1
|
Monteith BE, Sandhu I, Lee AS. Management of Multiple Myeloma: A Review for General Practitioners in Oncology. Curr Oncol 2023; 30:4382-4401. [PMID: 37232792 DOI: 10.3390/curroncol30050334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/15/2023] [Accepted: 04/18/2023] [Indexed: 05/27/2023] Open
Abstract
Multiple myeloma (MM) is a malignant clonal plasma cell disorder in the bone marrow and is the second-most common hematologic malignancy in adults. Although patients with MM have a moderate life expectancy, it remains a heterogeneous disease that often requires multiple lines of chemotherapy for durable control and long-term survival. This review outlines current management strategies for both transplant-eligible and transplant-ineligible patients as well as for relapsed and refractory disease. Advances in drug therapies have widened management options and improved survival. In this paper, we also discuss implications for special populations and survivorship care.
Collapse
Affiliation(s)
- Bethany E Monteith
- Department of Medicine, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Irwindeep Sandhu
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton AB T6G 1Z2, Canada
| | - Ann S Lee
- Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2T4, Canada
| |
Collapse
|
2
|
Hussain M, Khan F, Al Hadidi S. The use of bone-modifying agents in multiple myeloma. Blood Rev 2023; 57:100999. [PMID: 36050125 DOI: 10.1016/j.blre.2022.100999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 01/28/2023]
Abstract
Multiple myeloma is a hematological neoplasm characterized by abnormal proliferation of plasma cells in the bone marrow and is usually associated with increased bone pain and skeletal-related events such as pathological fracture and/or spinal cord compression. Myeloma bone disease results in changes in the bone-marrow microenvironment evidenced by increased osteoclastic activity and/or decreased osteoblastic activity, which negatively affect quality of life. Treatment of myeloma bone disease includes bisphosphonates or denosumab (bone-modifying agents). These agents do not induce the formation of new bone or repair existing bone damage, but they can decrease bone pain and the risk of pathological fracture. While these agents improve quality of life, it is not known whether they improve overall survival. This review focuses on different classes of bone-modifying agents, their mechanisms of action, time of initiation, duration of therapy, and potential survival benefits.
Collapse
Affiliation(s)
- Munawwar Hussain
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Fatima Khan
- Department of Hematology Oncology, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Samer Al Hadidi
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
| |
Collapse
|
3
|
Dao A, McDonald MM, Savage PB, Little DG, Schindeler A. Preventing osteolytic lesions and osteomyelitis in multiple myeloma. J Bone Oncol 2022; 37:100460. [DOI: 10.1016/j.jbo.2022.100460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/16/2022] [Accepted: 10/27/2022] [Indexed: 11/05/2022] Open
|
4
|
Bernstein ZS, Kim EB, Raje N. Bone Disease in Multiple Myeloma: Biologic and Clinical Implications. Cells 2022; 11:cells11152308. [PMID: 35954151 PMCID: PMC9367243 DOI: 10.3390/cells11152308] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/13/2022] [Accepted: 07/21/2022] [Indexed: 02/01/2023] Open
Abstract
Multiple Myeloma (MM) is a hematologic malignancy characterized by the proliferation of monoclonal plasma cells localized within the bone marrow. Bone disease with associated osteolytic lesions is a hallmark of MM and develops in the majority of MM patients. Approximately half of patients with bone disease will experience skeletal-related events (SREs), such as spinal cord compression and pathologic fractures, which increase the risk of mortality by 20–40%. At the cellular level, bone disease results from a tumor-cell-driven imbalance between osteoclast bone resorption and osteoblast bone formation, thereby creating a favorable cellular environment for bone resorption. The use of osteoclast inhibitory therapies with bisphosphonates, such as zoledronic acid and the RANKL inhibitor denosumab, have been shown to delay and lower the risk of SREs, as well as the need for surgery or radiation therapy to treat severe bone complications. This review outlines our current understanding of the molecular underpinnings of bone disease, available therapeutic options, and highlights recent advances in the management of MM-related bone disease.
Collapse
Affiliation(s)
- Zachary S. Bernstein
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA;
| | - E. Bridget Kim
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA 02114, USA;
| | - Noopur Raje
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Boston, MA 02114, USA;
- Harvard Medical School, Boston, MA 02115, USA
- Correspondence:
| |
Collapse
|
5
|
Anastasilakis AD, Pepe J, Napoli N, Palermo A, Magopoulos C, Khan AA, Zillikens MC, Body JJ. Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS. J Clin Endocrinol Metab 2022; 107:1441-1460. [PMID: 34922381 PMCID: PMC9016445 DOI: 10.1210/clinem/dgab888] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Antiresorptive therapy significantly reduces fracture risk in patients with benign bone disease and skeletal-related events (SREs) in patients with bone metastases (BM). Osteonecrosis of the jaw (ONJ) is a rare but severe condition manifested as necrotic bone lesion or lesions of the jaws. ONJ has been linked to the use of potent antiresorptive agents, termed medication-related ONJ (MRONJ). OBJECTIVE We aimed to identify the differences various aspects of MRONJ among distinct patient categories and provide recommendations on how to mitigate the risk and optimally manage MRONJ in each of them. METHODS A working group of the European Calcified Tissue Society (ECTS) and 2 experts performed an updated detailed review of existing literature on MRONJ incidence, characteristics, and treatment applied in bone diseases with variable severity of skeletal insult, ranging from osteoporosis to prevention of cancer treatment-induced bone loss and SREs in cancer patients with BM. RESULTS The risk for MRONJ is much higher in patients with advanced malignancies compared to those with benign bone diseases because of the higher doses and more frequent administration of antiresorptive agents in individuals with compromised general health, along with coadministration of other medications that predispose to MRONJ. The overall risk for MRONJ is considerably lower than the benefits in all categories of patients. CONCLUSION The risk for MRONJ largely depends on the underlying bone disease and the relevant antiresorptive regimen applied. Physicians and dentists should keep in mind that the benefits of antiresorptive therapy far outweigh the risk for MRONJ development.
Collapse
Affiliation(s)
- Athanasios D Anastasilakis
- Department of Endocrinology, 424 General Military Hospital, 564 29 N Efkarpia Thessaloniki, Greece
- Correspondence: Athanasios D. Anastasilakis, PhD, Department of Endocrinology, 424 General Military Hospital, Ring Rd, 564 29 N Efkarpia, Thessaloniki, Greece.
| | - Jessica Pepe
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, “Sapienza” University of Rome, 00185 Rome, Italy
| | - Nicola Napoli
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Andrea Palermo
- Unit of Endocrinology and Diabetes, Departmental Faculty of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Christos Magopoulos
- Department of Oral and Maxillofacial Surgery, 424 General Military Hospital, 56429 Thessaloniki, Greece
| | - Aliya A Khan
- Division of Endocrinology and Metabolism and Geriatrics, McMaster University, L8N3Z5 Hamilton, Ontario, Canada
| | - M Carola Zillikens
- Bone Center, Department of Internal Medicine, Erasmus MC, 2040 Rotterdam, the Netherlands
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, 1050 Brussels, Belgium
| |
Collapse
|
6
|
LeBlanc R, Bergstrom DJ, Côté J, Kotb R, Louzada ML, Sutherland HJ. Management of Myeloma Manifestations and Complications: The Cornerstone of Supportive Care: Recommendation of the Canadian Myeloma Research Group (formerly Myeloma Canada Research Network) Consensus Guideline Consortium. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:e41-e56. [PMID: 34456159 DOI: 10.1016/j.clml.2021.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/14/2021] [Accepted: 07/29/2021] [Indexed: 11/18/2022]
Abstract
Multiple myeloma (MM) is a hematological cancer associated with significant symptomatic burden. Bone disease, renal insufficiency, cytopenias, infection, and peripheral neuropathy, among other disease manifestations and complications, impair patients' quality of life. The Canadian Myeloma Research Group Consensus Guideline Consortium, formerly Myeloma Canada Research Network Consensus Guideline Consortium, proposes national consensus recommendations for the management of MM-related manifestations and complications. To address the needs of Canadian physicians and people living with MM across the country, this document focuses on the improvement and maintenance of patient care by clarifying best-practice approaches for the prevention, detection and management of disease manifestations and complications. The Canadian Myeloma Research Group Consensus Guideline Consortium will periodically review the recommendations herein and update as necessary.
Collapse
Affiliation(s)
- Richard LeBlanc
- Hôpital Maisonneuve-Rosemont, University of Montreal, Montreal, QC, Canada.
| | | | - Julie Côté
- Centre hospitalier universitaire de Québec, Quebec, QC, Canada
| | - Rami Kotb
- CancerCare Manitoba, University of Manitoba, Winnipeg, MB, Canada
| | - Martha L Louzada
- London Health Sciences Centre, Western University, London, ON, Canada
| | - Heather J Sutherland
- Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, BC Cancer, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
7
|
Lu H, Pundole X, Lee HC. The role of bone-modifying agents in myeloma bone disease. JBMR Plus 2021; 5:e10518. [PMID: 34368608 PMCID: PMC8328802 DOI: 10.1002/jbm4.10518] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 01/23/2023] Open
Abstract
Bone disease is common in patients with multiple myeloma (MM), which manifests as bone pain and skeletal-related events (SREs) such as pathological fractures and spinal cord compression. Myeloma bone disease (MBD) can adversely affect the quality of life of patients and have negative effects on morbidity and mortality. The pathogenesis of MBD is complex, and several factors are involved in the dysregulation of bone metabolism and uncoupling of bone remodeling, which result in net bone loss and devastating SREs. Broadly speaking, elevated osteoclast activity, suppressed osteoblast activity, and an aberrant marrow microenvironment play a role in MBD. Interaction of MM cells with the main bone cell osteocytes also promote further bone destruction. This review focuses on the role of bone-modifying agents in the prevention and treatment of MBD. The mainstay of MBD prevention are antiresorptive agents, bisphosphonates and denosumab. However, these agents do not play a direct role in bone formation and repair of existing MBD. Newer agents with anabolic effects such as anti-sclerostin antibodies, parathyroid hormone, anti-Dickkopf-1 antibodies, and others have shown potential in repair of MBD lesions. With the development of several new agents, the treatment landscape of MBD is likely to evolve in the coming years. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
Collapse
Affiliation(s)
- Huifang Lu
- Department of General Internal Medicine Section of Rheumatology and Clinical Immunology Houston Texas USA
| | - Xerxes Pundole
- Department of Health Services Research The University of Texas MD Anderson Cancer Center Houston Texas USA.,Present address: Amgen Inc. Thousand Oaks CA USA
| | - Hans C Lee
- Department of Lymphoma/Myeloma The University of Texas MD Anderson Cancer Center Houston Texas USA
| |
Collapse
|
8
|
Mukkamalla SKR, Malipeddi D. Myeloma Bone Disease: A Comprehensive Review. Int J Mol Sci 2021; 22:6208. [PMID: 34201396 PMCID: PMC8227693 DOI: 10.3390/ijms22126208] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 05/17/2021] [Accepted: 06/03/2021] [Indexed: 12/11/2022] Open
Abstract
Multiple myeloma (MM) is a neoplastic clonal proliferation of plasma cells in the bone marrow microenvironment, characterized by overproduction of heavy- and light-chain monoclonal proteins (M-protein). These proteins are mainly found in the serum and/or urine. Reduction in normal gammaglobulins (immunoparesis) leads to an increased risk of infection. The primary site of origin is the bone marrow for nearly all patients affected by MM with disseminated marrow involvement in most cases. MM is known to involve bones and result in myeloma bone disease. Osteolytic lesions are seen in 80% of patients with MM which are complicated frequently by skeletal-related events (SRE) such as hypercalcemia, bone pain, pathological fractures, vertebral collapse, and spinal cord compression. These deteriorate the patient's quality of life and affect the overall survival of the patient. The underlying pathogenesis of myeloma bone disease involves uncoupling of the bone remodeling processes. Interaction of myeloma cells with the bone marrow microenvironment promotes the release of many biochemical markers including osteoclast activating factors and osteoblast inhibitory factors. Elevated levels of osteoclast activating factors such as RANK/RANKL/OPG, MIP-1-α., TNF-α, IL-3, IL-6, and IL-11 increase bone resorption by osteoclast stimulation, differentiation, and maturation, whereas osteoblast inhibitory factors such as the Wnt/DKK1 pathway, secreted frizzle related protein-2, and runt-related transcription factor 2 inhibit osteoblast differentiation and formation leading to decreased bone formation. These biochemical factors also help in development and utilization of appropriate anti-myeloma treatments in myeloma patients. This review article summarizes the pathophysiology and the recent developments of abnormal bone remodeling in MM, while reviewing various approved and potential treatments for myeloma bone disease.
Collapse
Affiliation(s)
| | - Dhatri Malipeddi
- Internal Medicine, Canton Medical Education Foundation/NEOMED, Canton, OH 44710, USA;
| |
Collapse
|
9
|
Mohyuddin GR, Koehn K, Abdallah A, Sborov D, Rajkumar SV, Kumar S, McClune B. Use of endpoints in multiple myeloma randomized controlled trials over the last 15 years: A systematic review. Am J Hematol 2021; 96:690-697. [PMID: 33735453 DOI: 10.1002/ajh.26166] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 01/12/2023]
Abstract
Surrogate endpoints are being used more frequently in randomized controlled trials, even though they do not consistently corelate with patient outcomes. We systemically evaluated the use of surrogate endpoints in multiple myeloma randomized controlled trials over the past 15 years. We searched three databases (Pubmed, Embase, Cochrane) for multiple myeloma randomized controlled trials from January 1, 2005 to December 30, 2019. The primary outcome of our study was the proportion of randomized controlled trials that used overall survival as their primary endpoint. Secondary outcomes included the use of surrogate endpoints, and trends over time, and whether they differed based on study sponsorship. We included 151 randomized controlled trials in our analysis. The primary endpoint was overall survival (OS) in 17 (11.3%) of studies, progression free survival (PFS) or event-defined endpoints in 91 studies (60.3%) and response-based endpoints in 44 studies (29.1%). Quality of life was a primary endpoint in only three studies (2%). The use of OS as a primary endpoint decreased from 28.5% of trials from 2005 to 2009 to 5.5% from 2015 to 2019. There has been a decrease in the clinically meaningful endpoint of OS over the past 15 years in multiple myeloma randomized controlled trials. Use of quality of life as a primary endpoint remains exceedingly low. It remains paramount to recognize that the use of surrogate endpoints is imperfect, and care based upon them requires constant physician and patient re-analysis.
Collapse
Affiliation(s)
- Ghulam Rehman Mohyuddin
- Department of Hematological Malignancies and Cellular Therapeutics Kansas University Medical Center Westwood Kansas USA
| | - Kelly Koehn
- Department of Hematological Malignancies and Cellular Therapeutics Kansas University Medical Center Westwood Kansas USA
| | - Al‐Ola Abdallah
- Department of Hematological Malignancies and Cellular Therapeutics Kansas University Medical Center Westwood Kansas USA
| | - Douglas Sborov
- Division of Hematology and Hematologic Malignancies University of Utah Salt Lake City Utah USA
| | - S. Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine Mayo Clinic Rochester Minnesota USA
| | - Brian McClune
- Division of Hematology and Hematologic Malignancies University of Utah Salt Lake City Utah USA
| |
Collapse
|
10
|
Du JS, Yen CH, Hsu CM, Hsiao HH. Management of Myeloma Bone Lesions. Int J Mol Sci 2021; 22:3389. [PMID: 33806209 PMCID: PMC8036461 DOI: 10.3390/ijms22073389] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/17/2021] [Accepted: 03/22/2021] [Indexed: 01/29/2023] Open
Abstract
Multiple myeloma (MM) is a B-cell neoplasm characterized by clonal plasma-cell proliferation. The survival and prognosis of this condition have been significantly improved by treatment with active anti-MM drugs such as bortezomib or lenalidomide. Further, the discovery of novel agents has recently paved the way for new areas of investigation. However, MM, including myeloma-related bone diseases, remains fatal. Bone disease or bone destruction in MM is a consequence of skeletal involvement with bone pain, spinal cord compression, and bone fracture resulting from osteolytic lesions. These consequences affect disease outcomes, including patients' quality of life and survival. Several studies have sought to better understand MM bone disease (MBD) through the classification of its molecular mechanisms, including osteoclast activation and osteoblast inhibition. Bisphosphonates and the receptor activator of the nuclear factor-kappa B (NF-κB) ligand (RANKL) inhibitor, denosumab, prevent skeletal-related events in MM. In addition, several other bone-targeting agents, including bone-anabolic drugs, are currently used in preclinical and early clinical evaluations. This review summarizes the current knowledge of the pathogenesis of MBD and discusses novel agents that appear very promising and will soon enter clinical development.
Collapse
Affiliation(s)
- Jeng-Shiun Du
- Division of Hematology and Oncology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (J.-S.D.); (C.-M.H.)
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Chia-Hung Yen
- Graduate Institute of Natural Products, College of Pharmacy, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- National Natural Product Libraries and High-Throughput Screening Core Facility, Kaohsiung Medical University, Kaohsiung 80708, Taiwan;
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung 80708, Taiwan
| | - Chin-Mu Hsu
- Division of Hematology and Oncology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (J.-S.D.); (C.-M.H.)
| | - Hui-Hua Hsiao
- Division of Hematology and Oncology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (J.-S.D.); (C.-M.H.)
- Center for Cancer Research, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
- Cancer Center, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
- Faculty of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| |
Collapse
|
11
|
Ruiz-Argüelles GJ, Gómez-Almaguer D. Lessons Learned Treating Patients with Multiple Myeloma in Resource-Constrained Settings. Curr Hematol Malig Rep 2021; 16:40-44. [PMID: 33704651 DOI: 10.1007/s11899-021-00616-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Based on personal experiences, recommendations for physicians treating patients with multiple myeloma (MM) in low- and middle-income countries (LMICs) are proposed. RECOMMENDATIONS (1) Implement strategies to keep the patient in the best possible condition for the longest time, in addition to focusing on ways to avoid financial toxicity; (2) if lenalidomide is unavailable, start treatment with thalidomide and dexamethasone, include, if possible, bortezomib; (3) conduct an outpatient-based autologous stem cell transplantation (ASCT) in all eligible patients; (4) use thalidomide as post-ASCT maintenance treatment if lenalidomide is unavailable for the standard risk patients; (5) monitor monoclonal proteins with serum protein electrophoresis and free light chain measurements; (6) employ novel drugs in cases of relapsed or refractory disease; and (7) do not forget supportive therapy. The therapeutic recommendations to treat patients with MM are somewhat different for physicians working in LMICs, compared with those treating patients in high-income countries. These are relevant since more than 50% of the inhabitants of the world live in LMICs, thus indicating that the vast majority of patients with MM are being treated in resource-constrained settings. As time goes by, physicians may acquire the ability to analyze and express their feelings and experiences about topics in the practice of medicine in which they could have learned lessons (1). Since 1980, we have been treating patients with multiple myeloma (MM); to date, we have been personally involved in the study and treatment of more than 300 patients with this disease (2). Having gained experience dealing with MM patients in underprivileged circumstances, such as those prevailing in our country: México, having explored different ideas, treatments, and methods, and being aware of the financial implications which may impact our selection of therapeutic strategies and recommendations, we felt that it was appropriate to share in this article some of these ideas with practitioners around the world who are involved in the treatment of patients with MM in low- and middle-income countries (LMICs).
Collapse
Affiliation(s)
| | - David Gómez-Almaguer
- Hospital Universitario "Dr. Jose Eleuterio González", Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico
| |
Collapse
|
12
|
Terpos E, Zamagni E, Lentzsch S, Drake MT, García-Sanz R, Abildgaard N, Ntanasis-Stathopoulos I, Schjesvold F, de la Rubia J, Kyriakou C, Hillengass J, Zweegman S, Cavo M, Moreau P, San-Miguel J, Dimopoulos MA, Munshi N, Durie BGM, Raje N. Treatment of multiple myeloma-related bone disease: recommendations from the Bone Working Group of the International Myeloma Working Group. Lancet Oncol 2021; 22:e119-e130. [PMID: 33545067 DOI: 10.1016/s1470-2045(20)30559-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/06/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
In this Policy Review, the Bone Working Group of the International Myeloma Working Group updates its clinical practice recommendations for the management of multiple myeloma-related bone disease. After assessing the available literature and grading recommendations using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) method, experts from the working group recommend zoledronic acid as the preferred bone-targeted agent for patients with newly diagnosed multiple myeloma, with or without multiple myeloma-related bone disease. Once patients achieve a very good partial response or better, after receiving monthly zoledronic acid for at least 12 months, the treating physician can consider decreasing the frequency of or discontinuing zoledronic acid treatment. Denosumab can also be considered for the treatment of multiple myeloma-related bone disease, particularly in patients with renal impairment. Denosumab might prolong progression-free survival in patients with newly diagnosed multiple myeloma who have multiple myeloma-related bone disease and who are eligible for autologous stem-cell transplantation. Denosumab discontinuation is challenging due to the rebound effect. The Bone Working Group of the International Myeloma Working Group also found cement augmentation to be effective for painful vertebral compression fractures. Radiotherapy is recommended for uncontrolled pain, impeding or symptomatic spinal cord compression, or pathological fractures. Surgery should be used for the prevention and restoration of long-bone pathological fractures, vertebral column instability, and spinal cord compression with bone fragments within the spinal route.
Collapse
Affiliation(s)
- Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Elena Zamagni
- Seràgnoli Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, S Orsola Malpighi Hospital, Bologna, Italy
| | - Suzanne Lentzsch
- Division of Hematology and Oncology, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Matthew T Drake
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition and Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ramón García-Sanz
- Department of Hematology, University Hospital of Salamanca, Salamanca, Spain
| | - Niels Abildgaard
- Hematology Research Unit, Department of Clinical Research, and Department of Hematology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Fredrik Schjesvold
- Oslo Myeloma Center, Oslo University Hospital, and KG Jebsen Center for B Cell Malignancies, University of Oslo, Oslo, Norway
| | - Javier de la Rubia
- Department of Hematology, University Hospital Doctor Peset, School of Medicine and Dentistry, Catholic University of Valencia, Valencia, Spain
| | | | - Jens Hillengass
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Michele Cavo
- Seràgnoli Institute of Hematology, Department of Experimental, Diagnostic and Specialty Medicine, Bologna University School of Medicine, S Orsola Malpighi Hospital, Bologna, Italy
| | - Philippe Moreau
- Department of Hematology, University Hospital Hotel-Dieu, Nantes, France
| | - Jesus San-Miguel
- Center for Applied Medical Research, Clínica Universidad de Navarra, University of Navarra, and Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikhil Munshi
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Brian G M Durie
- Department of Hematology and Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Noopur Raje
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | | |
Collapse
|
13
|
Olesen TB, Andersen IT, Ording AG, Ehrenstein V, Seesaghur A, Helleberg C, Silkjær T, Hernandez RK, Niepel D, Abildgaard N. Use of bisphosphonates in multiple myeloma patients in Denmark, 2005-2015. Support Care Cancer 2021; 29:4501-4511. [PMID: 33458807 DOI: 10.1007/s00520-020-05934-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE To describe use of bisphosphonates in newly diagnosed multiple myeloma patients in Denmark. METHODS Using data from the Danish National Multiple Myeloma Registry, we conducted a population-based cohort study. Among patients newly diagnosed with multiple myeloma from 2005 to 2015, we examined use of bisphosphonates at first- and at progression/second-line anti-myeloma treatment overall, by patient characteristics, and myeloma complications. RESULTS Of 2947 patients starting first-line anti-myeloma treatment, 2207 patients (74.9%) received bisphosphonates. During a median follow-up of 27.6 (quartiles, 10.6-52.5) months, disease progression post-first-line treatment was recorded in 1546 patients, of whom 1065 (68.9%) were treated with bisphosphonates. Altogether, 80.9% of patients with and 37.6% of patients without myeloma bone disease were treated with bisphosphonates at first line and 73.0% and 42.7%, respectively, at progression/second line. Moreover, the proportion of patients treated with bisphosphonates decreased with increasing severity of renal impairment at first and at progression/second-line treatment. CONCLUSION The proportion of patients treated with bisphosphonates as part of first- and second-line anti-myeloma treatment increased with presence of myeloma bone disease and decreased by presence and severity of renal impairment. Overall, 25% of newly diagnosed multiple myeloma patients had no record of bisphosphonate treatment, potentially indicating an unmet need.
Collapse
Affiliation(s)
- Tina Bech Olesen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University, Olof Palmes Allé 43, 8200, Aarhus, Denmark.
| | - Ina Trolle Andersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University, Olof Palmes Allé 43, 8200, Aarhus, Denmark
| | - Anne Gulbech Ording
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University, Olof Palmes Allé 43, 8200, Aarhus, Denmark
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus University, Olof Palmes Allé 43, 8200, Aarhus, Denmark
| | | | | | - Trine Silkjær
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Niels Abildgaard
- Haematology Research Unit, Department of Haematology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
14
|
Romero-Morelos P, Ruvalcaba-Paredes E, Garciadiego-Cázares D, Pérez-Santos M, Reyes-Long S, Alfaro-Rodriguez A, Salcedo M, Mancilla-Ramírez J, Bandala C. Neurophysiological Mechanisms Related to Pain Management in Bone Tumors. Curr Neuropharmacol 2021; 19:308-319. [PMID: 33176655 PMCID: PMC8033964 DOI: 10.2174/1570159x18666201111112748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/24/2020] [Accepted: 10/22/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Primary and metastatic bone tumor incidence has increased in the previous years. Pain is a common symptom and is one of the most important related factors to the decrease of quality of life in patients with bone tumor. Different pain management strategies are not completely effective and many patients afflicted by cancer pain cannot be controlled properly. In this sense, we need to elucidate the neurophysiology of cancer-induced pain, contemplating other components such as inflammation, neuropathies and cognitive components regarding bone tumors, and thus pave the way for novel therapeutic approaches in this field. AIM This study aims to identify the neurophysiology of the mechanisms related to pain management in bone tumors. METHODS Advanced searches were performed in scientific databases: PubMed, ProQuest, EBSCO, and the Science Citation index to get information about the neurophysiology mechanisms related to pain management in bone tumors. RESULTS The central and peripheral mechanisms that promote bone cancer pain are poorly understood. Studies have shown that bone cancer could be related to neurochemicals produced by tumor and inflammatory cells, coupled with peripheral sensitization due to nerve compression and injury caused by tumor growth. The activity of mesolimbic dopaminergic neurons, substance P, cysteine/ glutamate antiporter, and other neurochemical dynamics brings us putative strategies to suggest better and efficient treatments against pain in cancer patients. CONCLUSION Cancer-induced bone pain could include neuropathic and inflammatory pain, but with different modifications to the periphery tissue, nerves and neurochemical changes in different neurological levels. In this sense, we explore opportunity areas in pharmacological and nonpharmacological pain management, according to pain-involved mechanisms in this study.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Cindy Bandala
- Address correspondence to this author at the Departament of Neurosciences, Instituto Nacional de Rehabilitación “Luis Guillermo Ibarra Ibarra”, Calzada México-Xochimilco 289, Col. Arenal de Guadalupe, Del. Tlalpan, 14389 Ciudad de México, México; Tel: (+52) (55) 5999 1000, ext. 19303; E-mail:
| |
Collapse
|
15
|
Terpos E, Ntanasis-Stathopoulos I. Controversies in the use of new bone-modifying therapies in multiple myeloma. Br J Haematol 2020; 193:1034-1043. [PMID: 33249579 DOI: 10.1111/bjh.17256] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 12/22/2022]
Abstract
Bone-modifying therapies are essential in the treatment of patients with multiple myeloma. Zoledronic acid is preferred over other bisphosphonates due to its superiority in reducing the incidence of skeletal-related events and improving survival. The anti-receptor activator of nuclear factor-κΒ ligand (RANKL)-targeted agent denosumab has shown its non-inferiority compared to bisphosphonates in preventing skeletal-related events among newly diagnosed patients with myeloma bone disease. Denosumab may confer a survival benefit in patients eligible for autologous transplantation. Denosumab may present a safer profile for patients with renal impairment. Discontinuation of bone-directed therapies can be considered for patients with deep responses and after an adequate time period on treatment; however, a rebound effect may become evident especially in the case of denosumab. Three-monthly infusions of zoledronic acid or at-home denosumab administration should be considered during the coronavirus disease 2019 (COVID-19) pandemic. Measures to prevent hypocalcaemia, renal toxicity and osteonecrosis of the jaw are important for all bone-modifying agents.
Collapse
Affiliation(s)
- Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
16
|
Whitefield S, Lazarovici TS, Sommer-Umansky M, Friedlander-Barenboim S, Yahalom R, Yarom N. Changing face of medication-related osteonecrosis of the jaw: Sheba Medical Center experience-fifteen years. J Bone Miner Metab 2020; 38:819-825. [PMID: 32507944 DOI: 10.1007/s00774-020-01113-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/11/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Our aim is to track the development of the epidemiological characteristics in patient populations diagnosed with MRONJ at the Sheba Medical Center. MATERIALS AND METHODS The files of patients diagnosed with MRONJ from 2003 until December 2017 were retrieved. Data on demographics, medical background, type and duration of drug use and triggering events at presentation was collected. RESULTS The study included 448 patients, 336 females and 112 males. A decrease in the proportion of multiple myeloma patients (p < 0.05) and an increase in the proportion of patients with bone metastases of solid tumors has been observed recently. An increase in the proportion of cases in osteoporosis patients compared with oncology patients is evident (p < 0.01). Overtime a higher proportion of patients presented at an earlier stage of MRONJ (p < 0.01). CONCLUSIONS As a result of changes in treatment protocols and increased awareness of oncology caregivers, including referral and consultation with Oral Medicine specialists, there has been a change in the demographics and presentation of the disease.
Collapse
Affiliation(s)
- Sara Whitefield
- Oral Medicine Unit, Sheba Medical Center, Tel Hashomer, Israel
- School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Towi Sorel Lazarovici
- Department of Oral and Maxillofacial Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | - Ran Yahalom
- Department of Oral and Maxillofacial Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - Noam Yarom
- Oral Medicine Unit, Sheba Medical Center, Tel Hashomer, Israel.
- School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
| |
Collapse
|
17
|
Application of pamidronate disodium for the treatment of diffuse sclerosing osteomyelitis of the mandible: A clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol 2020; 130:616-624. [PMID: 32771415 DOI: 10.1016/j.oooo.2020.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/31/2020] [Accepted: 06/30/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study aimed to assess the clinical effectiveness of using pamidronate disodium to treat patients with diffuse sclerosing osteomyelitis of the mandible (DSOM ). STUDY DESIGN Patients with DSOM who were hospitalized in the Department of Oral and Maxillofacial Surgery, Peking University Hospital of Stomatology (Beijing, China), between March 2018 and March 2019 were included. All patients were treated with intravenous administration of pamidronate disodium for 3 days. Pain intensity, mouth opening, blood workup findings, imaging examination findings, and incidence of complications before and after treatment and during the follow-up period, were recorded and compared. RESULTS Forty-three patients were treated with pamidronate disodium. Adverse reactions, including fever, hypocalcemia, hypokalemia, and diarrhea, were observed during treatment. Fourteen patients had moderate to severe pain before treatment, and the pain was markedly alleviated after days 2 and 3 of treatment. Pain and swelling were found to have disappeared at the 6-month follow-up in 39 patients (90.7%). Mean mouth opening increased from 28.5 mm to 38.1 mm. Imaging examinations showed that the bone mass in the affected area had markedly improved in 32 patients (74.4%). CONCLUSIONS Pamidronate disodium alleviated pain and swelling and improved mouth opening in patients with DSOM. Follow-up after 6 to 18 months demonstrated stable treatment effectiveness.
Collapse
|
18
|
Zanwar S, Abeykoon JP, Kapoor P. Challenges and Strategies in the Management of Multiple Myeloma in the Elderly Population. Curr Hematol Malig Rep 2020; 14:70-82. [PMID: 30820879 DOI: 10.1007/s11899-019-00500-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Approximately one half of the patient-population in multiple myeloma (MM) is > 70 years at diagnosis. Despite notable strides in the management and improved survival, MM remains incurable, with an increasing proportion of elderly patients comprising the relapsed-refractory cohort. RECENT FINDINGS The arbitrary age cutoff at 65 years to define the elderly patient-population has evolved to a more nuanced categorization, incorporating a comprehensive assessment for determining frailty prior to commencing treatment. This step is critical in determining the therapy-intensity, including transplant-eligibility, to minimize toxicity. Dose-modifications are crucial, as the merits of continuous therapy are becoming evident in this patient-population. Bortezomib, lenalidomide, and dexamethasone (VRd) combination has emerged as standard of care for newly diagnosed MM. Fixed-duration Rd followed by reduced-dosed continuous R may be considered in select frail patients with standard-risk MM. Herein, we review the unique challenges encountered in elderly MM and discuss strategies for optimal management.
Collapse
Affiliation(s)
- Saurabh Zanwar
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Prashant Kapoor
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
19
|
Larsen RF, Jarden M, Minet LR, Frølund UC, Möller S, Abildgaard N. Physical function in patients newly diagnosed with multiple myeloma; a Danish cohort study. BMC Cancer 2020; 20:169. [PMID: 32126972 PMCID: PMC7055017 DOI: 10.1186/s12885-020-6637-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 02/17/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Multiple myeloma is a cancer in the bone marrow causing bone destruction. Patients experience various symptoms related to the disease and/or treatment, such as pain and fatigue, leading to poorer quality of life. The symptom burden might affect physical function and physical activity levels, posing a risk of physical deterioration. The aim was to investigate whether physical function in newly diagnosed patients with multiple myeloma differs from the reference values of the normal population and other cancer patients. METHODS The study is a cross sectional descriptive analysis of a prospective cohort of 100 patients newly diagnosed with multiple myeloma. Four physical function tests were carried out; Six-Minute-Walk-Test, Sit-to-Stand-Test, grip strength and knee extension strength. Age and gender specific results of physical function from the multiple myeloma population were compared to normative data and to data from other cancer populations. RESULTS Of the 100 patients included, 73% had bone disease and 55% received pain relieving medicine. Mean age was 67.7 years (SD 10.3). Patients with multiple myeloma had significantly poorer physical function compared to normative data, both regarding aerobic capacity and muscle strength, although not grip strength. No differences in physical function were found between patients with multiple myeloma and other cancer populations. CONCLUSIONS Physical function in newly diagnosed Danish patients with multiple myeloma is lower than in the normal population. Exercise intervention studies are warranted to explore the value of physical exercise on physical function. TRIAL REGISTRATION ClinicalTrials.gov, ID NCT02439112, registered 8 May 2015.
Collapse
Affiliation(s)
- Rikke Faebo Larsen
- Department of Physiotherapy and Occupational Therapy, Zealand University Hospital, Roskilde, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark.
| | - Mary Jarden
- Department of Haematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lisbeth Rosenbek Minet
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Rehabilitation, Odense University Hospital, Odense, Denmark.,Health Science Research Centre, UCL University College, Odense, Denmark
| | | | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Niels Abildgaard
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
| |
Collapse
|
20
|
Coluzzi F, Rolke R, Mercadante S. Pain Management in Patients with Multiple Myeloma: An Update. Cancers (Basel) 2019; 11:E2037. [PMID: 31861097 PMCID: PMC6966684 DOI: 10.3390/cancers11122037] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/10/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022] Open
Abstract
Most patients with multiple myeloma (MM) suffer from chronic pain at every stage of the natural disease process. This review focuses on the most common causes of chronic pain in MM patients: (1) pain from myeloma bone disease (MBD); (2) chemotherapy-induced peripheral neuropathy as a possible consequence of proteasome inhibitor therapy (i.e., bortezomib-induced); (3) post-herpetic neuralgia as a possible complication of varicella zoster virus reactivation because of post-transplantation immunodepression; and (4) pain in cancer survivors, with increasing numbers due to the success of antiblastic treatments, which have significantly improved overall survival and quality of life. In this review, non-pain specialists will find an overview including a detailed description of physiopathological mechanisms underlying central sensitization and pain chronification in bone pain, the rationale for the correct use of analgesics and invasive techniques in different pain syndromes, and the most recent recommendations published on these topics. The ultimate target of this review was to underlie that different types of pain can be observed in MM patients, and highlight that only after an accurate pain assessment, clinical examination, and pain classification, can pain be safely and effectively addressed by selecting the right analgesic option for the right patient.
Collapse
Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, 04100 Latina, Italy
| | - Roman Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, 52062 Aachen, Germany;
| | - Sebastiano Mercadante
- Main regional center for Pain Relief & Supportive Care, La Maddalena Cancer Center, 90100 Palermo, Italy;
| |
Collapse
|
21
|
Parrondo RD, Sher T. Prevention Of Skeletal Related Events In Multiple Myeloma: Focus On The RANK-L Pathway In The Treatment Of Multiple Myeloma. Onco Targets Ther 2019; 12:8467-8478. [PMID: 31686861 PMCID: PMC6798817 DOI: 10.2147/ott.s192490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 09/20/2019] [Indexed: 01/11/2023] Open
Abstract
More than 90% of patients with multiple myeloma (MM) have osteolytic bone lesions which increase the risk of skeletal-related events (SRE). The cytokine milieu in the bone marrow microenvironment (BMME) of MM plays a key role in myeloma bone disease by impairing the balance between osteoclastogenesis and osteoblastogenesis. This is orchestrated by the malignant plasma cell (MPC) with the ultimate outcome of MPC proliferation and survival at the expense of excess osteoclast activation resulting in osteolytic bone lesions. Prevention of SRE is currently accomplished by the inhibition of osteoclasts. Bisphosphonates (BPs) are pyrophosphate analogues that cause apoptosis of osteoclasts and have been proven to prevent and delay SRE. Denosumab, a fully humanized monoclonal antibody that binds and inhibits receptor activator of nuclear factor-ĸB ligand (RANKL), a key molecule in the BMME crucial for osteoclastogenesis, is also approved for the prevention of SRE in MM. The addition of BPs and denosumab to standard MM treatment affords a survival benefit for patients with MM. Specifically, the addition of denosumab to standard MM treatments results in superior PFS compared to BPs, highlighting the key role of the RANKL pathway in MM. This review focuses on the pathophysiology of myeloma bone disease as well as on the importance of targeting the RANK-L pathway for the treatment of MM and prevention of SRE.
Collapse
Affiliation(s)
- Ricardo D Parrondo
- Department of Medicine, Hematology-Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Taimur Sher
- Department of Medicine, Hematology-Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| |
Collapse
|
22
|
Olszewski AJ, Barth PM, Reagan JL. Use of bone-modifying agents and clinical outcomes in older adults with multiple myeloma. Cancer Med 2019; 8:6945-6954. [PMID: 31566898 PMCID: PMC6853813 DOI: 10.1002/cam4.2591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/04/2019] [Accepted: 09/04/2019] [Indexed: 12/28/2022] Open
Abstract
Background Guidelines recommend bone‐modifying agents (BMAs) for all patients initiating treatment for myeloma. We examined adherence to this recommendation, and BMA effectiveness in the era of bortezomib/lenalidomide‐based therapy among Medicare beneficiaries. Methods From the linked Surveillance, Epidemiology, and End Results‐Medicare registry, we selected beneficiaries receiving anti‐myeloma chemotherapy in 2007‐2013. We matched BMA recipients (within 90 days of first chemotherapy) to nonrecipients using a propensity score, balancing patient‐, disease‐, and therapy‐related confounders. Cumulative incidence of skeletal‐related events (SREs) and overall survival (OS) was compared in proportional hazard models accounting for competing risks and immortal‐time bias. Results Among 4611 patients with median age of 76 years, 51% received BMA. Bone‐modifying agents use remained steady over time (P = .87) and was significantly less frequent for patients who were older, with comorbidities, without prior SRE, and those treated without bortezomib or lenalidomide. In a propensity score‐matched cohort, BMA recipients experienced a lower incidence of SRE (11.0% vs 14.6% at 3 years; subhazard ratio, 0.73; 95% CI, 0.60‐0.89) and better OS (53.3% vs 47.8% at 3 years; hazard ratio, 0.86; 95% CI, 0.77‐0.95). The results were consistent in the subgroup (76%) treated with bortezomib and/or immunomodulatory drugs (IMiDs). The incidence of osteonecrosis of the jaw (ONJ) was 3.2% at 3 years. Conclusions In this observational study, the observed benefits of early BMA administration among patients treated with contemporary anti‐myeloma regimens were similar to historical clinical trials. Frequent omission of BMA highlights a remediable deficiency in the quality of supportive care, and suggests that timely administration may be a useful indicator of quality care in myeloma.
Collapse
Affiliation(s)
- Adam J Olszewski
- Alpert Medical School of Brown University, Providence, RI, USA.,Division of Hematology-Oncology, Lifespan Cancer Institute, Providence, RI, USA
| | - Peter M Barth
- Alpert Medical School of Brown University, Providence, RI, USA.,Division of Hematology-Oncology, Lifespan Cancer Institute, Providence, RI, USA
| | - John L Reagan
- Alpert Medical School of Brown University, Providence, RI, USA.,Division of Hematology-Oncology, Lifespan Cancer Institute, Providence, RI, USA
| |
Collapse
|
23
|
Yarom N, Shapiro CL, Peterson DE, Van Poznak CH, Bohlke K, Ruggiero SL, Migliorati CA, Khan A, Morrison A, Anderson H, Murphy BA, Alston-Johnson D, Mendes RA, Beadle BM, Jensen SB, Saunders DP. Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline. J Clin Oncol 2019; 37:2270-2290. [PMID: 31329513 DOI: 10.1200/jco.19.01186] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer. METHODS Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. PubMed and EMBASE were searched for studies of the prevention and management of MRONJ related to bone-modifying agents (BMAs) for oncologic indications published between January 2009 and December 2017. Results from an earlier systematic review (2003 to 2008) were also included. RESULTS The systematic review identified 132 publications, only 10 of which were randomized controlled trials. Recommendations underwent two rounds of consensus voting. RECOMMENDATIONS Currently, MRONJ is defined by (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws. In patients who initiate a BMA, preventive care includes comprehensive dental assessments, discussion of modifiable risk factors, and avoidance of elective dentoalveolar surgery (ie, surgery that involves the teeth or contiguous alveolar bone) during BMA treatment. It remains uncertain whether BMAs should be discontinued before dentoalveolar surgery. Staging of MRONJ should be performed by a clinician with experience in the management of MRONJ. Conservative measures comprise the initial approach to MRONJ treatment. Ongoing collaboration among the dentist, dental specialist, and oncologist is essential to optimal patient care.
Collapse
Affiliation(s)
- Noam Yarom
- Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Tel Aviv University, Tel Aviv, Israel
| | | | | | | | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Salvatore L Ruggiero
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY.,Stony Brook School of Dental Medicine, Stony Brook, NY.,New York Center for Orthognathic and Maxillofacial Surgery, New York, NY
| | | | - Aliya Khan
- McMaster University, Hamilton, Ontario, Canada
| | - Archie Morrison
- Dalhousie University, Halifax, Nova Scotia, Canada.,Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Kleber M, Ntanasis-Stathopoulos I, Dimopoulos MA, Terpos E. Monoclonal antibodies against RANKL and sclerostin for myeloma-related bone disease: can they change the standard of care? Expert Rev Hematol 2019; 12:651-663. [PMID: 31268745 DOI: 10.1080/17474086.2019.1640115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Over 80% of the patients with multiple myeloma (MM) develop myeloma bone disease (MBD) during the disease course. The clinical consequences include serious skeletal-related events (SRE) that impact survival and quality of life. Bisphosphonates are the mainstay in the treatment of MBD. Currently, new therapeutic strategies are being introduced and broaden the therapeutic options in MBD. Areas covered: The purpose of this review is to summarize the current clinical management of MBD and present novel data regarding monoclonal antibodies against the receptor activator of NF-kappa B ligand (RANKL) and sclerostin that may change the clinical practice. Expert opinion: Our better understanding of the pathophysiology of MBD has identified several factors as potential therapeutic targets. Recent data have shown that the RANKL inhibitor denosumab constitutes a new promising option. The non-inferiority compared with bisphosphonates in terms of SRE prevention, the potential survival benefit, the convenience of subcutaneous administration, and the favorable toxicity profile makes denosumab a valuable alternative for physicians in the current treatment of MBD. Anti-sclerostin antibodies are currently under clinical development. Further investigations are needed to address open questions in the field including the value of anabolic agents combined with anti-resorptive and anti-MM drugs in MBD.
Collapse
Affiliation(s)
- Martina Kleber
- a Division of Hematology, Department of Medicine, University Hospital Basel , Basel , Switzerland.,b Division of Internal Medicine, Department of Medicine, University Hospital Basel , Basel , Switzerland
| | - Ioannis Ntanasis-Stathopoulos
- c Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens , Athens , Greece
| | - Meletios A Dimopoulos
- c Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens , Athens , Greece
| | - Evangelos Terpos
- c Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens , Athens , Greece
| |
Collapse
|
25
|
Myeloma bone disease: from biology findings to treatment approaches. Blood 2019; 133:1534-1539. [PMID: 30760454 DOI: 10.1182/blood-2018-11-852459] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/10/2019] [Indexed: 12/16/2022] Open
Abstract
Bone disease is a cardinal complication of multiple myeloma that affects quality of life and survival. Osteocytes have emerged as key players in the development of myeloma-related bone disease. Along with other factors, they participate in increased osteoclast activity, decreased osteoblast function, and immunosuppressed marrow microenvironment, which deregulate bone turnover and result in bone loss and skeletal-related events. Denosumab is a novel alternative to bisphosphonates against myeloma bone disease. Special considerations in this constantly evolving field are thoroughly discussed.
Collapse
|
26
|
Nielsen LK, Abildgaard N, Jarden M, Klausen TW. Methodological aspects of health-related quality of life measurement and analysis in patients with multiple myeloma. Br J Haematol 2019; 185:11-24. [PMID: 30656677 DOI: 10.1111/bjh.15759] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Multiple myeloma (MM) is an incurable but treatment-sensitive cancer. For most patients, this means treatment with multiple lines of anti-myeloma therapy and a life with disease- and treatment-related symptoms and complications. Health-related quality of life (HRQoL) issues play an important role in treatment decision-making. Methodological challenges in longitudinal HRQoL measurements and analyses have been identified, including non-responses (NR) to scheduled questionnaires. Publications were identified for inclusion in a systematic review of longitudinal HRQoL studies in MM, focussing on methodological aspects of HRQoL measurement and analysis. Diversity in timing of HRQoL data collection and applied statistical methods were noted. We observed a high rate of NR, but the impact of NR was investigated in only 8/23 studies. Thus, evidence-based knowledge of HRQoL in patients with MM is compromised. To improve quality of HRQoL results and their implementation in daily practice, future studies should follow established guidelines.
Collapse
Affiliation(s)
- Lene Kongsgaard Nielsen
- Quality of Life Research Center, Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
| | - Niels Abildgaard
- Quality of Life Research Center, Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
| | - Mary Jarden
- Department of Haematology, Copenhagen University Hospital, Copenhagen, Denmark
| | | |
Collapse
|
27
|
Kanellias N, Gavriatopoulou M, Terpos E, Dimopoulos MA. Management of multiple myeloma bone disease: impact of treatment on renal function. Expert Rev Hematol 2018; 11:881-888. [DOI: 10.1080/17474086.2018.1531702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Nikolaos Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Meletios Athanasios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
| |
Collapse
|
28
|
Klausen TW, Gregersen H, Abildgaard N, Andersen NF, Frølund UC, Gimsing P, Helleberg C, Vangsted AJ. The majority of newly diagnosed myeloma patients do not fulfill the inclusion criteria in clinical phase III trials. Leukemia 2018; 33:546-549. [DOI: 10.1038/s41375-018-0272-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/18/2018] [Accepted: 09/03/2018] [Indexed: 01/10/2023]
|
29
|
Campagnaro E, Reimers MA, Qin A, Alva AS, Schneider BJ, Van Poznak CH. Use of Bone-Modifying Agents in Myeloma and Bone Metastases: How Recent Dosing Interval Studies Have Affected Our Practice. J Oncol Pract 2018; 14:457-464. [DOI: 10.1200/jop.18.00236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The management of bone lesions from advanced solid tumors and multiple myeloma typically includes use of a bone-modifying agent to reduce the risk of skeletal-related events. Recent data demonstrate that when using zoledronic acid to reduce the risk of skeletal-related events in metastatic breast cancer, metastatic prostate cancer, and multiple myeloma, the dosing interval of zoledronic acid may be extended from every 4 weeks to every 12 weeks. The ASCO guidelines on the role of bone-modifying agents in metastatic breast cancer and multiple myeloma address zoledronic acid dosing intervals. Herein, we discuss how new data on dosing of bone-modifying agents influence our clinical practice.
Collapse
Affiliation(s)
| | | | - Angel Qin
- University of Michigan, Ann Arbor, MI
| | | | | | | |
Collapse
|
30
|
Westhrin M, Moen SH, Kristensen IB, Buene G, Mylin AK, Turesson I, Abildgaard N, Waage A, Standal T. Chemerin is elevated in multiple myeloma patients and is expressed by stromal cells and pre-adipocytes. Biomark Res 2018; 6:21. [PMID: 29946468 PMCID: PMC6001014 DOI: 10.1186/s40364-018-0134-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/30/2018] [Indexed: 12/05/2022] Open
Abstract
Chemerin is a recently discovered adipokine shown to be involved in both inflammatory and metabolic processes. Here, we demonstrate that chemerin serum levels are elevated in patients with multiple myeloma and that it increases with disease progression. We found that chemerin is expressed by stromal cells and preadipocytes, whereas its receptor CCRL2 is expressed by primary myeloma cells, suggesting a paracrine signaling loop between bone marrow stromal cells/adipocytes and myeloma cells. This is the first study exploring chemerin and its receptors in multiple myeloma.
Collapse
Affiliation(s)
- Marita Westhrin
- 1Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,2Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Siv Helen Moen
- 1Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,2Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Glenn Buene
- 1Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,2Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Kærsgaard Mylin
- 4Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ingemar Turesson
- 5Department of Hematology, Skane University Hospital, Malmo, Sweden
| | - Niels Abildgaard
- 3Department of Hematology, Odense University Hospital, Odense, Denmark
| | - Anders Waage
- 1Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,6Department of Hematology, St. Olav's University Hospital, Trondheim, Norway
| | - Therese Standal
- 1Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,2Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway.,6Department of Hematology, St. Olav's University Hospital, Trondheim, Norway
| |
Collapse
|
31
|
Engelhardt M, Herget GW, Graziani G, Ihorst G, Reinhardt H, Ajayi S, Knop S, Wasch R. Osteoprotective medication in the era of novel agents: a European perspective on values, risks and future solutions. Haematologica 2018; 103:755-758. [PMID: 29712821 PMCID: PMC5927973 DOI: 10.3324/haematol.2018.188516] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Monika Engelhardt
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center, University of Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, University of Freiburg, Germany
| | - Georg W Herget
- Department of Orthopedics and Trauma Surgery, Medical Center, University of Freiburg, Germany
| | - Giulia Graziani
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center, University of Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, University of Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Medical Center, University of Freiburg, Germany
| | - Heike Reinhardt
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center, University of Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, University of Freiburg, Germany
| | - Stefanie Ajayi
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center, University of Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, University of Freiburg, Germany
| | - Stefan Knop
- Hematology, Oncology, Gastroenterology, University of Würzburg, Germany
| | - Ralph Wasch
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center, University of Freiburg, Germany
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, University of Freiburg, Germany
| |
Collapse
|
32
|
Lee OL, Horvath N, Lee C, Joshua D, Ho J, Szer J, Quach H, Spencer A, Harrison S, Mollee P, Roberts AW, Talaulikar D, Brown R, Augustson B, Ling S, Jaksic W, Gibson J, Kalff A, Johnston A, Kalro A, Ward C, Prince HM, Zannettino A. Bisphosphonate guidelines for treatment and prevention of myeloma bone disease. Intern Med J 2018; 47:938-951. [PMID: 28782211 DOI: 10.1111/imj.13502] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/26/2017] [Accepted: 05/15/2017] [Indexed: 01/10/2023]
Abstract
Multiple myeloma (MM) is a haematological malignancy characterised by the clonal proliferation of plasma cells in the bone marrow. More than 80% of patients with MM display evidence of myeloma bone disease (MBD), characterised by the formation of osteolytic lesions throughout the axial and appendicular skeleton. MBD significantly increases the risk of skeletal-related events such as pathologic fracture, spinal cord compression and hypercalcaemia. MBD is the result of MM plasma cells-mediated activation of osteoclast activity and suppression of osteoblast activity. Bisphosphonates (BP), pyrophosphate analogues with high bone affinity, are the only pharmacological agents currently recommended for the treatment and prevention of MBD and remain the standard of care. Pamidronate and zoledronic acid are the most commonly used BP to treat MBD. Although generally safe, frequent high doses of BP are associated with adverse events such as renal toxicity and osteonecrosis of the jaw. As such, optimal duration and dosing of BP therapy is required in order to minimise BP-associated adverse events. The following guidelines provide currently available evidence for the adoption of a tailored approach when using BP for the management of MBD.
Collapse
Affiliation(s)
- Oi Lin Lee
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Noemi Horvath
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia
| | - Cindy Lee
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Doug Joshua
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Joy Ho
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Jeff Szer
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Clinical Haematology and BMT, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Hang Quach
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Andrew Spencer
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Simon Harrison
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Peter Mollee
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Andrew W Roberts
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Clinical Haematology and BMT, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Dipti Talaulikar
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Canberra Hospital, Canberra, Australian Capital Territory, Australia.,College of Medicine, Biology and Environment, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Ross Brown
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Bradley Augustson
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Silvia Ling
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Wilfrid Jaksic
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - John Gibson
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Anna Kalff
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Anna Johnston
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Akash Kalro
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Haematology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Chris Ward
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Department of Cancer and Haematology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - H Miles Prince
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew Zannettino
- Medical and Scientific Advisory Group, Myeloma Australia, Melbourne, Victoria, Australia.,Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| |
Collapse
|
33
|
Anderson K, Ismaila N, Flynn PJ, Halabi S, Jagannath S, Ogaily MS, Omel J, Raje N, Roodman GD, Yee GC, Kyle RA. Role of Bone-Modifying Agents in Multiple Myeloma: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2018; 36:812-818. [PMID: 29341831 DOI: 10.1200/jco.2017.76.6402] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Purpose To update guideline recommendations on the role of bone-modifying agents in multiple myeloma. Methods An update panel conducted a targeted systematic literature review by searching PubMed and the Cochrane Library for randomized controlled trials, systematic reviews, meta-analyses, clinical practice guidelines, and observational studies. Results Thirty-five relevant studies were identified, and updated evidence supports the current recommendations. Recommendations For patients with active symptomatic multiple myeloma that requires systemic therapy with or without evidence of lytic destruction of bone or compression fracture of the spine from osteopenia on plain radiograph(s) or other imaging studies, intravenous administration of pamidronate 90 mg over at least 2 hours or zoledronic acid 4 mg over at least 15 minutes every 3 to 4 weeks is recommended. Denosumab has shown to be noninferior to zoledronic acid for the prevention of skeletal-related events and provides an alternative. Fewer adverse events related to renal toxicity have been noted with denosumab compared with zoledronic acid and may be preferred in this setting. The update panel recommends that clinicians consider reducing the initial pamidronate dose in patients with preexisting renal impairment. Zoledronic acid has not been studied in patients with severe renal impairment and is not recommended in this setting. The update panel suggests that bone-modifying treatment continue for up to 2 years. Less frequent dosing has been evaluated and should be considered in patients with responsive or stable disease. Continuous use is at the discretion of the treating physician and the risk of ongoing skeletal morbidity. Retreatment should be initiated at the time of disease relapse. The update panel discusses measures regarding osteonecrosis of the jaw. Additional information is available at www.asco.org/hematologic-malignancies-guidelines and www.asco.org/guidelineswiki .
Collapse
Affiliation(s)
- Kenneth Anderson
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| | - Nofisat Ismaila
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| | - Patrick J Flynn
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| | - Susan Halabi
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| | - Sundar Jagannath
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| | - Mohammed S Ogaily
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| | - Jim Omel
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| | - Noopur Raje
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| | - G David Roodman
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| | - Gary C Yee
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| | - Robert A Kyle
- Kenneth Anderson, Dana-Farber Cancer Institute; Noopur Raje, Massachusetts General Hospital, Boston, MA; Nofisat Ismaila, American Society of Clinical Oncology, Alexandria, VA; Patrick J. Flynn, Minnesota Oncology, Woodbury; Robert A. Kyle, Mayo Clinic, Rochester, MN; Susan Halabi, Duke University Medical Center, Durham, NC; Sundar Jagannath, Mount Sinai Medical Center, New York, NY; Mohammed S. Ogaily, Beuamont Center for Hematology and Oncology-Downriver, Brownstown, MI; Jim Omel, Education and Advocacy, Grand Island; Gary C. Yee, University of Nebraska Medical Center, Omaha, NE; and G. David Roodman, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
34
|
Terpos E, Christoulas D, Gavriatopoulou M. Biology and treatment of myeloma related bone disease. Metabolism 2018; 80:80-90. [PMID: 29175022 DOI: 10.1016/j.metabol.2017.11.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/16/2017] [Accepted: 11/18/2017] [Indexed: 02/08/2023]
Abstract
Myeloma bone disease (MBD) is the most common complication of multiple myeloma (MM), resulting in skeleton-related events (SREs) such as severe bone pain, pathologic fractures, vertebral collapse, hypercalcemia, and spinal cord compression that cause significant morbidity and mortality. It is due to an increased activity of osteoclasts coupled to the suppressed bone formation by osteoblasts. Novel molecules and pathways that are implicated in osteoclast activation and osteoblast inhibition have recently been described, including the receptor activator of nuclear factor-kB ligand/osteoprotegerin pathway, activin-A and the wingless-type signaling inhibitors, dickkopf-1 (DKK-1) and sclerostin. These molecules interfere with tumor growth and survival, providing possible targets for the development of novel drugs for the management of lytic disease in myeloma but also for the treatment of MM itself. Currently, bisphosphonates are the mainstay of the treatment of myeloma bone disease although several novel agents such as denosumab and sotatercept appear promising. This review focuses on recent advances in MBD pathophysiology and treatment, in addition to the established therapeutic guidelines.
Collapse
Affiliation(s)
- Evangelos Terpos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece.
| | - Dimitrios Christoulas
- Department of Clinical Therapeutics, University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, University of Athens School of Medicine, Alexandra General Hospital, Athens, Greece
| |
Collapse
|
35
|
Mhaskar R, Kumar A, Miladinovic B, Djulbegovic B. Bisphosphonates in multiple myeloma: an updated network meta-analysis. Cochrane Database Syst Rev 2017; 12:CD003188. [PMID: 29253322 PMCID: PMC6486151 DOI: 10.1002/14651858.cd003188.pub4] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Bisphosphonates are specific inhibitors of osteoclastic activity and are used in the treatment of patients with multiple myeloma (MM). While bisphosphonates are shown to be effective in reducing vertebral fractures and pain, their role in improving overall survival (OS) remains unclear. This is an update of a Cochrane review first published in 2002 and previously updated in 2010 and 2012. OBJECTIVES To assess the evidence related to benefits and harms associated with use of various types of bisphosphonates (aminobisphosphonates versus non-aminobisphosphonates) in the management of patients with MM. Our primary objective was to determine whether adding bisphosphonates to standard therapy in MM improves OS and progression-free survival (PFS), and decreases skeletal-related morbidity. Our secondary objectives were to determine the effects of bisphosphonates on pain, quality of life, incidence of hypercalcemia, incidence of bisphosphonate-related gastrointestinal toxicities, osteonecrosis of jaw (ONJ) and hypocalcemia. SEARCH METHODS We searched MEDLINE, Embase (September 2011 to July 2017) and the CENTRAL (2017, Issue 7) to identify all randomized controlled trial (RCT) in MM up to July 2017 using a combination of text and MeSH terms. SELECTION CRITERIA Any randomized controlled trial (RCT) comparing bisphosphonates versus placebo/no treatment/bisphosphonates and observational studies or case reports examining bisphosphonate-related ONJ in patients with MM were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors extracted the data. Data were pooled and reported as hazard ratio (HR) or risk ratio (RR) using a random-effects model. We used meta-regression to explore statistical heterogeneity. Network meta-analysis using Bayesian approach was conducted. MAIN RESULTS In this update, we included four new studies (601 participants), resulting in a total of 24 included studies.Twenty RCTs compared bisphosphonates with either placebo or no treatment and four RCTs involved another bisphosphonate as a comparator. The 24 included RCTs enrolled 7293 participants. Pooled results showed that there was moderate-quality evidence of a reduction in mortality with on OS from 41% to 31%, but the confidence interval is consistent with a larger reduction and small increase in mortality compared with placebo or no treatment (HR 0.90, 95% CI 0.76 to 1.07; 14 studies; 2706 participants). There was substantial heterogeneity among the included RCTs (I2 = 65%) for OS. To explain this heterogeneity we performed a meta-regression assessing the relationship between bisphosphonate potency and improvement in OS, which found an OS benefit with zoledronate but limited evidence of an effect on PFS. This provided a further rationale for performing a network meta-analyses of the various types of bisphosphonates that were not compared head-to-head in RCTs. Results from network meta-analyses showed evidence of a benefit for OS with zoledronate compared with etidronate (HR 0.56, 95% CI 0.29 to 0.87) and placebo (HR 0.67, 95% CI 0.46 to 0.91). However, there was no evidence for a difference between zoledronate and other bisphosphonates.The effect of bisphosphonates on disease progression (PFS) is uncertain. Based on the HR of 0.75 (95% CI 0.57 to 1.00; seven studies; 908 participants), 47% participants would experience disease progression without treatment compared with between 30% and 47% with bisphosphonates (low-quality evidence). There is probably a similar risk of non-vertebral fractures between treatment groups (RR 1.03, 95% CI 0.68 to 1.56; six studies; 1389 participants; moderate-quality evidence). Pooled analysis demonstrated evidence for a difference favoring bisphosphonates compared with placebo or no treatment on prevention of pathological vertebral fractures (RR 0.74, 95% CI 0.62 to 0.89; seven studies; 1116 participants; moderate-quality evidence) and skeletal-related events (SREs) (RR 0.74, 95% CI 0.63 to 0.88; 10 studies; 2141 participants; moderate-quality evidence). The evidence for less pain with bisphosphonates was of very low quality (RR 0.75, 95% CI 0.60 to 0.95; eight studies; 1281 participants).Bisphosphonates may increase ONJ compared with placebo but the confidence interval is very wide (RR 4.61, 95% CI 0.99 to 21.35; P = 0.05; six studies; 1284 participants; low-quality evidence). The results from the network meta-analysis did not show any evidence for a difference in the incidence of ONJ (eight RCTs, 3746 participants) between bisphosphonates. Data from nine observational studies (1400 participants) reported an incidence of 5% to 51% with combination of pamidronate and zoledronate, 3% to 11% with zoledronate alone, and 0% to 18% with pamidronate alone.The pooled results showed no evidence for a difference in increase in frequency of gastrointestinal symptoms with the use of bisphosphonates compared with placebo or no treatment (RR 1.23, 95% CI 0.95 to 1.59; seven studies; 1829 participants; low-quality evidence).The pooled results showed no evidence for a difference in increase in frequency of hypocalcemia with the use of bisphosphonates compared with placebo or no treatment (RR 2.19, 95% CI 0.49 to 9.74; three studies; 1090 participants; low-quality evidence). The results from network meta-analysis did not show any evidence for differences in the incidence of hypocalcemia, renal dysfunction and gastrointestinal toxicity between the bisphosphonates used. AUTHORS' CONCLUSIONS Use of bisphosphonates in participants with MM reduces pathological vertebral fractures, SREs and pain. Bisphosphonates were associated with an increased risk of developing ONJ. For every 1000 participants treated with bisphosphonates, about one patient will suffer from the ONJ. We found no evidence of superiority of any specific aminobisphosphonate (zoledronate, pamidronate or ibandronate) or non-aminobisphosphonate (etidronate or clodronate) for any outcome. However, zoledronate was found to be better than placebo and first-generation bisposphonate (etidronate) in pooled direct and indirect analyses for improving OS and other outcomes such as vertebral fractures. Direct head-to-head trials of the second-generation bisphosphonates are needed to settle the issue if zoledronate is truly the most efficacious bisphosphonate currently used in practice.
Collapse
Affiliation(s)
- Rahul Mhaskar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Ambuj Kumar
- University of South FloridaCenter for Evidence Based Medicine and Health Outcomes ResearchTampaFloridaUSA
| | - Branko Miladinovic
- University of South FloridaCenter for Evidence‐based MedicineTampaFloridaUSA
| | - Benjamin Djulbegovic
- University of South Florida & Mofftt Cancer CenterUSF Program for Comparative Effectiveness Research & Dpt of Hematology, Moffitt Cancer CtrTampaFloridaUSA
| | | |
Collapse
|
36
|
Abstract
PURPOSE OF REVIEW Bone disease is a defining characteristic of multiple myeloma (MM) and the major cause of morbidity. It manifests as lytic lesions or osteopenia and is often associated with severe pain, pathological fracture, spinal cord compression, vertebral collapse, and hypercalcemia. Here, we have reviewed recent data on understanding its biology and treatment. RECENT FINDINGS The imbalance between bone regeneration and bone resorption underlies the pathogenesis of osteolytic bone disease. Increased osteoclast proliferation and activity accompanied by inhibition of bone-forming osteoblasts leads to progressive bone loss and lytic lesions. Although tremendous progress has been made, MM remains an incurable disease. Novel agents targeting bone disease are under investigation with the goal of not only preventing bone loss and improving bone quality but also harnessing MM tumor growth. Current data illustrate that the interactions between MM cells and the tumor-bone microenvironment contribute to the bone disease and continued MM progression. A better understanding of this microenvironment is critical for novel therapeutic treatments of both MM and associated bone disease.
Collapse
Affiliation(s)
- Cristina Panaroni
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Professional Office Building 216, 55 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Andrew J Yee
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Professional Office Building 216, 55 Fruit Street, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Noopur S Raje
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Professional Office Building 216, 55 Fruit Street, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, 02115, USA.
| |
Collapse
|
37
|
Nielsen LK, Jarden M, Andersen CL, Frederiksen H, Abildgaard N. A systematic review of health-related quality of life in longitudinal studies of myeloma patients. Eur J Haematol 2017; 99:3-17. [PMID: 28322018 DOI: 10.1111/ejh.12882] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Multiple myeloma (MM) patients report high symptom burden and reduced health-related quality of life (HRQoL) compared to patients with other haematological malignancies. The aim of this review was to analyse published longitudinal studies including MM patients according to a change in HRQoL scores, which is perceived as beneficial to the patient according to two published guidelines. METHODS A literature search was performed May 2016. Publications with longitudinal follow-up using the EORTC QLQ-C30 instrument for HRQoL measurement of physical functioning, global quality of life, fatigue and/or pain were included. An analysis of mean change from baseline was carried out according to minimal important difference (MID). RESULTS Large and medium HRQoL improvements were reported during first-line treatments. No clinically beneficial change or deteriorations in scores of global QoL or fatigue were reported during relapse treatment. HRQoL data during maintenance therapy are sparse and inconclusive. CONCLUSIONS Guidelines for interpreting changes in HRQoL including definitions of MID have been developed; however, consensus is missing. Improvements in HRQoL are far more likely to occur during first-line compared to relapsed treatment regimens. The background of these findings should be in focus in future studies, and HRQoL measurements should be integrated in maintenance studies.
Collapse
Affiliation(s)
- Lene Kongsgaard Nielsen
- Quality of Life Research Centre, Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
| | - Mary Jarden
- University Hospitals Centre for Health Research, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Henrik Frederiksen
- Quality of Life Research Centre, Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
| | - Niels Abildgaard
- Quality of Life Research Centre, Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
| |
Collapse
|
38
|
Osteonecrosis of the Jaws (ONJ) after Bisphosphonate Treatment in Patients with Multiple Myeloma: Decreasing ONJ Incidence after Adoption of Preventive Measures. Dent J (Basel) 2016; 4:dj4040045. [PMID: 29563487 PMCID: PMC5806954 DOI: 10.3390/dj4040045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/06/2016] [Accepted: 11/14/2016] [Indexed: 01/15/2023] Open
Abstract
Bisphosphonates (BPs) are administered to Multiple Myeloma (MM) patients with bone lytic lesion. Osteonecrosis of the Jaw (ONJ) is a complication reported since 2003 in patients treated with intravenous (IV) BPs such as zoledronic acid and pamidronate, with 6%–26.3% frequency in early literature series, before some preventive measures were recommended. We evaluated the occurrence of ONJ with and without dental preventive measures in MM patients treated with BPs in our centre between 1996 and 2015. Since 2005, MM patients (already under treatment or before treatment) underwent a baseline mouth assessment (dental visit, Rx orthopantomography, and eventual tooth avulsion or dental care if necessary) and were followed by a multidisciplinary team. We reviewed the charts of 119 MM patients receiving IV BPs, classified into 3 groups: (a) “historic group” (21 patients who had started BP treatment in years before the awareness of ONJ); (b) “screening group” (20 patients starting BPs without baseline evaluation); and (c) “prevention group” (78 patients starting therapy only after baseline preventive assessment and eventual dental care measures). ONJ was observed in 3/21 patients (14.2%) from group a, in 2/20 patients (10%) from group b, and in no patients from group c (0%). Notably, the median number of IV BP administrations decreased after 2005. Our data confirmed a meaningful reduction of ONJ risk in MM patients treated with BPs if preventive measures are applied. Both implementation of prevention measures and reduction of cumulative doses of IV BPs could have contributed to a decreased incidence of ONJ.
Collapse
|
39
|
Rugani P, Walter C, Kirnbauer B, Acham S, Begus-Nahrman Y, Jakse N. Prevalence of Medication-Related Osteonecrosis of the Jaw in Patients with Breast Cancer, Prostate Cancer, and Multiple Myeloma. Dent J (Basel) 2016; 4:E32. [PMID: 29563474 PMCID: PMC5806952 DOI: 10.3390/dj4040032] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 08/27/2016] [Accepted: 09/19/2016] [Indexed: 12/03/2022] Open
Abstract
Medication-related osteonecrosis of the jaw is a known side-effect of antiresorptive therapy in patients with malignant diseases. Nevertheless, the exact pathogenesis is still unknown and published prevalences show a significant range. The aim of the presented paper was to assess the prevalence of osteonecrosis (ONJ) in breast cancer, prostate cancer, and multiple myeloma patients receiving parenteral antiresorptive therapy. For this reason a PubMed search was performed and 69 matching articles comprising 29,437 patients were included in the analysis. Nine-hundred fifty-one cases of jaw necrosis were described. The overall ONJ-prevalence was 2.09% in the breast cancer group, 3.8% in the prostate cancer group, and 5.16% for multiple myeloma patients.
Collapse
Affiliation(s)
- Petra Rugani
- Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria.
| | - Christian Walter
- Oral and Maxillofacial Surgery of the Mediplus Clinic, 55128 Mainz, Germany.
| | - Barbara Kirnbauer
- Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria.
| | - Stephan Acham
- Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria.
| | | | - Norbert Jakse
- Divison of Oral Surgery and Orthodontics, Medical University of Graz, 8010 Graz, Austria.
| |
Collapse
|
40
|
Faiman B, Valent J. Assessment and monitoring of patients receiving chemotherapy for multiple myeloma: strategies to improve outcomes. Blood Lymphat Cancer 2016; 6:21-35. [PMID: 31360078 PMCID: PMC6467334 DOI: 10.2147/blctt.s90764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Improved understanding as to the biology of multiple myeloma (MM) and the bone marrow microenvironment has led to the development of new drugs to treat MM. This explosion of new and highly effective drugs has led to dramatic advances in the management of MM and underscores the need for supportive care. Impressive and deep response rates to chemotherapy, monoclonal antibodies, and small molecule drugs provide hope of a cure or prolonged remission for the majority of individuals. For most patients, long-term, continuous therapy is often required to suppress the malignant plasma cell clone, thus requiring clinicians to become more astute in assessment, monitoring, and intervention of side effects as well as monitoring response to therapy. Appropriate diagnosis and monitoring strategies are essential to ensure that patients receive the appropriate chemotherapy and supportive therapy at relapse, and that side effects are appropriately managed to allow for continued therapy and adherence to the regimen. Multiple drugs with complex regimens are currently available with varying side effect profiles. Knowledge of the drugs used to treat MM and the common adverse events will allow for preventative strategies to mitigate adverse events and prompt intervention. The purpose of this paper is to review updates in the diagnosis and management of MM, and to provide strategies for assessment and monitoring of patients receiving chemotherapy for MM.
Collapse
Affiliation(s)
- Beth Faiman
- Department of Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA,
| | - Jason Valent
- Department of Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA,
| |
Collapse
|
41
|
Wildes TM, Campagnaro E. Management of multiple myeloma in older adults: Gaining ground with geriatric assessment. J Geriatr Oncol 2016; 8:1-7. [PMID: 27118356 DOI: 10.1016/j.jgo.2016.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/28/2015] [Accepted: 04/05/2016] [Indexed: 01/22/2023]
Abstract
Multiple myeloma increases in incidence with age. With the aging of the population, the number of cases of multiple myeloma diagnosed in older adults each year will nearly double in the next 20years. The novel therapeutic agents have significantly improved survival in older adults, but their outcomes remain poorer than in younger patients. Older adults may be more vulnerable to toxicity of therapy, resulting in decreased dose intensity and contributing to poorer outcomes. Data are beginning to emerge to aid in identifying which individuals are at greater risk for toxicity of therapy; comorbidities, functional limitations, and age over 80years are among the factors associated with greater risk. Geriatric assessment holds promise in the care of older adults with multiple myeloma, both to allow modification of treatment to prevent toxicity, and to identify vulnerabilities that may require intervention. Emerging treatments with low toxicity and attention to individualizing therapy based on geriatric assessment may aid in further improving outcomes in older adults with multiple myeloma.
Collapse
Affiliation(s)
- Tanya M Wildes
- Washington University School of Medicine, St. Louis, MO, USA.
| | | |
Collapse
|
42
|
Terpos E, Kleber M, Engelhardt M, Zweegman S, Gay F, Kastritis E, van de Donk NWCJ, Bruno B, Sezer O, Broijl A, Bringhen S, Beksac M, Larocca A, Hajek R, Musto P, Johnsen HE, Morabito F, Ludwig H, Cavo M, Einsele H, Sonneveld P, Dimopoulos MA, Palumbo A. European Myeloma Network guidelines for the management of multiple myeloma-related complications. Haematologica 2016; 100:1254-66. [PMID: 26432383 DOI: 10.3324/haematol.2014.117176] [Citation(s) in RCA: 224] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The European Myeloma Network provides recommendations for the management of the most common complications of multiple myeloma. Whole body low-dose computed tomography is more sensitive than conventional radiography in depicting osteolytic disease and thus we recommend it as the novel standard for the detection of lytic lesions in myeloma (grade 1A). Myeloma patients with adequate renal function and bone disease at diagnosis should be treated with zoledronic acid or pamidronate (grade 1A). Symptomatic patients without lytic lesions on conventional radiography can be treated with zoledronic acid (grade 1B), but its advantage is not clear for patients with no bone involvement on computed tomography or magnetic resonance imaging. In asymptomatic myeloma, bisphosphonates are not recommended (grade 1A). Zoledronic acid should be given continuously, but it is not clear if patients who achieve at least a very good partial response benefit from its continuous use (grade 1B). Treatment with erythropoietic-stimulating agents may be initiated in patients with persistent symptomatic anemia (hemoglobin <10g/dL) in whom other causes of anemia have been excluded (grade 1B). Erythropoietic agents should be stopped after 6-8 weeks if no adequate hemoglobin response is achieved. For renal impairment, bortezomib-based regimens are the current standard of care (grade 1A). For the management of treatment-induced peripheral neuropathy, drug modification is needed (grade 1C). Vaccination against influenza is recommended; vaccination against streptococcus pneumonia and hemophilus influenza is appropriate, but efficacy is not guaranteed due to suboptimal immune response (grade 1C). Prophylactic aciclovir (or valacyclovir) is recommended for patients receiving proteasome inhibitors, autologous or allogeneic transplantation (grade 1A).
Collapse
Affiliation(s)
- Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | - Martina Kleber
- Department of Hematology and Oncology, University of Freiburg Medical Center, Germany Clinic for Internal Medicine, University Hospital Basel, Switzerland
| | - Monika Engelhardt
- Department of Hematology and Oncology, University of Freiburg Medical Center, Germany
| | - Sonja Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, the Netherlands
| | - Francesca Gay
- Division of Hematology, S. Giovanni Battista Hospital, University of Turin, Italy
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | | | - Benedetto Bruno
- Division of Hematology, S. Giovanni Battista Hospital, University of Turin, Italy
| | - Orhan Sezer
- Department of Hematology, Memorial Sisli Hospital, Istanbul, Turkey
| | - Annemiek Broijl
- Department of Hematology, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Sara Bringhen
- Division of Hematology, S. Giovanni Battista Hospital, University of Turin, Italy
| | - Meral Beksac
- Department of Hematology, Ankara University, Turkey
| | - Alessandra Larocca
- Division of Hematology, S. Giovanni Battista Hospital, University of Turin, Italy
| | - Roman Hajek
- Department of Hemato-Oncology, University Hospital Ostrava and Faculty of Medicine OU, Ostrava, Czech Republic
| | - Pellegrino Musto
- Centro di Riferimento Oncologico della Basilicata, Istituto di Ricovero e Cura a Carattere Scientifico, Rionero in Vulture, Italy
| | | | - Fortunato Morabito
- Department of Hematology, Azienda Ospedaliera dell'Annunziata, Cosenza, Italy
| | - Heinz Ludwig
- Department of Medicine I, Center of Oncology, Hematology and Palliative Care, Wilhelminenspital, Vienna, Austria
| | - Michele Cavo
- "Seràgnoli" Institute of Hematology and Medical Oncology, University of Bologna, Italy
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würburg, Würzburg, Germany
| | - Pieter Sonneveld
- Department of Hematology, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | - Antonio Palumbo
- Division of Hematology, S. Giovanni Battista Hospital, University of Turin, Italy
| | | |
Collapse
|
43
|
Kvam AK, Waage A. Health-related quality of life in patients with multiple myeloma--does it matter? Haematologica 2016; 100:704-5. [PMID: 26034111 DOI: 10.3324/haematol.2015.127860] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Ann Kristin Kvam
- Department of Hematology, Akershus University Hospital, Lørenskog, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anders Waage
- Department of Hematology, Department of Medicine, St Olavs University Hopsital, and Jebsen Center for Myeloma Research, Institute of Cancer Research and Moleclar Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| |
Collapse
|
44
|
Nash Smyth E, Conti I, Wooldridge JE, Bowman L, Li L, Nelson DR, Ball DE. Frequency of skeletal-related events and associated healthcare resource use and costs in US patients with multiple myeloma. J Med Econ 2016; 19:477-86. [PMID: 26671598 DOI: 10.3111/13696998.2015.1132225] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE A potential complication for all new multiple myeloma (MM) patients is the clinical presentation of osteolytic lesions which increase the risk for skeletal-related events (SREs). However, the contribution of SREs to the overall economic impact of MM is unclear. The impact of SREs on healthcare resource utilization (HCRU) and costs for US patients with MM was analyzed in Truven Health Marketscan Commercial Claims and Medicare Supplemental Databases. METHODS Adults diagnosed with MM between January 1, 2005 and December 31, 2010 with ≥2 claims ≥30 days apart (first claim = index date) were included. SREs included: hypercalcemia, pathologic fracture, surgery for the prevention and treatment of pathologic fractures or spinal cord compression, and radiation for bone pain. Rates of HCRU (outpatient [OP], inpatient [IP], emergency room [ER], orthopedic consultation [OC], and ancillary) and healthcare costs were compared between MM patients with and without SREs. Inverse propensity weighting was applied to adjust for potential bias. RESULTS Of 1028 MM patients (mean age = 67, standard deviation = 13.2), 596 patients with ≥1 SRE and 432 without SREs were assessed. HCRU rates in IP, ER, and ancillary (p < 0.01) and mean total costs of OP, IP, and ER were significantly higher (p < 0.05) for patients with vs without SREs during follow-up. HCRU rates also increased with SRE frequency (p < 0.05 in OP, IP, ER, OC, and ancillary), as did mean total healthcare costs, except for OC (p < 0.001). LIMITATIONS A broad assessment of pharmacotherapy for the treatment of MM was not an objective of the current study. Bisphosphonate use was evaluated; however, results were descriptively focused on frequency of utilization only and were not included in the broader cost and HCRU analysis. CONCLUSIONS Among US patients with MM, higher SRE frequency was associated with a significant trend of higher HCRU and total healthcare costs in several settings.
Collapse
Affiliation(s)
| | - Ilaria Conti
- a Eli Lilly and Company , Indianapolis , IN , USA
| | | | - Lee Bowman
- a Eli Lilly and Company , Indianapolis , IN , USA
| | - Li Li
- a Eli Lilly and Company , Indianapolis , IN , USA
| | | | | |
Collapse
|
45
|
Van Acker HH, Anguille S, Willemen Y, Smits EL, Van Tendeloo VF. Bisphosphonates for cancer treatment: Mechanisms of action and lessons from clinical trials. Pharmacol Ther 2015; 158:24-40. [PMID: 26617219 DOI: 10.1016/j.pharmthera.2015.11.008] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A growing body of evidence points toward an important anti-cancer effect of bisphosphonates, a group of inexpensive, safe, potent, and long-term stable pharmacologicals that are widely used as osteoporosis drugs. To date, they are already used in the prevention of complications of bone metastases. Because the bisphosphonates can also reduce mortality in among other multiple myeloma, breast, and prostate cancer patients, they are now thoroughly studied in oncology. In particular, the more potent nitrogen-containing bisphosphonates have the potential to improve prognosis. The first part of this review will elaborate on the direct and indirect anti-tumoral effects of bisphosphonates, including induction of tumor cell apoptosis, inhibition of tumor cell adhesion and invasion, anti-angiogenesis, synergism with anti-neoplastic drugs, and enhancement of immune surveillance (e.g., through activation of γδ T cells and targeting macrophages). In the second part, we shed light on the current clinical position of bisphosphonates in the treatment of hematological and solid malignancies, as well as on ongoing and completed clinical trials investigating the therapeutic effect of bisphosphonates in cancer. Based on these recent data, the role of bisphosphonates is expected to further expand in the near future outside the field of osteoporosis and to open up new avenues in the treatment of malignancies.
Collapse
Affiliation(s)
- Heleen H Van Acker
- Laboratory of Experimental Hematology, Tumor Immunology Group (TIGR), Faculty of Medicine and Health Sciences, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.
| | - Sébastien Anguille
- Laboratory of Experimental Hematology, Tumor Immunology Group (TIGR), Faculty of Medicine and Health Sciences, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium; Center for Cell Therapy and Regenerative Medicine, Antwerp University Hospital, Edegem, Belgium
| | - Yannick Willemen
- Laboratory of Experimental Hematology, Tumor Immunology Group (TIGR), Faculty of Medicine and Health Sciences, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Evelien L Smits
- Laboratory of Experimental Hematology, Tumor Immunology Group (TIGR), Faculty of Medicine and Health Sciences, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium; Center for Cell Therapy and Regenerative Medicine, Antwerp University Hospital, Edegem, Belgium; Center for Oncological Research (CORE), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Viggo F Van Tendeloo
- Laboratory of Experimental Hematology, Tumor Immunology Group (TIGR), Faculty of Medicine and Health Sciences, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| |
Collapse
|
46
|
Prognostic value of self-reported fatigue on overall survival in patients with myelodysplastic syndromes: a multicentre, prospective, observational, cohort study. Lancet Oncol 2015; 16:1506-1514. [PMID: 26404501 DOI: 10.1016/s1470-2045(15)00206-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical presentation of myelodysplastic syndromes is highly variable and so accurate prediction of outcomes in these patients is crucial. We aimed to assess whether self-reported fatigue severity predicts overall survival beyond gold-standard prognostic indices in patients with higher-risk myelodysplastic syndromes. METHODS We did a multicentre, prospective, observational, cohort study of patients from 37 centres in Europe, USA, and east Asia. Adults (≥18 years) with myelodysplastic syndromes were consecutively enrolled within 6 months of diagnosis with an intermediate-2-risk or high-risk score according to the International Prognostic Scoring System (IPSS). Patients were enrolled irrespective of older age, comorbidities, performance status, and progression from a lower IPSS risk score category. All patients had to complete a quality of life assessment at baseline. With use of univariate and then multivariate Cox proportional hazards regression analysis, we constructed a multivariate model of how prognostic variables, including IPSS and fatigue score from the European Organisation for Research and Treatment of Cancer quality-of-life questionnaire-core 30, predicted overall survival. The primary endpoint was overall survival by baseline self-reported fatigue scale ratings. This study was registered with ClinicalTrials.gov, number NCT00809575. FINDINGS Between Nov 10, 2008, and Aug 13, 2012, we enrolled 280 patients with a median age of 71 years (IQR 64-77). The median follow-up was 15 months (IQR 8-27), and the last patient was assessed Feb 16, 2015. The median overall survival from diagnosis was 17 months (95% CI 15-19). In univariate analysis, the baseline factors that were significantly associated with reduced overall survival were increasing age, transfusion dependency (defined as having received at least one red blood cell transfusion every 8 weeks over a period of 4 months), Eastern Cooperative Oncology Group (ECOG) performance status of two or more, increased white blood cell count, high-risk IPSS score, and higher self-reported fatigue severity. In multivariate analysis, baseline factors independently associated with reduced overall survival were high-risk IPSS score (hazard ratio [HR] 2·525, 95% CI 1·357-4·697; p=0·0035) and a higher score for fatigue (1·110, 1·040-1·170, for every ten points of fatigue deterioration; p=0·0007). In further multivariate models for survival, including either the WHO-based prognostic scoring system or the revised version of the IPSS classification, fatigue remained a statistically significant independent prognostic factor with a HR of 1·120 (1·050-1·180, p=0.0003) and a HR of 1·130 (1·060-1·190, p=0·0002), respectively. INTERPRETATION In patients with newly diagnosed higher-risk myelodysplastic syndromes, self-reported fatigue severity provides prognostic information for survival independent from gold-standard risk classifications. Our findings suggest that fatigue assessment should be included in routine diagnostic investigation for these patients and considered as a standard baseline stratification factor in future randomised controlled trials. FUNDING Associazione Italiana contro le Leucemie, Linfomi e Mieloma (AIL).
Collapse
|
47
|
Westhrin M, Moen SH, Holien T, Mylin AK, Heickendorff L, Olsen OE, Sundan A, Turesson I, Gimsing P, Waage A, Standal T. Growth differentiation factor 15 (GDF15) promotes osteoclast differentiation and inhibits osteoblast differentiation and high serum GDF15 levels are associated with multiple myeloma bone disease. Haematologica 2015; 100:e511-4. [PMID: 26294726 DOI: 10.3324/haematol.2015.124511] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Marita Westhrin
- K.G. Jebsen Center for Myeloma Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Siv Helen Moen
- K.G. Jebsen Center for Myeloma Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Toril Holien
- K.G. Jebsen Center for Myeloma Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Lene Heickendorff
- Department of Clinical Biochemistry, Aarhus University Hospital, Denmark
| | - Oddrun Elise Olsen
- K.G. Jebsen Center for Myeloma Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anders Sundan
- K.G. Jebsen Center for Myeloma Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ingemar Turesson
- Department of Hematology, Skane University Hospital, Malmo, Sweden
| | - Peter Gimsing
- Department of Haematology, Rigshospitalet, University of Copenhagen, Denmark
| | - Anders Waage
- K.G. Jebsen Center for Myeloma Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Therese Standal
- K.G. Jebsen Center for Myeloma Research, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| |
Collapse
|
48
|
Mylin AK, Goetze JP, Heickendorff L, Ahlberg L, Dahl IM, Abildgaard N, Gimsing P. N-terminal pro-C-type natriuretic peptide in serum associated with bone destruction in patients with multiple myeloma. Biomark Med 2015; 9:679-89. [DOI: 10.2217/bmm.15.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Aim: To examine whether N-terminal proCNP concentrations in serum is associated with bone destruction in patients with multiple myeloma. Materials & methods: N-terminal proCNP and biochemical bone markers were measured in 153 patients. Radiographic bone disease and skeletal-related events were evaluated at specific time-points. Results: N-terminal proCNP concentrations increased with age. High N-terminal proCNP concentrations were associated with high-risk disease and renal impairment. Renal function explained 22% of the variation. N-terminal proCNP concentrations correlated with serum bone ALP and serum PINP, but lacked association with bone resorption markers, radiographic bone disease and skeletal-related events. Conclusion: Serum N-terminal proCNP are associated with bone formation activity in patients with multiple myeloma, but should be interpreted with caution in patients with renal impairment.
Collapse
Affiliation(s)
- Anne K Mylin
- Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lene Heickendorff
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Lucia Ahlberg
- Division of Hematology, Linköping University Hospital, Linköping, Sweden
| | - Inger Marie Dahl
- Section of Hematology, TromsøUniversity Hospital, Tromsø, Norway
| | - Niels Abildgaard
- Department of Hematology, Odense University Hospital, Odense, Denmark
| | - Peter Gimsing
- Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | |
Collapse
|
49
|
Kumar SK. Bisphosphonates in multiple myeloma: a fractured consensus. Leuk Lymphoma 2015; 56:553-4. [DOI: 10.3109/10428194.2014.964703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
50
|
Mylin AK, Abildgaard N, Johansen JS, Heickendorff L, Kreiner S, Waage A, Turesson I, Gimsing P. Serum YKL-40: a new independent prognostic marker for skeletal complications in patients with multiple myeloma. Leuk Lymphoma 2015; 56:2650-9. [PMID: 25573204 DOI: 10.3109/10428194.2015.1004168] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In a time of increasing treatment options for multiple myeloma bone disease, risk factors predicting progression need to be elucidated. This study investigated the value of serum YKL-40, previously shown to be associated with radiographic progression of bone destruction, as a predictor for time to clinical progression, i.e. skeletal-related events (SREs), in 230 newly diagnosed patients with multiple myeloma receiving intravenous bisphosphonates. Serum concentrations of YKL-40 and biochemical bone markers (CTX-MMP, CTX-I, PINP) were measured at diagnosis. Patients were evaluated every third month for SRE and at 9 and 24 months for radiographic progression. Elevated serum YKL-40 was seen in 47% of patients and associated with high-risk disease (International Staging System stage III; p < 0.001), increased bone resorption (serum CTX/MMP; p < 0.001) and early radiographic progression at 9 months (p = 0.01). Serum YKL-40 together with serum CTX-MMP/PINP ratio and World Health Organization status were independent predictors of time to first SRE.
Collapse
Affiliation(s)
- Anne K Mylin
- a Department of Hematology , Rigshospitalet, University of Copenhagen , Copenhagen , Denmark
| | - Niels Abildgaard
- b Department of Hematology , Odense University Hospital , Odense , Denmark
| | - Julia S Johansen
- c Departments of Medicine and Oncology , Herlev Hospital, University of Copenhagen , Herlev , Denmark
| | - Lene Heickendorff
- d Department of Clinical Biochemistry , Aarhus University Hospital , Aarhus , Denmark
| | - Svend Kreiner
- e Department of Biostatistics , University of Copenhagen , Copenhagen , Denmark
| | - Anders Waage
- f Department of Hematology , St Olav Hospital, Norwegian University of Science and Technology , Trondheim , Norway
| | - Ingemar Turesson
- g Department of Hematology , Skane University Hospital , Malmö , Sweden
| | - Peter Gimsing
- a Department of Hematology , Rigshospitalet, University of Copenhagen , Copenhagen , Denmark
| | | |
Collapse
|