Monumental-6: A Phase 3 Study of Talquetamab + Pomalidomide or Talquetamab + Teclistamab Vs Elotuzumab + Pomalidomide + Dexamethasone (EPd) or Pomalidomide + Bortezomib + Dexamethasone (PVd) in Patients with Relapsed/Refractory Multiple Myeloma Who Received 1-4 Prior Lines of Therapy, Including Lenalidomide and an Anti-CD38 Monoclonal Antibody
Authors: Nooka Ajay K. , Mian Hira , Lee Cindy , Rodríguez-Otero Paula , Kumar Shaji , Einsele Hermann , Vishwamitra Deeksha , Vieyra Diego , Kane Colleen , Kosh Michele , Masterson Tara J , Heuck Christoph , Kansagra Ankit , Moreau Philippe 
Published: December 2024

Background:Patients (pts) with multiple myeloma (MM) often receive immunomodulatory drugs (IMiDs; eg, lenalidomide), proteasome inhibitors (eg, bortezomib), and anti-CD38 monoclonal antibodies (mAbs) as part of their initial treatment. However, most pts relapse following initial treatment, with increasing attrition rates observed at each subsequent line of therapy (LOT), creating an unmet need for treatment options for pts with relapsed/refractory MM (RRMM) who have prior exposure to these agents. Current regimens for pts who have prior exposure to lenalidomide and anti-CD38 mAbs include elotuzumab, pomalidomide, and dexamethasone (EPd; approved in Europe and the US) and pomalidomide, bortezomib, and dexamethasone (PVd; approved in Europe and Australia), but disease control, as well as depth and durability of response, could be improved. Talquetamab (tal) and teclistamab (tec), targeting CD3 and either G protein-coupled receptor family C group 5 member D (GPRC5D, tal) or B-cell maturation antigen (tec), are the first T-cell redirecting bispecific antibodies (BsAbs) approved as monotherapies in Europe and the US for the treatment of pts with triple-class exposed (TCE) RRMM. Use of these novel immunotherapies in earlier LOTs, either with a dual-antigen targeting approach or by enhancing the activity of the BsAb with an IMiD (pomalidomide), may provide deeper, more durable responses and improve pt quality of life. Preliminary data using these combination treatments have shown promising results: in the phase 1b MonumenTAL-2 study (NCT05050097), tal+pomalidomide (tal-P) demonstrated overall response rates (ORRs) of &gt;84% in pts with RRMM with ≥2 prior LOTs and in the phase 1b/2 RedirecTT-1 study (NCT04586426), tal+tec (tal-tec) showed ORRs of &gt;77% in pts with TCE RRMM. MonumenTAL-6 (NCT06208150) is a randomized, open-label, multicenter, phase 3 study comparing the efficacy of tal-P vs investigator's choice of EPd or PVd and tal-tec vs investigator's choice of EPd or PVd in pts with RRMM with 1-4 prior LOTs, including lenalidomide and an anti-CD38 mAb.
Study Design and Methods: Eligibility includes pts aged ≥18 years with documented MM per International Myeloma Working Group (IMWG) criteria, with measurable disease at screening, an Eastern Cooperative Oncology Group performance status of 0-2, who have received 1-4 prior LOTs (including lenalidomide and an anti-CD38 mAb in any prior LOT), and have progressive disease on or after their last therapy. Pts with prior exposure to pomalidomide, tec, or GPRC5D-directed therapies are excluded. Approximately 795 pts are randomized 1:1:1 to receive tal-P, tal-tec, or investigator's choice of EPd or PVd. Tal is administered subcutaneously at 0.8 mg/kg every other week (Q2W), and tec is administered subcutaneously at 3.0 mg/kg every 4 weeks (Q4W) following step-up doses of each. Pts are permitted to switch from Q2W to Q4W tal dosing following a confirmed very good partial response or better (≥VGPR) at cycle 5. Pomalidomide, EPd, and PVd are administered per approved dosing schedules. Randomization is stratified by number of prior LOTs (1 vs ≥2), International Staging System stage at screening (I vs II/III), and investigator's choice of treatment (EPd vs PVd). Pts receive study treatment until disease progression, start of subsequent anti-MM treatment, death, intolerable toxicity, withdrawal of consent, or end of study, whichever occurs first. A finite dosing approach is employed for tal and tec. The primary endpoint is progression-free survival (PFS). Secondary endpoints include ORR assessed per IMWG 2016 criteria, ≥VGPR rate, complete response (CR) or better rate, rate of minimal residual disease-negative CR, overall survival, PFS on next LOT, time-to-next treatment, and pt-reported outcomes. This study is actively recruiting, with more than 160 locations in 26 countries. Results will provide insights into the efficacy of the combination of BsAbs in therapeutic strategies that exploit their different mechanisms of action to overcome treatment resistance and improve outcomes of pts with TCE RRMM in earlier LOTs.