A matched comparison of cyclophosphamide, bortezomib and dexamethasone (CVD) versus risk-adapted cyclophosphamide, thalidomide and dexamethasone (CTD) in AL amyloidosis

Despite improvements in therapy amyloid light-chain (AL) amyloidosis, there are few studies comparing different regimens. Here we present a matched comparison with 69 patients in each cohort examining upfront therapy with cyclophosphamide, bortezomib and dexamethasone (CVD) vs cyclophosphamide, thalidomide and dexamethasone (CTD). On an intention-to-treat basis, the overall response rates were 71.0% vs 79.7% in the CVD and CTD arms, respectively, (P = 0.32). A higher complete response (CR) rate was observed in the CVD arm (40.5%) vs CTD (24.6%), P = 0.046. One-year overall survival (OS) was 65.2% and 66.7% for CVD and CTD, respectively (P = 0.87). The median progression-free survival (PFS) was 28.0 and 14.0 m for CVD and CTD, respectively (P = 0.039). In a landmark analysis assessing outcomes performed at 6 months, the CR rate with CVD was 59.6% vs 34.0% for CTD (P = 0.03). The 1-year OS was 96% with CVD and 92% with CTD (P = 0.40). The median PFS with CVD was not reached and was 19.2 m with CTD, P = 0.028). In summary, both regimens are unable to overcome the high rate of early deaths in AL amyloidosis. However, CVD correlates with improved depth of response and superior PFS supporting its use in the frontline setting. Further optimisation and better supportive-care strategies are required to increase the proportion of patients fully benefiting from therapy.