151
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Cao Y, Zhao L, Zhang T, Cao W. Cost-Effectiveness Analysis of Adding Daratumumab to Bortezomib, Melphalan, and Prednisone for Untreated Multiple Myeloma. Front Pharmacol 2021; 12:608685. [PMID: 33732154 PMCID: PMC7957051 DOI: 10.3389/fphar.2021.608685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To evaluate the cost-effectiveness of adding daratumumab to bortezomib, melphalan, and prednisone for transplant-ineligible newly diagnosed multiple myeloma patients. Methods: A three-state Markov model was developed from the perspective of US payers to simulate the disease development of patient's life time for daratumumab plus bortezomib, melphalan, and prednisone (D-VMP) and bortezomib, melphalan, and prednisone (VMP) regimens. The primary outputs were total costs, expected life-years (LYs), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs). Results: The base case results showed that adding daratumumab to VMP provided an additional 3.00 Lys or 2.03 QALYs, at a cost of $262,526 per LY or $388,364 per QALY. Sensitivity analysis indicated that the results were most sensitive to utility of progression disease of D-VMP regimens, but no matter how these parameters changed, ICERs remained higher than $150,000 per QALY. Conclusion: In the case that the upper limit of willingness to pay threshold was $150,000 per QALY from the perspective of US payers, D-VMP was not a cost-effective regimen compared to VMP.
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Affiliation(s)
- Yaohua Cao
- Department of Pharmacy, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, Shenzhen, China
| | - Lina Zhao
- College of Pharmacy, Jinan University, Guangzhou, China
| | - Tiantian Zhang
- College of Pharmacy, Jinan University, Guangzhou, China.,Guangzhou Huabo Biopharmaceutical Research Institute, Guangzhou, China
| | - Weiling Cao
- Department of Pharmacy, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, Shenzhen, China
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152
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Bolaman AZ, Turgutkaya A, Sahip B, Selim C, Eroğlu Küçükerdiler H, Ertop Ş, Sargın G, Yavaşoğlu İ. Original Versus Generic Lenalidomide in Patients with Relapsed/Refractory Multiple Myeloma: Comparison of Efficacy and Adverse Events. Turk J Haematol 2021; 38:41-48. [PMID: 33342205 PMCID: PMC7927438 DOI: 10.4274/tjh.galenos.2020.2020.0169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective: Lenalidomide is an effective immunomodulatory derivative drug used in the treatment of multiple myeloma (MM). It is available in original and generic forms in Turkey, but there is no clinical study that has compared the effectiveness and adverse events (AEs) of the generic and original forms of lenalidomide. We compared the effectivity and AEs of generic and original lenalidomide in patients with relapsed/refractory MM (RRMM). Materials and Methods: Patients with RRMM using original or generic lenalidomide were evaluated retrospectively. Overall response (OR), complete response (CR), very good partial response (VGPR), partial response (PR), stable disease, and progressive disease rates and hematologic and nonhematologic AEs were evaluated in these RRMM patients. The results were described as numbers, frequencies, and percentages and were analyzed using PASW 19.0 for Windows with chi-square and Fisher exact tests. Results: The number of patients using original lenalidomide was 55 and the number of patients using generic lenalidomide was 43. The OR rate was 67.2% for patients using original lenalidomide and 60.4% for those on generic lenalidomide. CR and VGPR rates were 14.5% and 45.4% in the original group while the CR and VGPR rates were 20.9% and 18.6%, respectively, in patients using generic lenalidomide. Hematologic AEs were similar in the two groups while some nonhematologic AEs were less common in the original lenalidomide group than the generic group. Only pyrexia as a grade 3-4 AE was more common in the original lenalidomide than the generic lenalidomide group. Conclusion: This study showed that the generic form of lenalidomide has similar efficacy with the original form of lenalidomide in the treatment of RRMM. The AEs of original lenalidomide were generally fewer than those of generic lenalidomide. Further studies involving a larger number of patients with RRMM would be useful for comparing the efficacy and AEs of original and generic lenalidomide.
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Affiliation(s)
- Ali Zahit Bolaman
- Aydın Adnan Menderes University Faculty of Medicine, Department of Hematology, Aydın, Turkey
| | - Atakan Turgutkaya
- Aydın Adnan Menderes University Faculty of Medicine, Department of Hematology, Aydın, Turkey
| | - Birsen Sahip
- Zonguldak Bülent Ecevit University Faculty of Medicine, Division of Hematology, Zonguldak, Turkey
| | - Cem Selim
- Aydın Adnan Menderes University Faculty of Medicine, Department of Hematology, Aydın, Turkey
| | | | - Şehmus Ertop
- Zonguldak Bülent Ecevit University Faculty of Medicine, Division of Hematology, Zonguldak, Turkey
| | - Gökhan Sargın
- Aydın Adnan Menderes University Faculty of Medicine, Department of Immunology-Rheumatology, Aydın, Turkey
| | - İrfan Yavaşoğlu
- Aydın Adnan Menderes University Faculty of Medicine, Department of Hematology, Aydın, Turkey
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153
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Rosenberg AS, Facon T, Parikh K, Chung W, Srinivasan S, Kotey S, Tuscano J. Association of Morbid Progression With Overall Survival Among Patients With Multiple Myeloma: Validation of the Progression-free Survival Endpoint. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:345-354.e4. [PMID: 33563582 DOI: 10.1016/j.clml.2020.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Multiple myeloma (MM) is an incurable malignancy, marked by end-organ damage that is frequently irreversible. Progressive disease (PD) can be defined as morbid PD, associated with new-onset hypercalcemia, renal insufficiency, anemia, or lytic bone lesions (CRAB symptoms), or as asymptomatic biochemical progression. The frequency of morbid versus asymptomatic PD and its effect on survival is unknown. Our aim was to determine the incidence of morbid PD, and to evaluate if this influences survival. PATIENTS AND METHODS Data from 2 phase III trials of transplant-ineligible patients with newly diagnosed MM were included in a post hoc analysis. RESULTS Of 2082 patients enrolled, 1243 (59.7%) experienced PD. At first progression, 543 (43.7%) patients had morbid PD; 12 (2.2%) had hypercalcemia, 271 (49.9%) had renal insufficiency, 370 (68.1%) developed anemia, and 79 (14.5%) developed new or enlarged bone lesions. A total of 700 (56.3%) patients had asymptomatic PD. Patients with morbid PD had worse second progression-free survival (PFS) versus patients with asymptomatic biochemical PD (median second PFS, 11.5 months vs. 20.0 months; hazard ratio, 1.63; 95% confidence interval, 1.43-1.85; P < .0001) and worse overall survival (OS) (median OS, 23.2 months vs 39.3 months; hazard ratio, 1.51; 95% confidence interval, 1.30, 1.74; P < .0001). CONCLUSIONS Morbid PD occurs frequently and is associated with inferior second PFS and OS. As CRAB symptoms may not reverse with therapy, morbid PD is a meaningful event, and its association with a shortened PFS adds validity to PFS as a relevant endpoint in patients with MM.
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Affiliation(s)
- Aaron S Rosenberg
- Division of Hematology/Oncology, University of California Davis School of Medicine, UC Davis Comprehensive Cancer Center, Sacramento, CA.
| | - Thierry Facon
- Department of Haematology, Lille University Hospital, Lille, France
| | | | | | | | | | - Joseph Tuscano
- Division of Hematology/Oncology, University of California Davis School of Medicine, UC Davis Comprehensive Cancer Center, Sacramento, CA; Veterans Administration Northern California Health Care System, Sacramento, CA
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154
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Jimenez-Zepeda VH, Venner C, McCurdy A, Masih-Khan E, Atenafu EG, Sebag M, Stakiw J, Song K, LeBlanc R, Reiman T, Louzada M, Kotb R, Gul E, Reece D. Real-world outcomes with bortezomib-containing regimens and lenalidomide plus dexamethasone for the treatment of transplant-ineligible multiple myeloma: a multi-institutional report from the Canadian Myeloma Research Group database. Br J Haematol 2021; 193:532-541. [PMID: 33559897 DOI: 10.1111/bjh.17350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/04/2021] [Indexed: 11/26/2022]
Abstract
Bortezomib-containing regimens (BCRs) represented standard, first-line therapy for transplant-ineligible multiple myeloma (TIMM) in Canada until the introduction of lenalidomide and low-dose dexamethasone (Ld). However, little comparative data exist to inform the selection of regimens. We assessed the outcomes for TIMM patients treated with cyclophosphamide, bortezomib and dexamethasone or prednisone (CyBorD/P), bortezomib, melphalan and prednisone (VMP), bortezomib and dexamethasone or prednisone (VD/P) and lenalidomide and low-dose dexamethasone (Ld) using the Canadian Myeloma Research Group database. Of 1156 TIMM patients evaluated, 82% received bortezomib combinations while 18% received Ld. Median progression-free survival (PFS) was 21·0, 21·1, 13·2 and 28·5 months (P = 0·0002) and median overall survival (OS) was 52·0, 63·6, 30·8 and 65·7 months (P < 0·0001) in the CyBorD/P, VMP, VD/P and Ld groups respectively. There was no significant difference in PFS and OS between the two triplet bortezomib regimens (VMP and CyBorD/P). Ld was associated with a longer PFS but not a significantly superior OS to date. Outcomes with the bortezomib-steroid doublet were inferior (VD/P). However, multivariable analysis identified features related to disease biology as the most important prognostic factors for PFS and OS. Such factors, as well as those affecting the physician's choice of regimen, are likely to influence the results observed with different regimens. This study demonstrated real-world outcomes in TIMM similar to those reported in clinical trials.
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Affiliation(s)
| | - Christopher Venner
- Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Esther Masih-Khan
- Canadian Myeloma Research Group, Toronto, Ontario, Canada.,Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | | | - Michael Sebag
- Departments of Medicine and Oncology, Division of Hematology, McGill University, Montreal, QC, Canada
| | - Julie Stakiw
- Saskatoon Cancer Centre, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Kevin Song
- BC Cancer, Vancouver General Hospital, British Columbia, Canada
| | - Richard LeBlanc
- Maisonneuve-Rosemont Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada
| | - Tony Reiman
- Department of Oncology, Saint John Regional Hospital, Saint John, NB, Canada
| | | | - Rami Kotb
- Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Engin Gul
- Canadian Myeloma Research Group, Toronto, Ontario, Canada
| | - Donna Reece
- Canadian Myeloma Research Group, Toronto, Ontario, Canada.,Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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155
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Rampotas A, Djebbari F, Panitsas F, Lees C, Tsagkaraki I, Gomes AR, Prideaux S, Chen L, Prodger C, Khera A, Gray N, Ellis L, Sangha G, Lim WY, Eyre TA, Moore S, Ramasamy K, Kothari J. Efficacy and tolerability of VCD chemotherapy in a UK real-world dataset of elderly transplant-ineligible newly diagnosed myeloma patients. Eur J Haematol 2021; 106:563-573. [PMID: 33496996 DOI: 10.1111/ejh.13588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/19/2021] [Accepted: 01/21/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE There are limited data on the efficacy and tolerability of VCD chemotherapy in transplant-non-eligible (TNE) newly diagnosed myeloma (NDMM) patients. In this retrospective study, we set out to evaluate this triplet combination in this setting across Thames Valley Cancer Network (UK). METHODS The primary end point was overall response rate (ORR). Secondary outcomes included event-free survival (EFS), overall survival (OS) and adverse events (AEs). RESULTS In a total cohort of 158 patients, ORR for total cohort was 72.1%. Median EFS was 10.5 months, and for subgroups by age (<75:11.7 vs ≥75:10.3 months, P = .124), by Charlson Co-morbidity Index (CCI) (<5:11.1 vs ≥5:8.2 months, P = .345). The 4-month landmark analysis showed the following median EFS results: by cumulative bortezomib dose (≥26 mg/m2 : 9.0 months vs <26 mg/m2 : 6.4, P = .13), by cumulative cyclophosphamide dose (≥7000 mg: 9.2 vs <7000 mg: 7.0 months, P = .02) and by cumulative dexamethasone dose (>600 mg: 7.8 vs ≤600 mg: 8.3 months, P = .665). Median OS was 46.9 months. The incidence rate of AE was as follows: any grade (76.8%), ≥G3 (27.1%), ≥G3 haematological AEs (7.9%), any grade infections (31.1%) and ≥G3 infections (11.9%). CONCLUSION This study demonstrated a good ORR achieved from fixed duration VCD, which was reasonably well tolerated. This was followed by modest median EFS. We envisage that the latter may be improved in this patient group with the use of a higher cumulative bortezomib dose (≥26 mg/m2 ) which showed a trend for improved EFS although without statistical significance (P = .13), and with the use of a higher cumulative cyclophosphamide doses (≥7000 mg, P = .02), subject to tolerability and close monitoring.
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Affiliation(s)
- Alexandros Rampotas
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford University Clinical Academic Graduate School, Oxford, UK
| | - Faouzi Djebbari
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Fotios Panitsas
- Department of Haematology, Laiko General Hospital, Athens, Greece
| | | | | | - Ana Rita Gomes
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Steve Prideaux
- Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Lucia Chen
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Catherine Prodger
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Akhil Khera
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Lauren Ellis
- Frimley Health NHS Foundation Trust, Frimley, UK
| | - Gavinda Sangha
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Wen Yuen Lim
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Toby A Eyre
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sally Moore
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karthik Ramasamy
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jaimal Kothari
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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156
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Multiple Myeloma: EHA-ESMO Clinical Practice Guidelines for Diagnosis, Treatment and Follow-up. Hemasphere 2021; 5:e528. [PMID: 33554050 PMCID: PMC7861652 DOI: 10.1097/hs9.0000000000000528] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 12/24/2022] Open
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157
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Sugi T, Nishigami Y, Saigo H, Hanai H, Takabatake K, Mita M, Ohara S, Ide S, Uchida T, Inoue M, Hagihara M. Analysis of risk factors for lenalidomide-associated skin rash in patients with multiple myeloma. Leuk Lymphoma 2021; 62:1405-1410. [DOI: 10.1080/10428194.2021.1876867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tomiyuki Sugi
- Department of Pharmacy, Eiju General Hospital, Tokyo, Japan
- Department of Cardiovascular Pharmacology, Education and Research Unit for Comprehensive Clinical Pharmacy, Meiji Pharmaceutical University, Kiyose, Japan
| | | | - Hirohisa Saigo
- Department of Pharmacy, Eiju General Hospital, Tokyo, Japan
| | - Homare Hanai
- Department of Pharmacy, Eiju General Hospital, Tokyo, Japan
| | | | - Mitsuo Mita
- Department of Cardiovascular Pharmacology, Education and Research Unit for Comprehensive Clinical Pharmacy, Meiji Pharmaceutical University, Kiyose, Japan
| | - Shin Ohara
- Department of Hematology, Eiju General Hospital, Tokyo, Japan
| | - Shiro Ide
- Department of Hematology, Eiju General Hospital, Tokyo, Japan
| | - Tomoyuki Uchida
- Department of Hematology, Eiju General Hospital, Tokyo, Japan
| | - Morihiro Inoue
- Department of Hematology, Eiju General Hospital, Tokyo, Japan
| | - Masao Hagihara
- Department of Hematology, Eiju General Hospital, Tokyo, Japan
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158
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Yamamoto L, Amodio N, Gulla A, Anderson KC. Harnessing the Immune System Against Multiple Myeloma: Challenges and Opportunities. Front Oncol 2021; 10:606368. [PMID: 33585226 PMCID: PMC7873734 DOI: 10.3389/fonc.2020.606368] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/07/2020] [Indexed: 12/29/2022] Open
Abstract
Multiple myeloma (MM) is an incurable malignancy of plasma cells that grow within a permissive bone marrow microenvironment (BMM). The bone marrow milieu supports the malignant transformation both by promoting uncontrolled proliferation and resistance to cell death in MM cells, and by hampering the immune response against the tumor clone. Hence, it is expected that restoring host anti-MM immunity may provide therapeutic benefit for MM patients. Already several immunotherapeutic approaches have shown promising results in the clinical setting. In this review, we outline recent findings demonstrating the potential advantages of targeting the immunosuppressive bone marrow niche to restore effective anti-MM immunity. We discuss different approaches aiming to boost the effector function of T cells and/or exploit innate or adaptive immunity, and highlight novel therapeutic opportunities to increase the immunogenicity of the MM clone. We also discuss the main challenges that hamper the efficacy of immune-based approaches, including intrinsic resistance of MM cells to activated immune-effectors, as well as the protective role of the immune-suppressive and inflammatory bone marrow milieu. Targeting mechanisms to convert the immunologically “cold” to “hot” MM BMM may induce durable immune responses, which in turn may result in long-lasting clinical benefit, even in patient subgroups with high-risk features and poor survival.
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Affiliation(s)
- Leona Yamamoto
- Division of Hematologic Malignancy, Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Nicola Amodio
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Annamaria Gulla
- Division of Hematologic Malignancy, Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
| | - Kenneth Carl Anderson
- Division of Hematologic Malignancy, Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
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159
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Perrot A, Facon T, Plesner T, Usmani SZ, Kumar S, Bahlis NJ, Hulin C, Orlowski RZ, Nahi H, Mollee P, Ramasamy K, Roussel M, Jaccard A, Delforge M, Karlin L, Arnulf B, Chari A, He J, Ho KF, Van Rampelbergh R, Uhlar CM, Wang J, Kobos R, Gries KS, Fastenau J, Weisel K. Health-Related Quality of Life in Transplant-Ineligible Patients With Newly Diagnosed Multiple Myeloma: Findings From the Phase III MAIA Trial. J Clin Oncol 2021; 39:227-237. [PMID: 33326255 PMCID: PMC8078427 DOI: 10.1200/jco.20.01370] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To evaluate the effects of daratumumab, lenalidomide, and dexamethasone (D-Rd) versus lenalidomide and dexamethasone (Rd) on patient-reported outcomes (PROs) in the phase III MAIA study. PATIENTS AND METHODS PROs were assessed on the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30-item and the EuroQol 5-dimensional descriptive system at baseline and every 3 months during treatment. By mixed-effects model, changes from baseline are presented as least squares means with 95% CIs. RESULTS A total of 737 transplant-ineligible (TIE) patients with newly diagnosed multiple myeloma were randomly assigned to D-Rd (n = 368) or Rd (n = 369). Compliance with PRO assessments was high at baseline (> 90%) through month 12 (> 78%) for both groups. European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30-item global health status scores improved from baseline in both groups and were consistently greater with D-Rd at all time points. A global health status benefit was achieved with D-Rd, regardless of age (< 75 and ≥ 75 years), baseline Eastern Cooperative Oncology Group (ECOG) performance status score, or depth of response. D-Rd treatment resulted in significantly greater reduction in pain scores as early as cycle 3 (P = .0007 v Rd); the magnitude of change was sustained through cycle 12. Reductions in pain with D-Rd were clinically meaningful in patients regardless of age, ECOG status, or depth of response. Similarly, PRO improvements were observed with D-Rd and Rd on the EuroQol 5-dimensional descriptive system visual analog scale score. CONCLUSION D-Rd compared with Rd was associated with faster and sustained clinically meaningful improvements in PROs, including pain, in transplant-ineligible patients with newly diagnosed multiple myeloma regardless of age, baseline ECOG status, or depth of treatment response.
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Affiliation(s)
- Aurore Perrot
- Hematology Department, Cancer University Institute Oncopole, Toulouse, France
- Aurore Perrot, MD, PhD, Institut Universitaire du Cancer Toulouse- Oncopole, 1 avenue Irène Joliot-Curie, 31059 Toulouse Cedex 9, France; e-mail:
| | - Thierry Facon
- Service des Maladies du Sang, Hôpital Claude Huriez, Lille, France
| | - Torben Plesner
- Vejle Hospital and University of Southern Denmark, Vejle, Denmark
| | | | - Shaji Kumar
- Department of Hematology, Mayo Clinic Rochester, Rochester, MN
| | - Nizar J. Bahlis
- University of Calgary, Arnie Charbonneau Cancer Research Institute, Calgary, AB, Canada
| | - Cyrille Hulin
- Department of Hematology, Hospital Haut Leveque, University Hospital, Pessac, France
| | - Robert Z. Orlowski
- Department of Lymphoma-Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hareth Nahi
- Division of Hematology, Department of Medicine, Karolinska Institute, Karolinska University Hospital at Huddinge, Stockholm, Sweden
| | - Peter Mollee
- Princess Alexandra Hospital and University of Queensland, Brisbane, Australia
| | - Karthik Ramasamy
- Oxford University Hospital and NIHR BRC Blood Theme, Oxford, United Kingdom
| | - Murielle Roussel
- Hematology Department, Cancer University Institute Oncopole, Toulouse, France
| | | | - Michel Delforge
- Department of Hematology, University Hospital Leuven, Belgium
| | - Lionel Karlin
- Centre Hospitalier Lyon-Sud Hematologie (HCL), Pierre—Benite Cedex, France
| | | | - Ajai Chari
- Tisch Cancer Institute, Mount Sinai School of Medicine, New York, NY
| | | | | | | | | | | | | | | | | | - Katja Weisel
- Department of Oncology, Hematology, BMT with Department of Pneumology, University Medical Center Hamburg, Hamburg, Germany
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160
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Mohyuddin GR, Koehn K, Shune L, Aziz M, Abdallah AO, McClune B, Ganguly S, McGuirk J, Kambhampati S. Renal insufficiency in multiple myeloma: a systematic review and meta-analysis of all randomized trials from 2005-2019. Leuk Lymphoma 2021; 62:1386-1395. [PMID: 33416412 DOI: 10.1080/10428194.2020.1867725] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Clinical trials may be inconsistent in their enrollment and reporting of patients with multiple myeloma (MM) who have renal insufficiency (RI). We performed a systematic review of all MM randomized clinical trials (RCT) from 2005-2019 to evaluate reporting of prevalence, eligibility criteria and outcomes of patients with RI and MM. One-hundred and twenty-three RCTs were included. Only 30% of studies clearly reported on the proportion of patients who had RI. Only 68.2% reported eligibility criteria pertaining to RI, with no uniformity in the reported criteria. The relative risk (RR) of disease progression or death in patients with RI was higher than those without, RR of 1.20 (1.003-1.431) for relapsed/refractory and 1.07 (1.001-1.046) for newly diagnosed. There is inconsistent reporting and enrollment of patients with RI on MM RCT's. We advocate for higher enrollment of patients with RI and transparent reporting of their eligibility criteria and outcomes.
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Affiliation(s)
- Ghulam Rehman Mohyuddin
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Kelly Koehn
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Leyla Shune
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Muhammad Aziz
- Department of Medicine, University of Toledo, Toledo, OH, USA
| | - Al-Ola Abdallah
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Brian McClune
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Siddhartha Ganguly
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Joseph McGuirk
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Suman Kambhampati
- Department of Hematology and Oncology, Kansas City Veterans Affairs Medical Center, Kansas City, MO, USA
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161
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Patel KK, Giri S, Parker TL, Bar N, Neparidze N, Huntington SF. Cost-Effectiveness of First-Line Versus Second-Line Use of Daratumumab in Older, Transplant-Ineligible Patients With Multiple Myeloma. J Clin Oncol 2021; 39:1119-1128. [PMID: 33411586 DOI: 10.1200/jco.20.01849] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The MAIA trial found that addition of daratumumab to lenalidomide and dexamethasone (DRd) significantly prolonged progression-free survival in transplant-ineligible patients with newly diagnosed multiple myeloma, compared with lenalidomide and dexamethasone alone (Rd). However, daratumumab is a costly treatment and is administered indefinitely until disease progression. Therefore, it is unclear whether it is cost-effective to use daratumumab in the first-line setting compared with reserving its use until later lines of therapy. METHODS We created a Markov model to compare healthcare costs and clinical outcomes of transplant-ineligible patients treated with daratumumab in the first-line setting compared with a strategy of reserving daratumumab until the second-line. We estimated transition probabilities from randomized trials using parametric survival modeling. Lifetime direct healthcare costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for first-line daratumumab versus second-line daratumumab from a US payer perspective. RESULTS First-line daratumumab was associated with an improvement of 0.52 QALYs and 0.66 discounted life-years compared with second-line daratumumab. While both treatment strategies were associated with considerable lifetime expenditures ($1,434,937 v $1,112,101 in US dollars), an incremental cost of $322,836 for first-line daratumumab led to an ICER of $618,018 per QALY. The cost of daratumumab would need to be decreased by 67% for first-line daratumumab to be cost-effective at a willingness-to-pay threshold of $150,000 per QALY. CONCLUSION Using daratumumab in the first-line setting for transplant-ineligible patients may not be cost-effective under current pricing. Delaying daratumumab until subsequent lines of therapy may be a reasonable strategy to limit healthcare costs without significantly compromising clinical outcomes. Mature overall survival data are necessary to more fully evaluate cost-effectiveness in this setting.
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Affiliation(s)
- Kishan K Patel
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Smith Giri
- Department of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Terri L Parker
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Noffar Bar
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Natalia Neparidze
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT
| | - Scott F Huntington
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, CT.,Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT
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162
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Effect of autologous hematopoietic stem cell transplant on the development of second primary malignancies in multiple myeloma patients. Blood Cancer J 2021; 11:5. [PMID: 33414400 PMCID: PMC7791054 DOI: 10.1038/s41408-020-00400-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 02/06/2023] Open
Abstract
Autologous stem cell transplant (aHSCT) is associated with improved survival for multiple myeloma (MM) patients but may be associated with second primary malignancy (SPM) development. Using the California Cancer Registry linked to statewide hospitalization data, we determined the cumulative incidence (CMI) of SPMs more than 1 year after MM diagnosis, accounting for the competing risk of death. AHSCT recipients were matched 1:2 to non-aHSCT patients. Adjusted hazard ratios (aHR) were estimated using the Fine and Gray method. Among 16,331 patients, 933 (5.7%) developed a SPM more than 1 year after diagnosis. The 10-year CMI of developing any SPM was 6.6%, 5.7% for solid tumor SPM and 0.9% for hematologic malignancies. The 10-year CMI of developing any SPM was similar among aHSCT [9.1% (7.7-10.7%)] and non-aHSCT [7.5% (6.5-8.6%)] (P = 0.26) recipients and there was no difference in solid-tumor SPMs (P = 0.98). The 10-year CMI of hematologic SPMs was higher among aHSCT recipients [2.1% (1.4-2.9%) vs. 0.8% (0.5-1.2%); P = 0.005], corresponding to a 1.3% absolute increase and an aHR of 1.51 (1.01-2.27). Ten-year myeloma-specific and non-cancer mortality rates were 59% (58.2-60.0%) and 18.1% (17.4-18.8%), respectively. Although aHSCT was associated with a small increase in hematologic SPMs, mortality was driven by MM and non-cancer causes.
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163
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Lenalidomide versus bortezomib maintenance after frontline autologous stem cell transplantation for multiple myeloma. Blood Cancer J 2021; 11:1. [PMID: 33414374 PMCID: PMC7791127 DOI: 10.1038/s41408-020-00390-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/29/2020] [Accepted: 11/10/2020] [Indexed: 12/22/2022] Open
Abstract
Lenalidomide (LEN) maintenance (MT) post autologous stem cell transplantation (ASCT) is standard of care in newly diagnosed multiple myeloma (MM) but has not been compared to other agents in clinical trials. We retrospectively compared bortezomib (BTZ; n = 138) or LEN (n = 183) MT from two subsequent GMMG phase III trials. All patients received three cycles of BTZ-based triplet induction and post-ASCT MT. BTZ MT (1.3 mg/m2 i.v.) was administered every 2 weeks for 2 years. LEN MT included two consolidation cycles (25 mg p.o., days 1–21 of 28 day cycles) followed by 10–15 mg/day for 2 years. The BTZ cohort more frequently received tandem ASCT (91% vs. 33%) due to different tandem ASCT strategies. In the LEN and BTZ cohort, 43% and 46% of patients completed 2 years of MT as intended (p = 0.57). Progression-free survival (PFS; HR = 0.83, p = 0.18) and overall survival (OS; HR = 0.70, p = 0.15) did not differ significantly with LEN vs. BTZ MT. Patients with <nCR after first ASCT were assigned tandem ASCT in both trials. In patients with <nCR and tandem ASCT (LEN: n = 54 vs. BTZ: n = 84), LEN MT significantly improved PFS (HR = 0.61, p = 0.04) but not OS (HR = 0.46, p = 0.09). In conclusion, the significant PFS benefit after eliminating the impact of different tandem ASCT rates supports the current standard of LEN MT after ASCT.
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164
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Barth P, Giri S, Reagan JL, Olszewski AJ. Outcomes of lenalidomide- or bortezomib-based regimens in older patients with plasma cell myeloma. Am J Hematol 2021; 96:14-22. [PMID: 32918301 DOI: 10.1002/ajh.25996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/05/2020] [Accepted: 09/06/2020] [Indexed: 11/12/2022]
Abstract
The "triplet" regimen of lenalidomide, bortezomib, and dexamethasone (RVD) showed survival advantage over lenalidomide-dexamethasone (RD) in clinical trials, but older patients with myeloma often receive doublet regimens (RD or bortezomib-dexamethasone, VD), or VD plus cyclophosphamide (VCD). We compared these first-line regimens using real-world data from Medicare beneficiaries receiving therapy between 2007 and 2015. In each comparative analysis, we balanced confounding characteristics using a propensity score. Outcomes included overall (OS) and event-free survival (EFS, reporting hazard ratios [HR] with 95% confidence intervals [CI]), adverse events, and costs. We identified 6076 patients with median age 76 and median OS of 2.6 years. In the comparison of RVD vs RD/VD doublets, RVD showed significantly better OS (HR = 0.83; 95% CI, 0.72-0.95) and EFS (HR = 0.68; 95% CI, 0.61-0.76). So, RVD was associated with more frequent hospitalizations, anemia, and neuropathy, but no increase in thromboembolism or secondary cancers. Costs were higher with RVD. In the comparison of RD vs VD, RD demonstrated better EFS (HR = 0.74; 95% CI, 0.68-0.81) and marginally better OS (HR = 0.91; 95% CI, 0.83-0.99). And, RD resulted in significantly more thromboembolic events, less neuropathy, and no significant difference in hospitalizations, transfusions, or secondary cancers. In the comparison of VCD vs VD, we observed no significant difference in any outcome. Superior survival favors RVD over doublet regimens, but even in 2015 RVD was applied for only about 25% of Medicare beneficiaries with myeloma. For patients not eligible for RVD due to toxicity, VCD offers no survival benefit over VD. Lenalidomide-dexamethasone may be the preferred line doublet considering its advantage over VD.
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Affiliation(s)
- Peter Barth
- Department of Medicine Alpert Medical School of Brown University Providence Rhode Island
- Division of Hematology/Oncology Rhode Island Hospital/The Miriam Hospital Providence Rhode Island
| | - Smith Giri
- Division of Hematology/Oncology University of Alabama at Birmingham Birmingham Alabama
| | - John L Reagan
- Department of Medicine Alpert Medical School of Brown University Providence Rhode Island
- Division of Hematology/Oncology Rhode Island Hospital/The Miriam Hospital Providence Rhode Island
| | - Adam J Olszewski
- Department of Medicine Alpert Medical School of Brown University Providence Rhode Island
- Division of Hematology/Oncology Rhode Island Hospital/The Miriam Hospital Providence Rhode Island
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165
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Richter J, Thibaud S. Anti-body building: The exercise of advancing immune based myeloma therapies. Blood Rev 2020; 48:100789. [PMID: 33384171 DOI: 10.1016/j.blre.2020.100789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 11/27/2020] [Accepted: 12/16/2020] [Indexed: 12/26/2022]
Abstract
The last decade has seen a marked improvement in the outcomes of patients with multiple myeloma. Much of this has been due to not only the advent of new therapies, but their inherent ability to be combined into 3 and 4 drug regimens without resulting in unacceptable toxicity. The general gestalt has been to combine agents of varied mechanisms of action. With the primary classes of agents such as proteasome inhibitors and immunomodulatory drugs as bases, the advent of antibody-based therapy in myeloma has allowed us to easily augment these therapies; much in the same way rituximab impacted the lymphoma world. With the approvals of daratumumab, elotuzumab and isatuximab; the myeloma world was ushered into the next wave of targeted agents. Here, we take a look at the current landscape of "off-the-shelf" antibody-based therapies in myeloma and peer into the next wave of multi-functional targeted agents.
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Affiliation(s)
- Joshua Richter
- Tisch Cancer Institute: Icahn School of Medicine at Mount Sinai, USA.
| | - Santiago Thibaud
- Tisch Cancer Institute: Icahn School of Medicine at Mount Sinai, USA.
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166
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Grant SJ, Mian HS, Giri S, Boutin M, Dottorini L, Neuendorff NR, Krok-Schoen JL, Nikita N, Rosko AE, Wildes TM, Zweegman S. Transplant-ineligible newly diagnosed multiple myeloma: Current and future approaches to clinical care: A Young International Society of Geriatric Oncology Review Paper. J Geriatr Oncol 2020; 12:499-507. [PMID: 33342724 DOI: 10.1016/j.jgo.2020.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 12/29/2022]
Abstract
Multiple myeloma is the second most common hematological malignancy in the USA and Europe. Despite improvements in the 5-year and overall survival rates over the past decade, older adults (aged ≥65 years) with multiple myeloma continue to experience disproportionately worse outcomes than their younger counterparts. These differences in outcomes arise from the increased prevalence of vulnerabilities such as medical comorbidities and frailty seen with advancing age that can influence treatment-delivery and tolerance and impact survival. In general, geriatric assessments can help identify those patients more likely to benefit from enhanced toxicity risk-prediction and aid treatment decision-making. Despite the observed benefits of geriatric assessments and other screening frailty tools, provider and systems-level barriers continue to influence the overall perception of the feasibility of geriatric assessments in clinical practice settings. Clinical trials are underway evaluating the efficacy and safety of various multiple myeloma therapies in less fit/frail older adults, with a minority examining fitness-based/risk-adapted approaches. Thus, significant gaps exist in knowing which myeloma therapies are most appropriate for older and more vulnerable adults with multiple myeloma. The purpose of this Review is to discuss how geriatric assessments can be used to guide the management of transplant-ineligible patients; and to highlight frontline therapies for standard-risk and high-risk cytogenetic abnormalities [i.e., t(4;14), t(14;16), and del(17p)] associated with multiple myeloma. We also discuss the current shortcomings of the existing clinical approaches to care and highlight ongoing clinical trials evaluating newer fitness-based approaches to managing transplant-ineligible patients.
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Affiliation(s)
- Shakira J Grant
- Division of Hematology-Oncology, University of Washington-Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Hira S Mian
- Department of Oncology, McMaster University, Ontario, Canada
| | - Smith Giri
- Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Melina Boutin
- Department of Hemato-Oncology, Université of Sherbrooke, Québec, Canada
| | - Lorenzo Dottorini
- Oncology Unit, Medical Sciences Department, ASST Bergamo Est, Alzano Lombardo, Bergamo, Italy
| | - Nina R Neuendorff
- Department of Hematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jessica L Krok-Schoen
- School of Health and Rehabilitation Sciences, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Nikita Nikita
- Department of Medical Oncology, Sidney Kimmel Cancer Center at Jefferson, Sidney Kimmel Medical College, Philadelphia, PA, USA
| | - Ashley E Rosko
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Tanya M Wildes
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, VU University Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
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167
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Touzeau C, Antier C, Moreau P. Carfilzomib in combination with daratumumab in the management of relapsed multiple myeloma. Future Oncol 2020; 17:993-998. [PMID: 33289427 DOI: 10.2217/fon-2020-0907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The therapeutic landscape of relapsed multiple myeloma (MM) is constantly evolving. To date, a large proportion of patients present with lenalidomide refractory disease at the time of first or second relapse. In this context, few efficient options are currently available. Carfilzomib and daratumumab are approved in the relapse setting. Recently, Phase Ib and Phase III trials evaluated the triplet drug combination daratumumab-carfilzomib-dexamethasone in the relapse setting and demonstrated strong clinical efficacy, especially in lenalidomide refractory patients. Based on these results, this combination has been approved by the US FDA for relapsed MM patients. The present review discusses the safety and efficacy of daratumumab-carfilzomib-dexamethasone in MM.
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Affiliation(s)
- Cyrille Touzeau
- Department of Hematology, University Hospital, Nantes, France.,CRCINA, INSERM, CNRS, Université d'Angers, Université de Nantes, France.,Site de Recherche Intégrée sur le Cancer (SIRIC) «ILIAD», INCA-DGOS-Inserm_12558
| | - Chloé Antier
- Department of Hematology, University Hospital, Nantes, France
| | - Philippe Moreau
- Department of Hematology, University Hospital, Nantes, France.,CRCINA, INSERM, CNRS, Université d'Angers, Université de Nantes, France.,Site de Recherche Intégrée sur le Cancer (SIRIC) «ILIAD», INCA-DGOS-Inserm_12558
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168
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van de Donk NWCJ. Sequencing multiple myeloma therapies with and after antibody therapies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:248-258. [PMID: 33275724 PMCID: PMC7727523 DOI: 10.1182/hematology.2020000109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In multiple myeloma (MM), treatment selection and sequencing become increasingly complex with the increasing number of therapeutic options, including antibodies. Choice of treatment is dependent on various factors including patient- and tumor-related features. In addition, treatment-related factors, such as type and response to prior therapy, are also critical in terms of the selection of a new treatment regimen. Furthermore, approval status and reimbursement policies influence treatment choice. At the time of first relapse, patients who received a bortezomib-based regimen can switch to lenalidomide-based treatment, whereas patients who received lenalidomide until progression can switch to a proteasome inhibitor-based therapy. Alternatively, there is increasing evidence that pomalidomide-based triplets are also effective following the development of lenalidomide-refractory disease both in early and later relapse settings. Patients who become refractory to immunomodulatory drugs, proteasome inhibitors, and CD38 antibodies have a poor prognosis. These triple-class refractory patients may benefit from novel, recently approved agents such as XPO1 inhibitors or from participation in a clinical trial. Furthermore, retreatment with agents that were received in previous lines of therapy can also be considered in heavily pretreated patients, for example, in combination with classic cytotoxic drugs. Importantly, with the increasing use of CD38 antibodies in newly diagnosed and early relapsed/refractory MM, more information is needed on the potential value of retreatment with CD38 antibodies. With the introduction of new immunotherapies with novel modes of action, we also need a better understanding of sequencing of immunotherapeutic agents by taking into account the effect of prior therapy on immune function.
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Affiliation(s)
- Niels W C J van de Donk
- Department of Hematology, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam University Medical Centers (UMC), Amsterdam, The Netherlands
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169
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Kumar SK, Callander NS, Adekola K, Anderson L, Baljevic M, Campagnaro E, Castillo JJ, Chandler JC, Costello C, Efebera Y, Faiman M, Garfall A, Godby K, Hillengass J, Holmberg L, Htut M, Huff CA, Kang Y, Hultcrantz M, Larson S, Liedtke M, Martin T, Omel J, Shain K, Sborov D, Stockerl-Goldstein K, Weber D, Keller J, Kumar R. Multiple Myeloma, Version 3.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:1685-1717. [PMID: 33285522 DOI: 10.6004/jnccn.2020.0057] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Multiple myeloma is a malignant neoplasm of plasma cells that accumulate in bone marrow, leading to bone destruction and marrow failure. This manuscript discusses the management of patients with solitary plasmacytoma, smoldering multiple myeloma, and newly diagnosed multiple myeloma.
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Affiliation(s)
| | | | - Kehinde Adekola
- 3Robert H. Lurie Comprehensive Cancer of Center Northwestern University
| | | | | | | | - Jorge J Castillo
- 7Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | - Jason C Chandler
- 8St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Yvonne Efebera
- 10The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Matthew Faiman
- 11Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Alfred Garfall
- 12Abramson Cancer Center at the University of Pennsylvania
| | | | | | - Leona Holmberg
- 15Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Myo Htut
- 16City of Hope National Medical Center
| | - Carol Ann Huff
- 17The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - Thomas Martin
- 22UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | - Donna Weber
- 27The University of Texas MD Anderson Cancer Center; and
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170
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Zweegman S, Stege CA, Haukas E, Schjesvold FH, Levin MD, Waage A, Leys RB, Klein SK, Szatkowski D, Axelsson P, Do TH, Knut-Bojanowska D, van der Spek E, Svirskaite A, Klostergaard A, Salomo M, Blimark C, Ypma PF, Mellqvist UH, Poddighe PJ, Stevens-Kroef M, van de Donk NW, Sonneveld P, Hansson M, van der Holt B, Abildgaard N. Ixazomib-Thalidomide-low dose dexamethasone induction followed by maintenance therapy with ixazomib or placebo in newly diagnosed multiple myeloma patients not eligible for autologous stem cell transplantation; results from the randomized phase II HOVON-126/NMSG 21.13 trial. Haematologica 2020; 105:2879-2882. [PMID: 33256392 PMCID: PMC7716358 DOI: 10.3324/haematol.2019.240374] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Claudia A.M. Stege
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Einar Haukas
- Stavanger University Hospital-Rogaland Hospital, Stavanger, Norway
| | | | | | - Anders Waage
- St Olavs Hospital and Norwegian University of Science, Trondheim, Norway
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Pino J. Poddighe
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Niels W.C.J. van de Donk
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Pieter Sonneveld
- Erasmus Medical Center Cancer Institute, Rotterdam, the Netherlands and
| | | | | | - Niels Abildgaard
- Hematology Research Unit and Academy of Geriatric Cancer Research, Odense University Hospital and University of Southern Denmark, Denmark
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171
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Quality of patient-reported outcome reporting in randomised controlled trials of haematological malignancies according to international quality standards: a systematic review. LANCET HAEMATOLOGY 2020; 7:e892-e901. [DOI: 10.1016/s2352-3026(20)30292-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 11/23/2022]
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172
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Hungria V, Martínez-Baños DM, Mateos MV, Dimopoulos MA, Cavo M, Heeg B, Garcia A, Lam A, Machnicki G, He J, Fernandez M. Daratumumab Plus Bortezomib, Melphalan, and Prednisone Versus Standard of Care in Latin America for Transplant-Ineligible Newly Diagnosed Multiple Myeloma: Propensity Score Matching Analysis. Adv Ther 2020; 37:4996-5009. [PMID: 33067698 PMCID: PMC7595972 DOI: 10.1007/s12325-020-01521-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/30/2020] [Indexed: 01/14/2023]
Abstract
Introduction The phase 3 ALCYONE study demonstrated significantly longer progression-free and overall survival (PFS/OS) and higher overall response rates (ORR) with daratumumab plus bortezomib, melphalan, and prednisone (D-VMP) versus VMP alone in transplant-ineligible patients with newly diagnosed multiple myeloma (NDMM). In Latin America, bortezomib- or thalidomide-based regimens remain standard of care (SoC) for this population. No head-to-head trials have compared D-VMP with SoC regimens used in Latin America. Methods Propensity score matching (PSM) was used to control for baseline differences between patient populations and compare outcomes for D-VMP versus SoC regimens used in Latin America. Data for the D-VMP cohort were from the D-VMP arm of the ALCYONE trial (n = 350). Data for the SoC cohort were from the retrospective, observational Hemato-Oncology Latin America (HOLA) study, which included patients with NDMM who did not receive a transplant (n = 729). Propensity scores were estimated using logistic regression. Exact, optimal, and nearest-neighbor PSM were applied to pick the best-performing method. Doubly robust estimation was the base case, since some baseline imbalances persisted. Results All 350 patients from the D-VMP arm of ALCYONE were included in OS/PFS analyses and 338 in ORR analysis; 478 and 324 patients, respectively, from HOLA were included in these analyses. Naïve comparison revealed important differences in baseline characteristics (age, chronic kidney disease, hypercalcemia, and International Staging System [ISS] stage). After nearest-neighbor matching, baseline characteristics, except ISS stage, were well balanced; comparisons favored D-VMP over SoC for OS (hazard ratio = 0.41; 95% confidence interval [CI] 0.25–0.66; P = 0.002) and PFS (hazard ratio = 0.48; 95% CI 0.35–0.67; P < 0.001). After exact matching, imbalances remained in age and ISS stage; comparisons favored D-VMP over SoC for ORR (odds ratio = 5.44; 95% CI 2.65–11.82; P < 0.001). Conclusion In transplant-ineligible patients with NDMM, D-VMP showed superior effectiveness versus bortezomib- and thalidomide-based regimens, supporting adoption of daratumumab-containing regimens in Latin America.
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173
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Jasielec JK, Kubicki T, Raje N, Vij R, Reece D, Berdeja J, Derman BA, Rosenbaum CA, Richardson P, Gurbuxani S, Major S, Wolfe B, Stefka AT, Stephens L, Tinari KM, Hycner T, Rojek AE, Dytfeld D, Griffith KA, Zimmerman TM, Jakubowiak AJ. Carfilzomib, lenalidomide, and dexamethasone plus transplant in newly diagnosed multiple myeloma. Blood 2020; 136:2513-2523. [PMID: 32735641 PMCID: PMC7714092 DOI: 10.1182/blood.2020007522] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/22/2020] [Indexed: 12/22/2022] Open
Abstract
In this phase 2 multicenter study, we evaluated the incorporation of autologous stem cell transplantation (ASCT) into a carfilzomib-lenalidomide-dexamethasone (KRd) regimen for patients with newly diagnosed multiple myeloma (NDMM). Transplant-eligible patients with NDMM received 4 cycles of KRd induction, ASCT, 4 cycles of KRd consolidation, and 10 cycles of KRd maintenance. The primary end point was rate of stringent complete response (sCR) after 8 cycles of KRd with a predefined threshold of ≥50% to support further study. Seventy-six patients were enrolled with a median age of 59 years (range, 40-76 years), and 35.5% had high-risk cytogenetics. The primary end point was met, with an sCR rate of 60% after 8 cycles. Depth of response improved over time. On intent-to-treat (ITT), the sCR rate reached 76%. The rate of minimal residual disease (MRD) negativity using modified ITT was 70% according to next-generation sequencing (<10-5 sensitivity). After median follow-up of 56 months, 5-year progression-free survival (PFS) and overall survival (OS) rates were 72% and 84% for ITT, 85% and 91% for MRD-negative patients, and 57% and 72% for patients with high-risk cytogenetics. For high-risk patients who were MRD negative, 5-year rates were 77% and 81%. Grade 3 to 4 adverse events included neutropenia (34%), lymphopenia (32%), infection (22%), and cardiac events (3%). There was no grade 3 to 4 peripheral neuropathy. Patients with NDMM treated with KRd with ASCT achieved high rates of sCR and MRD-negative disease at the end of KRd consolidation. Extended KRd maintenance after consolidation contributed to deepening of responses and likely to prolonged PFS and OS. Safety and tolerability were manageable. This trial was registered at www.clinicaltrials.gov as #NCT01816971.
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Affiliation(s)
| | - Tadeusz Kubicki
- University of Chicago Medical Center, Chicago, IL
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Noopur Raje
- Center for Multiple Myeloma, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Ravi Vij
- Section of Stem Cell Transplant and Leukemia, Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Donna Reece
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jesus Berdeja
- Sarah Cannon Center for Blood Cancer, Sarah Cannon Research Institute, Nashville, TN
| | | | - Cara A Rosenbaum
- University of Chicago Medical Center, Chicago, IL
- Weill Cornell Medicine, New York, NY
| | - Paul Richardson
- Division of Hematologic Malignancy, Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Harvard Medical School, Dana-Farber Cancer Institute, Boston, MA
| | | | - Sarah Major
- University of Chicago Medical Center, Chicago, IL
| | | | | | | | | | - Tyler Hycner
- University of Chicago Medical Center, Chicago, IL
| | | | - Dominik Dytfeld
- University of Chicago Medical Center, Chicago, IL
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Kent A Griffith
- Center for Cancer Biostatistics, University of Michigan Health System, Ann Arbor, MI; and
| | - Todd M Zimmerman
- University of Chicago Medical Center, Chicago, IL
- BeiGene, San Mateo, CA
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174
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Bonello F, Boccadoro M, Larocca A. Diagnostic and Therapeutic Challenges in the Management of Intermediate and Frail Elderly Multiple Myeloma Patients. Cancers (Basel) 2020; 12:E3106. [PMID: 33114320 PMCID: PMC7690866 DOI: 10.3390/cancers12113106] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022] Open
Abstract
Multiple myeloma (MM) mostly affects elderly patients, which represent a highly heterogeneous population. Indeed, comorbidities, frailty status and functional reserve may vary considerably among patients with similar chronological age. For this reason, the choice of treatment goals and intensity is particularly challenging in elderly patients, and it requires a multidimensional evaluation of the patients and the disease. In recent years, different tools to detect patient frailty have been developed, and the International Myeloma Working Group frailty score currently represents the gold standard. It identifies intermediate-fit and frail patients requiring gentler treatment approaches compared to fit patients, aiming to preserve quality of life and prevent toxicities. This subset of patients is underrepresented in clinical trials, and studies exploring frailty-adapted approaches are scarce, making the choice of therapy extremely challenging. Treatment options for intermediate-fit and frail patients might include dose-adapted combinations, doublets, and less toxic combinations based on novel agents. This review analyzes the available tools for the assessment of frailty and possible strategies to improve the discriminative power of the scores and expand their use in real-life and clinical trial settings. Moreover, it addresses the main therapeutic challenges in the management of intermediate-fit and frail MM patients at diagnosis and at relapse.
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Affiliation(s)
| | | | - Alessandra Larocca
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy; (F.B.); (M.B.)
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175
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Mian HS, Seow H, Wildes TM, Kouroukis CT, Pond GR, Sivapathasundaram B, Sussman J. Disparities in treatment patterns and outcomes among younger and older adults with newly diagnosed multiple myeloma: A population-based study. J Geriatr Oncol 2020; 12:508-514. [PMID: 33109484 DOI: 10.1016/j.jgo.2020.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/13/2020] [Accepted: 10/16/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Multiple myeloma, a cancer of older adults, has seen significant improvement in therapeutic options over the past two decades. Uncovering disparities in treatment patterns and outcomes is imperative in order to ensure older adults, who are underrepresented in clinical trials, are benefitting from these advances. METHODS Adults with newly diagnosed multiple myeloma (NDMM) were identified using linked provincial administrative databases between 2007 and 2017 in Ontario, Canada. Trends in rate of no treatment, novel drug and autologous stem cell transplant (ASCT) usage was evaluated within one year following diagnosis along with the associated early mortality (<12 months) for the aforementioned cohorts among younger (≤65 years) and older adults (>65 years) with NDMM. RESULTS A total of 8841 adults with NDMM were identified. Rates of no treatment decreased in both age groups during the study period; however still remain considerably high among older patients (from 34.9% in 2007 to 27.4% in 2017) with high associated early mortality in the older untreated group (54.1% 1 yr mortality over study period). Despite increased usage of novel drugs in both age groups, early mortality decreased among younger patients utilizing novel drugs (16.1% to 5.6%) but remained high and stagnant in older patients using novel drugs (18.2% 1 yr mortality over study period). ASCT utilization increased in both age groups during the study period with decreasing early mortality among older patients undergoing ASCT (from 26.3% in 2007 to 1.1% in 2017). CONCLUSION While several improvements have been made, rates of no treatment and early mortality among patients not treated and those started on novel drugs remains a concern in older adults with NDMM.
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Affiliation(s)
- Hira S Mian
- Juravinski Cancer Center, Department of Oncology, McMaster University, Hamilton, ON, Canada.
| | - Hsien Seow
- Juravinski Cancer Center, Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Tanya M Wildes
- Washington University School of Medicine, St. Louis, MO, United States of America
| | - C Tom Kouroukis
- Juravinski Cancer Center, Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Gregory R Pond
- Juravinski Cancer Center, Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Jonathan Sussman
- Juravinski Cancer Center, Department of Oncology, McMaster University, Hamilton, ON, Canada
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176
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Nadeem O, Tai YT, Anderson KC. Immunotherapeutic and Targeted Approaches in Multiple Myeloma. Immunotargets Ther 2020; 9:201-215. [PMID: 33117743 PMCID: PMC7569026 DOI: 10.2147/itt.s240886] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/22/2020] [Indexed: 12/20/2022] Open
Abstract
The multiple myeloma (MM) therapeutic landscape has evolved significantly with the approval of numerous novel agents, including next generation proteasome inhibitors (PIs), immunomodulatory agents (IMIDs), and monoclonal antibodies (MoABs) targeting CD38 and SLAMF7. While these discoveries have led to an unprecedented improval in patient outcomes, the disease still remains incurable. Immunotherapeutic approaches have shown substantial promise in recent studies of chimeric antigen receptor T-cell (CAR T-cell) therapy, bispecific antibodies, and antibody drug conjugates targeting B-cell maturation antigen (BCMA). This review will highlight these novel and targeted therapies in MM, with particular focus on PIs, IMIDs, MoAb and BCMA-directed immunotherapy.
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Affiliation(s)
- Omar Nadeem
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Yu-Tzu Tai
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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177
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Belch A, Bahlis N, White D, Cheung M, Chen C, Shustik C, Song K, Tosikyan A, Dispenzieri A, Anderson K, Brown D, Robinson S, Srinivasan S, Facon T. Continuous lenalidomide and low-dose dexamethasone in patients with transplant-ineligible newly diagnosed MM: FIRST trial subanalysis of Canadian/US patients. Cancer Med 2020; 9:8923-8930. [PMID: 33049118 PMCID: PMC7724300 DOI: 10.1002/cam4.3511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/16/2020] [Accepted: 09/05/2020] [Indexed: 12/14/2022] Open
Abstract
The phase 3 FIRST trial demonstrated significant improvement in progression-free survival (PFS) and overall survival (OS) with an immune-stimulatory agent, lenalidomide, in combination with low-dose dexamethasone until disease progression (Rd continuous) vs melphalan +prednisone + thalidomide (MPT) in transplant-ineligible patients with newly diagnosed multiple myeloma (NDMM). Rd continuous similarly extended PFS vs fixed-duration Rd for 18 cycles (Rd18). Outcomes in the Canadian/US subgroup (104 patients per arm) are reported in this analysis. Rd continuous demonstrated a significant improvement in PFS vs MPT (median, 29.3 vs 20.2 months; HR, 0.69 [95% CI, 0.49-0.97]; p = 0.03326) and an improvement vs Rd18 (median, 21.9 months). Median OS was 56.9 vs 46.8 months with Rd continuous vs MPT (p = 0.15346) and 59.5 months with Rd18. The overall response rate was higher with Rd continuous and Rd18 (78.8% and 79.8%) vs MPT (65.4%). In the 49.0%, 52.9%, and 29.8% of patients with at least very good partial response in the Rd continuous, Rd18, and MPT arms, respectively, the median PFS was 56.0, 30.9, and 40.2 months, respectively. The most common grade 3/4 treatment-emergent adverse events were neutropenia (28.4%, 30.1%, and 52.0%), anemia (23.5%, 21.4%, and 23.5%), and infections (37.3%, 30.1%, and 24.5%) with Rd continuous, Rd18, and MPT, respectively. These results were consistent with those in the intent-to-treat population, confirming the benefit of Rd continuous vs MPT in the Canadian/US subgroup and supporting the role of Rd continuous as a standard of care for transplant-ineligible patients with NDMM.
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Affiliation(s)
| | | | - Darrell White
- Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | | | - Chaim Shustik
- McGill University Health Centre, Montréal, QC, Canada
| | - Kevin Song
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Axel Tosikyan
- Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada
| | | | | | - Diane Brown
- Celgene, a Bristol-Myers Squibb Company, Mississauga, ON, Canada
| | | | | | - Thierry Facon
- Service des Maladies du Sang, Hôpital Claude Huriez, Lille, France
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178
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Dimopoulos MA, Špička I, Quach H, Oriol A, Hájek R, Garg M, Beksac M, Bringhen S, Katodritou E, Chng WJ, Leleu X, Iida S, Mateos MV, Morgan G, Vorog A, Labotka R, Wang B, Palumbo A, Lonial S. Ixazomib as Postinduction Maintenance for Patients With Newly Diagnosed Multiple Myeloma Not Undergoing Autologous Stem Cell Transplantation: The Phase III TOURMALINE-MM4 Trial. J Clin Oncol 2020; 38:4030-4041. [PMID: 33021870 PMCID: PMC7768338 DOI: 10.1200/jco.20.02060] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Maintenance therapy prolongs progression-free survival (PFS) in patients with newly diagnosed multiple myeloma (NDMM) not undergoing autologous stem cell transplantation (ASCT) but has generally been limited to immunomodulatory agents. Other options that complement the induction regimen with favorable toxicity are needed.
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Affiliation(s)
- Meletios A Dimopoulos
- Hematology and Medical Oncology, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ivan Špička
- First Department of Medicine, Department of Hematology, First Faculty of Medicine, Charles University and General Hospital in Prague, Prague, Czech Republic
| | - Hang Quach
- Department of Hematology, University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Albert Oriol
- Institut d'Investigació contra la Leucèmia Josep Carreras and Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Roman Hájek
- Department of Hemato-oncology, University Hospital Ostrava, University of Ostrava, and Faculty of Medicine, Ostrava, Czech Republic
| | - Mamta Garg
- Hematology, Leicester Royal Infirmary/University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Meral Beksac
- Department of Hematology, Ankara University, Ankara, Turkey
| | - Sara Bringhen
- Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Eirini Katodritou
- Department of Hematology, Theagenion Cancer Hospital, Thessaloniki, Greece
| | - Wee-Joo Chng
- Department of Hematology-Oncology, National University Cancer Institute, National University Health System, and Yong Loo Lin School of Medicine and Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Xavier Leleu
- Pôle Régional de Cancérologie, Department of Haematology, Centre Hospitalier Universitaire La Milétrie-Poitiers, Poitiers, France
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - María-Victoria Mateos
- Hematology, Hospital Universitario de Salamanca, University Hospital of Salamanca, Centro de Investigación del Cáncer, Instituto de Biología Molecular y Celular del Cáncer, (Universitario de Salamanca Consejo Superior de Investigaciones Científicas), Salamanca, Spain
| | - Gareth Morgan
- Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | - Alexander Vorog
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA
| | - Richard Labotka
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA
| | - Bingxia Wang
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA
| | - Antonio Palumbo
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
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179
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Gulla' A, Anderson KC. Multiple myeloma: the (r)evolution of current therapy and a glance into future. Haematologica 2020; 105:2358-2367. [PMID: 33054076 PMCID: PMC7556665 DOI: 10.3324/haematol.2020.247015] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 07/16/2020] [Indexed: 12/17/2022] Open
Abstract
Over the past 20 years, the regulatory approval of several novel agents to treat multiple myeloma (MM) has prolonged median patient survival from 3 to 8-10 years. Increased understanding of MM biology has translated to advances in diagnosis, prognosis, and response assessment, as well as informed the development of targeted and immune agents. Here we provide an overview of the recent progress in MM, and highlight research areas of greatest promise to further improve patient outcome in the future.
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Affiliation(s)
| | - Kenneth C. Anderson
- Division of Hematologic Neoplasia, Department of Medical Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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180
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Rajkumar SV, Kumar S. Multiple myeloma current treatment algorithms. Blood Cancer J 2020; 10:94. [PMID: 32989217 PMCID: PMC7523011 DOI: 10.1038/s41408-020-00359-2] [Citation(s) in RCA: 178] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/11/2020] [Accepted: 08/20/2020] [Indexed: 12/22/2022] Open
Abstract
The treatment of multiple myeloma (MM) continues to evolve rapidly with arrival of multiple new drugs, and emerging data from randomized trials to guide therapy. Along the disease course, the choice of specific therapy is affected by many variables including age, performance status, comorbidities, and eligibility for stem cell transplantation. In addition, another key variable that affects treatment strategy is risk stratification of patients into standard and high-risk MM. High-risk MM is defined by the presence of t(4;14), t(14;16), t(14;20), gain 1q, del(17p), or p53 mutation. In this paper, we provide algorithms for the treatment of newly diagnosed and relapsed MM based on the best available evidence. We have relied on data from randomized controlled trials whenever possible, and when appropriate trials to guide therapy are not available, our recommendations reflect best practices based on non-randomized data, and expert opinion. Each algorithm has been designed to facilitate easy decision-making for practicing clinicians. In all patients, clinical trials should be considered first, prior to resorting to the standard of care algorithms we outline.
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Affiliation(s)
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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181
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Mateos MV, Bladé J, Bringhen S, Ocio EM, Efebera Y, Pour L, Gay F, Sonneveld P, Gullbo J, Richardson PG. Melflufen: A Peptide-Drug Conjugate for the Treatment of Multiple Myeloma. J Clin Med 2020; 9:E3120. [PMID: 32992506 PMCID: PMC7601491 DOI: 10.3390/jcm9103120] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/15/2020] [Accepted: 09/23/2020] [Indexed: 02/06/2023] Open
Abstract
Despite the availability of new therapies that have led to improved outcomes for patients with multiple myeloma, most patients will eventually relapse. With triplet and even quadruplet combination therapies becoming standard in the first and second line, many patients will have few treatment options after second-line treatment. Melflufen (melphalan flufenamide) is a first-in-class peptide-drug conjugate (PDC) that targets aminopeptidases and rapidly releases alkylating agents into tumor cells. Once inside the tumor cells, melflufen is hydrolyzed by peptidases to release alkylator molecules, which become entrapped. Melflufen showed anti-myeloma activity in myeloma cells that were resistant to bortezomib and the alkylator melphalan. In early phase studies (O-12-M1 and HORIZON [OP-106]), melflufen plus dexamethasone has demonstrated encouraging clinical activity and a manageable safety profile in heavily pretreated patients with relapsed/refractory multiple myeloma, including those with triple-class refractory disease and extramedullary disease. The Phase III OCEAN study (OP-104) is further evaluating melflufen plus dexamethasone in patients with relapsed/refractory multiple myeloma. The safety profile of melflufen is characterized primarily by clinically manageable hematologic adverse events. Melflufen, with its novel mechanism of action, has the potential to provide clinically meaningful benefits to patients with relapsed/refractory multiple myeloma, including those with high unmet needs.
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Affiliation(s)
| | - Joan Bladé
- Hematology Department, Institut d’Investigacions Biomèdiques August Pi I Sunyer, Hospital Clinic, 08036 Barcelona, Spain;
| | - Sara Bringhen
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy; (S.B.); (F.G.)
| | - Enrique M Ocio
- University Hospital Marqués de Valdecilla (IDIVAL), University of Cantabria, 39008 Santander, Spain;
| | - Yvonne Efebera
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA;
| | - Luděk Pour
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, 62500 Brno, Czech Republic;
| | - Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy; (S.B.); (F.G.)
| | - Pieter Sonneveld
- Erasmus MC Cancer Institute, 3075 EA Rotterdam, The Netherlands;
| | - Joachim Gullbo
- Department of Medical Sciences, Division of Clinical Pharmacology, Uppsala University, 751 85 Uppsala, Sweden;
| | - Paul G. Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
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182
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Impact of last lenalidomide dose, duration, and IMiD-free interval in patients with myeloma treated with pomalidomide/dexamethasone. Blood Adv 2020; 3:4095-4103. [PMID: 31821457 DOI: 10.1182/bloodadvances.2019000539] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/04/2019] [Indexed: 12/11/2022] Open
Abstract
To gain insights into the characteristics of clinical resistance to lenalidomide, we evaluated the outcomes of 147 consecutive patients with multiple myeloma (MM) homogeneously treated with immunomodulatory imide drugs (IMiDs) pomalidomide and dexamethasone (Pd) for relapsed and/or refractory MM (median, 3 prior lines of treatment). We focused our analysis on the effect of the lenalidomide dose at which resistance was developed, the duration of lenalidomide exposure, and lenalidomide-free interval. On intent to treat, 33% of patients achieved ≥partial remission (PR) with Pd. When Pd was given immediately after lenalidomide, ≥PR was 32% (vs 37% after bortezomib). The response rates were similar for patients that received 5 to 15 mg vs 25 mg of lenalidomide (38.5% vs 30.5%, P = .329). Response rates were higher for patients that had received at least 12 months of lenalidomide (44% vs 27%) and for those with ≥18 months from last lenalidomide dose to pomalidomide dose (65% vs 23%). Median progression-free survival (PFS) and overall survival (OS) were 5 and 12.1 months, respectively, which was similar for patients who received lenalidomide, bortezomib or other regimens just before Pd and similar for patients who were receiving different doses of lenalidomide. IMiD-free interval ≥18 months was associated with longer PFS (10.3 vs 3.9 months, P = .003) and OS (27.1 vs 9.3, P = .008) as well as duration of last lenalidomide therapy ≥12 months (PFS: 7.8 vs 3.2, P = .023; OS: 16.5 vs 7.9, P = .005) even after adjustment for the number of prior therapies, duration of disease, and last lenalidomide dose.
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183
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Derudas D, Capraro F, Martinelli G, Cerchione C. Old and new generation immunomodulatory drugs in multiple myeloma. Panminerva Med 2020; 62:207-219. [PMID: 32955182 DOI: 10.23736/s0031-0808.20.04125-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Over the last two decades, the outcomes of patients with multiple myeloma (MM), a malignant plasma cells dyscrasia, have dramatically improved. The development and the introduction of the immunomodulatory drugs (IMiDs) which include thalidomide, lenalidomide, and pomalidomide, have contributed significantly to these improvements. EVIDENCE ACQUISITION The IMiDs have been shown a multitude of mechanisms of action, including antiangiogenic, cytotoxic and immunomodulatory. The more recent discoveries that the IMiDs bind to cereblon and thus regulate the ubiquitination of key transcription factors including IKZF1 and IKZF3, have provided new insight about their activities. EVIDENCE SYNTHESIS The IMIDs are widely used in the treatment of the different setting of MM patients and particularly lenalidomide represents the backbone in the therapy of newly diagnosed transplant eligible and transplant ineligible patients, in the maintenance setting post-transplant and in the relapsed/refractory setting, while pomalidomide is currently utilized in the relapsed/refractory setting. CONCLUSIONS Here the mechanisms of action, the clinical efficacy and the management of side effects are reviewed as well as the new classes of cereblon E3 ligase modulator (CELMoD) and their promising clinical data are described.
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Affiliation(s)
- Daniele Derudas
- Department of Hematology and Bone Marrow Transplant Center, A. Businco Cancer Hospital, Cagliari, Italy -
| | - Francesca Capraro
- Department of Hematology and Bone Marrow Transplant Center, A. Businco Cancer Hospital, Cagliari, Italy
| | - Giovanni Martinelli
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
| | - Claudio Cerchione
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
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184
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Derudas D, Capraro F, Martinelli G, Cerchione C. How I manage frontline transplant-ineligible multiple myeloma. Hematol Rep 2020; 12:8956. [PMID: 33042505 PMCID: PMC7520858 DOI: 10.4081/hr.2020.8956] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Indexed: 12/24/2022] Open
Abstract
The Multiple Myeloma (MM) is a plasma cells hematological malignancy with a median age of 69 years at diagnosis. The autologous stem cell transplantation is the standard of care for this disease but less than half of newly diagnosed patients are assessed for this treatment due to comorbidities or complications of disease. The management of transplant ineligible MM patients is based on the balance safety and efficacy of the new available regimen and a careful assessment of the frailty status is mandatory to define the goals. In this review we discuss of the clinical dilemmas in the management and define how to manage them based on the evidence from clinical trials and "real life" experience.
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Affiliation(s)
- Daniele Derudas
- S.C. di Ematologia e C.T.M.O., Ospedale Oncologico di Riferimento Regionale “A. Businco”, Cagliari
| | - Francesca Capraro
- S.C. di Ematologia e C.T.M.O., Ospedale Oncologico di Riferimento Regionale “A. Businco”, Cagliari
| | - Giovanni Martinelli
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (FC), Italy
| | - Claudio Cerchione
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (FC), Italy
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185
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Abstract
Despite considerable advances in treatment approaches in the past two decades, multiple myeloma remains an incurable disease. Treatments for myeloma continue to evolve with many emerging immunotherapies. The first immunotherapy used to treat hematologic cancers, including multiple myeloma, was an allogeneic stem cell transplant. In the mid-2000s, immunomodulatory drugs thalidomide, lenalidomide, and subsequently pomalidomide were proven to be effective in multiple myeloma and substantially improved survival. The next wave of immunotherapies for multiple myeloma included the monoclonal antibodies daratumumab and elotuzumab, which were approved by the Food and Drug Administration in 2015. Subsequently, a variety of immunotherapies have been developed for multiple myeloma, including chimeric antigen receptor T cells, bispecific antibodies, antibody drug conjugates, and checkpoint inhibitors. Many of these emerging treatments target the B cell maturation antigen, which is expressed on plasma cells, although several other novel receptors are also being studied. This review summarizes the evidence of these various immunotherapies, their mechanism of action, and data from clinical trials regarding the treatments' safety and efficacy.
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Affiliation(s)
- Urvi A Shah
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, USA
| | - Sham Mailankody
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, USA
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186
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Takezako N, Kosugi H, Matsumoto M, Iida S, Ishikawa T, Kondo Y, Ando K, Miki H, Matsumura I, Sunami K, Teshima T, Iwasaki H, Onishi Y, Kizaki M, Izutsu K, Maruyama D, Tobinai K, Ghori R, Farooqui M, Liao J, Marinello P, Matsuda K, Koh Y, Shimamoto T, Suzuki K. Pembrolizumab plus lenalidomide and dexamethasone in treatment-naive multiple myeloma (KEYNOTE-185): subgroup analysis in Japanese patients. Int J Hematol 2020; 112:640-649. [PMID: 32949374 DOI: 10.1007/s12185-020-02953-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 06/30/2020] [Accepted: 07/14/2020] [Indexed: 01/12/2023]
Abstract
The global, randomized, open-label KEYNOTE-185 study closed early after an interim analysis showed an unfavorable benefit-risk profile with pembrolizumab plus lenalidomide and low-dose dexamethasone (Rd) versus Rd alone in treatment-naive, transplant-ineligible multiple myeloma. This subgroup analysis reported outcomes in the Japanese population. Patients were randomly assigned (1:1) to pembrolizumab plus Rd or Rd alone, stratified by age and International Staging System. The primary end point was progression-free survival (PFS). Fifty-two Japanese patients were randomly assigned to pembrolizumab plus Rd (n = 27) or Rd (n = 25). The median follow-up was 7.2 months (range, 0.4-13.8). The median PFS was not reached (NR); 6-month PFS was 91.2% versus 86.2% with pembrolizumab plus Rd versus Rd [hazard ratio (HR), 0.31; 95% CI, 0.06-1.63]. The median overall survival (OS) was NR; 6-month OS was 96.2% versus 95.7% with pembrolizumab plus Rd versus Rd (HR, 0.33; 95% CI, 0.03-3.72). With pembrolizumab plus Rd versus Rd, grade 3-5 adverse events occurred in 70.4% versus 69.6% of patients; serious adverse events occurred in 40.7% versus 52.5%. Although in the Japanese subgroup of KEYNOTE-185 adding pembrolizumab to Rd did not show an unfavorable risk-benefit, the analysis is limited by short follow-up and small sample size, affecting generalizability of the results.
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Affiliation(s)
- Naoki Takezako
- National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo, Japan.
| | | | - Morio Matsumoto
- National Hospital Organization, Shibukawa Medical Center, Shibukawa, Japan
| | | | | | - Yukio Kondo
- Kanazawa University Hospital, Kanazawa, Japan
| | - Kiyoshi Ando
- Tokai University School of Medicine, Isehara, Japan
| | | | | | - Kazutaka Sunami
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | | | - Hiromi Iwasaki
- National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | | | - Masahiro Kizaki
- Saitama Medical Center, Saitama Medical University, Kawagoe-shi, Japan
| | - Koji Izutsu
- National Cancer Center Hospital, Tokyo, Japan
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187
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Zhang PF, Zhang MX, Wu QJ, Li Q. WITHDRAWN: Cost-effectiveness analysis of daratumumab plus bortezomib, melphalan and prednisone for newly diagnosed multiple myeloma ineligible for stem cell transplantation. Leuk Res 2020. [DOI: 10.1016/j.leukres.2020.106444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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188
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Low-dose lenalidomide and dexamethasone therapy after melphalan-prednisolone induction in elderly patients with newly diagnosed multiple myeloma. Ann Hematol 2020; 99:2351-2356. [PMID: 32865607 DOI: 10.1007/s00277-020-04240-x] [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: 08/02/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
Lenalidomide (Len) and dexamethasone (dex) therapy is a standard therapy in patients with multiple myeloma. Elderly or unfit patients may reduce Len or dex doses to prevent toxicities that lead to treatment discontinuation. However, there have been few studies evaluating the efficacy and safety of lower doses of Len and dex. We conducted a phase II study of 1.5-year low-dose Len and dex therapy following melphalan and prednisolone (MP), the number of which cycles was determined by a response within 9 cycles. The Len dose was 10 mg daily and the dex dose was 20 mg weekly, which were continued for 1.5 years. Twenty-one patients were enrolled. The median number of cycles of MP was 3 (range, 2-9). The overall response rate was 81% and a very good partial response or better was achieved in 33.3% of patients. The median follow-up time for survivors was 70.5 months (range, 42-83 months), the median progression-free survival (PFS) was 27 months (95% CI, 21-33 months), and the median overall survival was not reached. Grade 3 or 4 adverse events were observed in 28.6% of patients. In conclusion, the low-dose Len and dex therapy safely achieved comparable efficacies to the standard-dose regimen in elderly patients with newly diagnosed multiple myeloma. UMIN000007889.
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189
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Djebbari F, Panitsas F, Eyre TA, Prodger C, Davies F, Burton K, Khera A, Vallance G, Moore S, Kothari J, Peniket A, Ramasamy K. Infection-related morbidity in a large study of transplant non-eligible newly diagnosed myeloma patients treated with UK standard of care. Haematologica 2020; 105:e474-479. [PMID: 33054067 PMCID: PMC7556501 DOI: 10.3324/haematol.2019.240762] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Faouzi Djebbari
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Fotios Panitsas
- Department of Haematology, Larissa University Hospital, Larissa, Greece
| | - Toby A Eyre
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Catherine Prodger
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Fearn Davies
- Department of Pharmacy, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kieran Burton
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Akhil Khera
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Grant Vallance
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sally Moore
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jaimal Kothari
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andy Peniket
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karthik Ramasamy
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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190
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Grant SJ, Lipe B. Management of Frail Older Adults with Newly Diagnosed Multiple Myeloma - Moving Toward a Personalized Approach. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2020; 20 Suppl 1:S76-S80. [PMID: 32862879 PMCID: PMC8931508 DOI: 10.1016/s2152-2650(20)30470-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
CASE VIGNETTE A 75-year-old male undergoes an evaluation for progressively worsening fatigue with associated shortness of breath. He also reports back pain worse at night, which does not resolve with acetaminophen. He is retired, but over the past 2 months he is unable to garden or perform household chores. Due to his pain and fatigue, he has limited his activity. He currently takes 9 prescription medications for chronic medical conditions, which include diabetes mellitus with neuropathy, hypertension, hyperlipidemia, and COPD. Initial evaluation reveals anemia (Hgb 9.0 g/dl last known normal was 2 years ago, Hgb 13.5 g/dl), renal impairment (serum creatinine 2.5 mg/dL), hypercalcemia (11.5 g/dl). Plain X-rays reveal compression fractures involving T3 and T4. Multiple myeloma is suspected, further labs confirm the diagnosis of IgG kappa multiple myeloma. LDH is elevated, beta-2-microglobulin is elevated at 6.1 mg/L and albumin < 3.5 mg/dl. Bone marrow aspiration and biopsy reveal plasmacytosis of 55% and on fluorescence in situ hybridization testing, del 17p/TP53 mutation in 85% of cells is detected. PET/CT confirms diffuse bone disease involving the axial and appendicular skeleton. His Karnofsky performance status (KPS) is 70%. He is widowed and lives alone but has 2 adult children who currently live out of state. This abstract will discuss how assessments of fitness/frailty may be used to develop personalized care tailored to the unique needs of older frail adults with multiple myeloma.
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Affiliation(s)
- Shakira J Grant
- University of Washington, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue, Seattle, WA, 98109 USA
| | - Brea Lipe
- University of Rochester, 301 Elmwood Ave, Rochester, NY 14627.
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191
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Sanchez L, Barley K, Richter J, Franz J, Cho HJ, Jagannath S, Madduri D, Parekh S, Richard S, Chari A. Immunomodulatory drug- and proteasome inhibitor-backbone regimens in the treatment of relapsed multiple myeloma: an evidence-based review. Expert Rev Hematol 2020; 13:943-958. [DOI: 10.1080/17474086.2020.1804356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Larysa Sanchez
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kevin Barley
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua Richter
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joseph Franz
- Department of Internal Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hearn Jay Cho
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sundar Jagannath
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepu Madduri
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samir Parekh
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shambavi Richard
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajai Chari
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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192
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Dima D, Dower J, Comenzo RL, Varga C. Evaluating Daratumumab in the Treatment of Multiple Myeloma: Safety, Efficacy and Place in Therapy. Cancer Manag Res 2020; 12:7891-7903. [PMID: 32904669 PMCID: PMC7457558 DOI: 10.2147/cmar.s212526] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/04/2020] [Indexed: 12/29/2022] Open
Abstract
Despite the tremendous advances in the treatment of multiple myeloma, mortality remains significant, highlighting the need for new effective strategies. In recent years, daratumumab, a novel human monoclonal antibody, binding CD38, has dramatically improved outcomes either as monotherapy or in combination with traditional regimens. Originally approved for relapsed/refractory multiple myeloma, this breakthrough medication is now being used as frontline therapy in patients with newly diagnosed multiple myeloma regardless of transplant eligibility, with trials showing promising results. Its tolerable side-effect profile and enhanced efficacy have led to its widespread incorporation into the management of multiple myeloma and further exploration about its use in other entities such as smoldering myeloma, MGUS, MGRS and amyloidosis. This comprehensive review will discuss daratumumab's mechanism of action and safety profile, as well as research which has defined its current approved indications, and ongoing clinical investigation that will define its future.
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Affiliation(s)
- Danai Dima
- Department of Medicine, Tufts Medical Center, Boston, MA02111, USA
| | - Joshua Dower
- Department of Medicine, Tufts Medical Center, Boston, MA02111, USA
| | - Raymond L Comenzo
- The John Conant Davis Myeloma and Amyloid Program, Division of Hematology-Oncology, Tufts Medical Center, Boston, MA02111, USA
| | - Cindy Varga
- The John Conant Davis Myeloma and Amyloid Program, Division of Hematology-Oncology, Tufts Medical Center, Boston, MA02111, USA
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193
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Balitsky AK, Karkar A, McCurdy A, Rochwerg B, Mian HS. Maintenance therapy in transplant ineligible adults with newly-diagnosed multiple myeloma: A systematic review and meta-analysis. Eur J Haematol 2020; 105:626-634. [PMID: 32710492 DOI: 10.1111/ejh.13496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND The role of maintenance therapy in transplant ineligible multiple myeloma (MM) patients following a period of fixed duration induction therapy remains unclear. OBJECTIVES We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) examining maintenance therapy compared to observation. METHODS We conducted a comprehensive search including MEDLINE, Embase, and the Cochrane database up to February 28, 2020, for RCTs comparing maintenance therapy to observation in newly diagnosed transplant ineligible MM patients. Two authors independently screened studies for eligibility, extracted data, and assessed risk of bias. We performed meta-analyses using a random-effects model and assessed certainty using GRADE methodology. MAIN RESULTS We included five RCTs with a total of 1139 patients. Patients receiving maintenance therapy had improved progression-free survival (PFS) compared to observation (Hazard ratio [HR] 0.48, 95% confidence interval [CI] 0.38 to 0.62, high certainty); however, there was no difference in overall survival (HR 0.96, 95% CI 0.76-1.2, moderate certainty). Adverse events were higher in the maintenance group compared to observation (very low to moderate certainty). CONCLUSION Maintenance therapy increases PFS in transplant ineligible MM patients following a fixed period of induction therapy; however, this must be weighed against the increased risk of adverse events.
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Affiliation(s)
- Amaris K Balitsky
- Division of Malignant Hematology, Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Aram Karkar
- Division of Internal Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Arleigh McCurdy
- Division of Hematology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Hira S Mian
- Division of Malignant Hematology, Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
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194
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Outcomes with autologous stem cell transplant vs. non-transplant therapy in patients 70 years and older with multiple myeloma. Bone Marrow Transplant 2020; 56:368-375. [PMID: 32782351 DOI: 10.1038/s41409-020-01026-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 11/08/2022]
Abstract
We evaluated 79 patients with multiple myeloma (MM) ≥70 years referred to our blood and marrow transplant clinic, within 1 year of diagnosis from 2010 to 2019, for consideration of autologous stem cell transplant (ASCT). Thirty-eight (48%) of 79 patients underwent ASCT. ASCT was not pursued in 41 (52%) patients due to: patient or physician preference in 80% (n = 33) or ineligibility in 20% (n = 8). Baseline characteristics of patients in the two groups were similar. Median PFS from treatment start amongst patients undergoing ASCT (n = 38) vs. not (n = 41) was 41 months vs. 33 months, p = 0.03. There was no difference in OS, with estimated 5-year OS of 73% vs. 83%, respectively (p = 0.86). Day +100 transplant-related mortality (TRM) was 0%. ASCT was an independent favorable prognostic factor for PFS in multivariate analysis, after accounting for HCT-CI score, performance status, hematologic response, and maintenance. Finally, patients ≥70 years undergoing ASCT had similar PFS compared to a contemporaneous institutional cohort of patients <70 years (n = 631) (median PFS from transplant: 36 vs. 47 months, p = 0.25). In this retrospective analysis, ASCT was associated with low TRM and better PFS in fit older adults with MM compared to non-transplant therapy, with comparable benefits as seen in younger patients.
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195
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Merz M, Dechow T, Scheytt M, Schmidt C, Hackanson B, Knop S. The clinical management of lenalidomide-based therapy in patients with newly diagnosed multiple myeloma. Ann Hematol 2020; 99:1709-1725. [PMID: 32296915 PMCID: PMC7340649 DOI: 10.1007/s00277-020-04023-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 04/04/2020] [Indexed: 02/06/2023]
Abstract
Lenalidomide is an integral, yet evolving, part of current treatment pathways for both transplant-eligible and transplant-ineligible patients with newly diagnosed multiple myeloma (NDMM). It is approved in combination with dexamethasone as first-line therapy for transplant-ineligible patients with NDMM, and as maintenance treatment following autologous stem cell transplantation (ASCT). Although strong clinical trial evidence has supported the integration of lenalidomide into current treatment paradigms for NDMM, applying those paradigms to individual patients and determining which patients are most likely to benefit from lenalidomide treatment are more complex. In this paper, we utilize the available clinical trial evidence to provide recommendations for patient selection and lenalidomide dosing in both the first-line setting in patients ineligible for ASCT and the maintenance setting in patients who have undergone ASCT. In addition, we provide guidance on management of those adverse events that are most commonly associated with lenalidomide treatment, and consider the optimal selection and sequencing of next-line agents following long-term frontline or maintenance treatment with lenalidomide.
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Affiliation(s)
- Maximilian Merz
- Department of Internal Medicine V, Multiple Myeloma Division, Heidelberg University Medical Center, Heidelberg, Germany
| | - Tobias Dechow
- Private Oncology Practice Ravensburg, Ravensburg, Germany
| | - Mithun Scheytt
- Department of Internal Medicine II, Hematology and Medical Oncology Division, Würzburg University Medical Center, Würzburg, Germany
| | - Christian Schmidt
- Grosshadern University Hospital, Department of Internal Medicine III, University Hospital of Ludwig Maximilians University, Munich, Germany
| | - Bjoern Hackanson
- Department of Internal Medicine II and ICCA, Augsburg University Hospital, Augsburg, Germany
| | - Stefan Knop
- Department of Internal Medicine II, Hematology and Medical Oncology Division, Würzburg University Medical Center, Würzburg, Germany.
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196
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Mai EK, Miah K, Bertsch U, Dürig J, Scheid C, Weisel KC, Kunz C, Munder M, Lindemann HW, Merz M, Hose D, Jauch A, Seckinger A, Luntz S, Sauer S, Fuhrmann S, Brossart P, Elmaagacli A, Goerner M, Bernhard H, Hoffmann M, Raab MS, Blau IW, Hänel M, Benner A, Salwender HJ, Goldschmidt H. Bortezomib-based induction, high-dose melphalan and lenalidomide maintenance in myeloma up to 70 years of age. Leukemia 2020; 35:809-822. [PMID: 32684633 PMCID: PMC8318883 DOI: 10.1038/s41375-020-0976-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/29/2020] [Accepted: 07/06/2020] [Indexed: 01/03/2023]
Abstract
Intensive upfront therapy in newly-diagnosed multiple myeloma (MM) including induction therapy (IT), high-dose melphalan (MEL200), and autologous blood stem cell transplantation (ASCT) followed by consolidation and/or maintenance is mostly restricted to patients up to 65 years of age. Prospective phase III trial data in the era of novel agents for patients up to 70 years of age are not available. The GMMG-MM5 trial included 601 patients between 18 and 70 years of age, divided in three groups for the present analysis: ≤60 years (S1, n = 353), 61–65 years (S2, n = 107) and 66–70 years (S3, n = 141). Treatment consisted of a bortezomib-containing IT, MEL200/ASCT, consolidation, and maintenance with lenalidomide. Adherence to treatment was similar among patients of the three age groups. Overall toxicity during all treatment phases was increased in S2 and S3 compared to S1 (any adverse event/any serious adverse event: S1:81.7/41.8% vs. S2:90.7/56.5% vs. S3:87.2/68.1%, p = 0.05/<0.001). With respect to progression-free survival (log-rank p = 0.73), overall survival (log-rank p = 0.54) as well as time-to-progression (Gray’s p = 0.83) and non-relapse mortality (Gray’s p = 0.25), no differences were found between the three age groups. Our results imply that an intensive upfront therapy with a bortezomib-containing IT, MEL200/ASCT, lenalidomide consolidation, and maintenance should be applied to transplant-eligible MM patients up to 70 years of age.
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Affiliation(s)
- Elias K Mai
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.,National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - Kaya Miah
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Uta Bertsch
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.,National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - Jan Dürig
- Department of Hematology, University Clinic Essen, Essen, Germany
| | - Christof Scheid
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - Katja C Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Hematology, Oncology and Immunology, University Hospital Tübingen, Tübingen, Germany
| | - Christina Kunz
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Institute of Child Nutrition, Max Rubner Institute, Federal Research Institute of Nutrition and Food, Karlsruhe, Germany
| | - Markus Munder
- Department of Internal Medicine III, University Medical Center Mainz, Mainz, Germany
| | - Hans-Walter Lindemann
- Department of Hematology and Oncology, Katholisches Krankenhaus Hagen, Hagen, Germany
| | - Maximilian Merz
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Dirk Hose
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna Jauch
- Institute of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Anja Seckinger
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Steffen Luntz
- Coordination Centre for Clinical Trials, University Hospital Heidelberg, Heidelberg, Germany
| | - Sandra Sauer
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Stephan Fuhrmann
- Department of Hematology and Oncology, Helios Hospital Berlin Buch, Berlin, Germany
| | | | - Ahmet Elmaagacli
- Department of Hematology and Oncology, Asklepios Hospital Hamburg St. Georg, Hamburg, Germany
| | - Martin Goerner
- Department of Hematology, Oncology and Palliative Care, Klinikum Bielefeld, Bielefeld, Germany
| | - Helga Bernhard
- Department of Internal Medicine V, Klinikum Darmstadt, Darmstadt, Germany
| | - Martin Hoffmann
- Medical Clinic A, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Marc S Raab
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Igor W Blau
- Medical Clinic, Charité University Medicine Berlin, Berlin, Germany
| | - Mathias Hänel
- Department of Internal Medicine III, Klinikum Chemnitz, Chemnitz, Germany
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hans J Salwender
- Department of Hematology and Oncology, Asklepios Hospital Hamburg Altona, Hamburg, Germany
| | - Hartmut Goldschmidt
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany. .,National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany.
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197
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Djebbari F, Panitsas F, Sharpley FA, Rampotas A, Larham J, Moore S, Gooding S, Kothari J, Ramasamy K. Myeloma care adaptations in the UK during SARS-CoV-2 pandemic: Challenges and measurable outcomes. Eur J Haematol 2020; 105:662-666. [PMID: 32592210 PMCID: PMC7361835 DOI: 10.1111/ejh.13479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/21/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Faouzi Djebbari
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Fotios Panitsas
- Department of Haematology, Laiko General Hospital, Athens, Greece
| | - Faye A Sharpley
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alexandros Rampotas
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jemma Larham
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sally Moore
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarah Gooding
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jaimal Kothari
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karthik Ramasamy
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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198
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Timing of Autologous Stem Cell Transplantation for Multiple Myeloma in the Era of Current Therapies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e734-e751. [PMID: 32660906 DOI: 10.1016/j.clml.2020.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 05/10/2020] [Accepted: 05/29/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Autologous stem cell transplantation (SCT) during the initial treatment of multiple myeloma has been shown to improve progression-free survival (PFS) but not overall survival (OS). While awaiting further prospective data, we retrospectively analyzed the outcomes of patients at our program. PATIENTS AND METHODS We included consecutive patients with newly diagnosed myeloma who had undergone stem cell harvest (SCH) from 2005 to 2014 and separated them into early (SCT within 12 months of diagnosis) and delayed (all others, including SCT not yet) groups. The outcomes were OS, PFS to first relapse, and PFS to second relapse. RESULTS Of the 514 patients who had undergone SCH, 227 were in the early and 287 in the delayed groups. Patients in the delayed group who had undergone SCT had received more therapy before SCT (55% had received ≥ 2 lines vs. 6% in the early group; P < .001), had had more progressive disease at SCT (34% vs. 4%; P < .001), had received melphalan doses < 200 mg/m2 (22% vs. 10%; P = .001), and had had lower rates of very good partial response or better after SCT (58% vs. 79%; P = .001). On multivariable analysis, no differences were found in median OS (90 vs. 84 months; P = .093), PFS to first relapse (40 vs. 37 months; P = .552), or PFS to second relapse (54 vs. 52 months; P = .488) between the early and delayed groups. CONCLUSION Delaying SCT did not affect OS or even PFS to second relapse in our cohort of patients with newly diagnosed myeloma who had received current era induction therapy.
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199
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Luttwak E, Gatt ME, Lebel E, Lavi N, Tadmor T, Natalia K, Benyamini N, Horowitz N, Geva M, Suriu C, Avivi I, Trestman S, Mittelman M, Rouvio O, Cohen YC. Bortezomib Maintenance Therapy as a Standard of Care Provides Favorable Outcomes in Newly Diagnosed Myeloma Patients: A Multisite Real-Life Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e850-e857. [PMID: 32624446 DOI: 10.1016/j.clml.2020.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/31/2020] [Accepted: 06/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lenalidomide and ixazomib maintenance improve long-term outcomes in newly diagnosed multiple myeloma (NDMM) patients. However, there is less evidence to support bortezomib (BTZ) maintenance therapy, and real-life data on maintenance are scarce. We investigated the efficacy and safety of BTZ maintenance therapy in NDMM. PATIENTS AND METHODS A retrospective multisite study was performed in 6 medical centers in Israel. All consecutive patients with NDMM diagnosed between January 1, 2010, and July 3, 2019, who received a BTZ-based induction, with or without an autologous transplantation, followed by BTZ maintenance therapy, were identified. Maintenance therapy was defined as BTZ (1.3 mg/m2) once every 2 weeks, administered subcutaneously alone or with dexamethasone, or weekly BTZ monotherapy. RESULTS A total of 105 patients were identified, 58 of whom had received a transplant (transplant eligible) and 47 who had not (not transplant eligible). During BTZ maintenance therapy, 96% had one or more adverse event, 11.5% had grade 3 or higher adverse events, and 11.5% discontinued treatment due to toxicity. Median progression-free survival (PFS) and overall survival were 45 and 91.5 months, respectively; 4-year survival was 88%. Adverse cytogenetics was associated with worse PFS (24 vs. 46 months, P = .001). In subgroup analysis, adverse cytogenetics were associated with worse PFS (P < .001) and OS (P < .001) among transplant-ineligible but not transplant-eligible patients. CONCLUSION Analysis of multisite real-life data showed that BTZ maintenance therapy is safe, well tolerated, and effective. Median PFS was similar to that reported with alternative maintenance strategies. Our findings further support its use among patients with adverse cytogenetics, it may also be relevant for patients with lenalidomide-intolerant disease.
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Affiliation(s)
- Efrat Luttwak
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Moshe E Gatt
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Eyal Lebel
- Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Noa Lavi
- Department of Hematology & Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Tamar Tadmor
- Hematology Unit, Bnai-Zion Medical Center, Haifa, Israel
| | | | - Noam Benyamini
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Netanel Horowitz
- Department of Hematology & Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Mika Geva
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Celia Suriu
- Department of Haematology, Galilee Medical Centre, Nahariya, Israel
| | - Irit Avivi
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Svetlana Trestman
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Moshe Mittelman
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ory Rouvio
- Soroka University Medical Center, Beersheba, Israel
| | - Yael C Cohen
- Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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200
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Atrash S, Bhutani M, Paul B, Voorhees PM, Usmani SZ. Management of newly diagnosed transplant ineligible multiple myeloma. Leuk Lymphoma 2020; 61:2549-2560. [PMID: 32623918 DOI: 10.1080/10428194.2020.1786558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multiple myeloma (MM) is a chronically managed blood cancer with a median age of 69 years at the time of diagnosis. Although high dose melphalan and autologous stem cell transplantation (ASCT) remains a standard of care for eligible patients, more than half of the newly diagnosed MM patients are deemed ineligible due to comorbidities or complications of the disease by itself. In this setting, where ASCT is deemed inappropriate, patients could still achieve durable and deep responses if given the appropriate treatment plan. The key concepts of optimizing induction and maintenance strategies while minimizing side-effects are discussed in this review, especially in the context of employing novel agent combinations. It is important to understand the balance between safety and efficacy for each regimen, utilizing maintenance strategy and the best supportive care measures (bone health, infection prevention, and treatment, pain management, etc.). Here, we examine the evidence behind each of those principles and review results from clinical trials for transplant-ineligible (TI) MM.
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Affiliation(s)
- Shebli Atrash
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Manisha Bhutani
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Barry Paul
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Peter M Voorhees
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Saad Z Usmani
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
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