluate in Part A, nivolumab combined with daratumumab with or without low-dose cyclophosphamide (total 40 patients). Based on efficacy and tolerability, the investigators will treat in Part B 20 additional patients with nivolumab combined with daratumumab either with or without low-dose cyclophosphamide based on tolerability and efficacy data obtained in Part A.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
62
nivolumab-daratumumab will be given without low-dose cyclophosphamide until progression
nivolumab-daratumumab with low-dose cyclophosphamide will be given until progression
Rijnstate ziekenhuis
Arnhem, Ge, Netherlands
Radboud MC
Nijmegen, Ge, Netherlands
MUMC
Maastricht, Li, Netherlands
VU University Medical Center
Amsterdam, North Holland, Netherlands
overall response rate
the best response obtained during treatment
Time frame: active treatment period up to 5 years
incidence of treatment emergent adverse events
type, frequency and severity of adverse events
Time frame: active treatment period up to 5 years
progression-free survival
time from registration to progression or death from any cause, whichever comes first)
Time frame: up to 5 years
overall survival
measured until death from any cause. Patients still alive or lost to follow up are censored at the date they were last known to be alive
Time frame: up to 5 years
tumor expression profile as prognostic factor for response/survival
tumor expresssion profile by flow-cytometric detection
Time frame: up to 5 years
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UMC Groningen
Groningen, Provincie Groningen, Netherlands
Albert Schweitzer Ziekenhuis
Dordrecht, South Holland, Netherlands
Meander MC
Amersfoort, Utrecht, Netherlands
St. Antonius Ziekenhuis
Nieuwegein, Utrecht, Netherlands
UMC Utrecht
Utrecht, Utrecht, Netherlands