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Costa BA, Mouhieddine TH, Ortiz RJ, Richter J. Revisiting the Role of Alkylating Agents in Multiple Myeloma: Up-to-Date Evidence and Future Perspectives. Crit Rev Oncol Hematol 2023; 187:104040. [PMID: 37244325 DOI: 10.1016/j.critrevonc.2023.104040] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023] Open
Abstract
From the 1960s to the early 2000s, alkylating agents (e.g., melphalan, cyclophosphamide, and bendamustine) remained a key component of standard therapy for newly-diagnosed or relapsed/refractory multiple myeloma (MM). Later on, their associated toxicities (including second primary malignancies) and the unprecedented efficacy of novel therapies have led clinicians to increasingly consider alkylator-free approaches. Meanwhile, new alkylating agents (e.g., melflufen) and new applications of old alkylators (e.g., lymphodepletion before chimeric antigen receptor T-cell [CAR-T] therapy) have emerged in recent years. Given the expanding use of antigen-directed modalities (e.g., monoclonal antibodies, bispecific antibodies, and CAR-T therapy), this review explores the current and future role of alkylating agents in different treatment settings (e.g., induction, consolidation, stem cell mobilization, pre-transplant conditioning, salvage, bridging, and lymphodepleting chemotherapy) to ellucidate the role of alkylator-based regimens in modern-day MM management.
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Affiliation(s)
- Bruno Almeida Costa
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tarek H Mouhieddine
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ricardo J Ortiz
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua Richter
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Grzasko N, Charlinski G, Morawska M, Kicinski P, Waszczuk-Gajda A, Drozd-Sokolowska J, Subocz E, Blonska D, Razny M, Druzd-Sitek A, Holojda J, Swiderska A, Usnarska-Zubkiewicz L, Masternak A, Giannopoulos K. Bendamustine-Based Regimens as Salvage Therapy in Refractory/Relapsed Multiple Myeloma Patients: A Retrospective Real-Life Analysis by the Polish Myeloma Group. J Clin Med 2021; 10:jcm10235504. [PMID: 34884206 PMCID: PMC8658377 DOI: 10.3390/jcm10235504] [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] [Received: 10/24/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022] Open
Abstract
Multiple myeloma (MM) is an incurable disease and patients become refractory to the treatment in the course of the disease. Bendamustine-based regimens containing steroids and other agents are among the therapeutic options offered to MM patients. Here, we investigated the safety and the efficacy of bendamustine used in patients with refractory/relapsed MM (RRMM). The patients were treated with bendamustine and steroids (n = 52) or bendamustine, steroids and immunomodulatory agents or proteasome inhibitors (n = 53). Response rates, progression-free survival (PFS), overall survival (OS) and frequency of adverse events were compared between both study groups. Most efficacy measurements were better in patients treated with three-drug regimens: overall response rate (55% versus 37%, p = 0.062), median PFS (9 months versus 4 months, p < 0.001), median OS survival (18 months versus 12 months, p = 0.679). The benefit from combining bendamustine and steroids with an additional agent was found in subgroups previously treated with both lenalidmide and bortezomib, with stem cell transplant and with more than two previous therapy lines. Toxicity was similar in both study groups and bendamustine-based therapies were generally well-tolerated. Our study suggests that bendamustine may be an effective treatment for patients with RRMM. Three-drug regimens containing bendamustine, steroids and novel agents produced better outcomes and had acceptable toxicity. The efficacy of bendamustine combined with steroids was limited.
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Affiliation(s)
- Norbert Grzasko
- Department of Experimental Hematooncology, Medical University of Lublin, 20-400 Lublin, Poland; (M.M.); (P.K.); (K.G.)
- Correspondence:
| | - Grzegorz Charlinski
- Department of Hematology, Medical Faculty, University of Warmia and Mazury in Olsztyn, 10-228 Olsztyn, Poland;
| | - Marta Morawska
- Department of Experimental Hematooncology, Medical University of Lublin, 20-400 Lublin, Poland; (M.M.); (P.K.); (K.G.)
| | - Pawel Kicinski
- Department of Experimental Hematooncology, Medical University of Lublin, 20-400 Lublin, Poland; (M.M.); (P.K.); (K.G.)
| | - Anna Waszczuk-Gajda
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.W.-G.); (J.D.-S.)
| | - Joanna Drozd-Sokolowska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (A.W.-G.); (J.D.-S.)
| | - Edyta Subocz
- Department of Internal Diseases and Hematology, Military Institute of Medicine, 04-141 Warsaw, Poland;
| | - Danuta Blonska
- Department of Hematology, Jan Biziel University Hospital No. 2, 85-168 Bydgoszcz, Poland;
| | - Malgorzata Razny
- Department of Hematology and Internal Diseases, Ludwik Rydygier Specialistic Hospital, 31-826 Cracow, Poland;
| | - Agnieszka Druzd-Sitek
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie National Research Institute of Oncology, 00-001 Warsaw, Poland;
| | - Jadwiga Holojda
- Department of Hematology, Specialistic City Hospital, 59-220 Legnica, Poland;
| | - Alina Swiderska
- Department of Hematology, University Hospital in Zielona Gora, 65-046 Zielona Gora, Poland;
| | - Lidia Usnarska-Zubkiewicz
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, 50-367 Wroclaw, Poland;
| | - Anna Masternak
- Department of Hematology, Specialist Hospital in Opole, 45-372 Opole, Poland;
| | - Krzysztof Giannopoulos
- Department of Experimental Hematooncology, Medical University of Lublin, 20-400 Lublin, Poland; (M.M.); (P.K.); (K.G.)
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Goldschmidt H, Ashcroft J, Szabo Z, Garderet L. Navigating the treatment landscape in multiple myeloma: which combinations to use and when? Ann Hematol 2018; 98:1-18. [PMID: 30470875 PMCID: PMC6334731 DOI: 10.1007/s00277-018-3546-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 11/06/2018] [Indexed: 12/31/2022]
Abstract
Multiple myeloma is one of the most common hematological malignancies, affecting mainly elderly patients. The treatment landscape for the management of this disease has evolved significantly over the past 15 years, and a vast array of therapeutics is now available, including immunomodulatory drugs, proteasome inhibitors, histone deacetylase inhibitors, and monoclonal antibodies. As a result, deciding which drugs to use and when, and whether these should be used in a particular order or combination, can be challenging. Although combination regimens are often associated with deeper responses and better long-term outcomes than monotherapy, and are becoming the standard of care, they may result in significant incremental toxicity; hence, a sequential approach may be more appropriate for some patients. In particular, treatment choices can vary depending on whether the patient has newly diagnosed multiple myeloma, is eligible for transplant, has relapsed and/or refractory multiple myeloma, or is considered to have high-risk disease. In this review, we discuss factors to be taken into account when making treatment decisions in each of these settings. We also briefly discuss possible therapeutic strategies involving agents that may become available in the future.
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Affiliation(s)
- Hartmut Goldschmidt
- Internal Medicine V and National Center for Tumor Diseases (NCT), University Clinic Heidelberg, 69120, Heidelberg, Germany.
| | - John Ashcroft
- Department of Haematology, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Zsolt Szabo
- Clinical Development, Amgen (Europe) GmbH, Zug, Switzerland
| | - Laurent Garderet
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, Paris, 75012, France.,AP-HP, Hôpital Saint Antoine, Département d'hématologie et de thérapie cellulaire, Sorbonne Université, Paris 6, Paris, France
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Cavo M, Terpos E, Bargay J, Einsele H, Cavet J, Greil R, de Wit E. The multiple myeloma treatment landscape: international guideline recommendations and clinical practice in Europe. Expert Rev Hematol 2018; 11:219-237. [PMID: 29415570 DOI: 10.1080/17474086.2018.1437345] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Guidelines provide recommendations on the management of multiple myeloma (MM), but there are no standard algorithms for the choice and sequencing of treatments. As a result, there is widespread variation in the interpretation and implementation of these guidelines. Areas covered: This review will cover: the real-world data on MM treatment patterns; the approved agents available for the treatment of MM; a comparative summary of the national and international clinical guidelines; a discussion on the impact reimbursement decisions have on treatment availability. Expert commentary: In the future, treatment choices may become even more complex as clonal heterogeneity is better understood in the context of response to treatment, and next-generation agents become available. Although information on real-world practice patterns can provide further guidance, to date, few studies have generated data on patients treated with the newer agents in real-world settings. Furthermore, the translation of guideline recommendations into clinical practice across Europe is inconsistent. Additional real-world data are therefore vital to understanding current clinical practice patterns, so that new agents can be effectively incorporated into existing treatment strategies. Such information may aid the development of better guidance, which will ultimately help to ensure that patients receive the best possible care.
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Affiliation(s)
- Michele Cavo
- a "Seràgnoli" Institute of Hematology and Medical Oncology , Bologna University School of Medicine , Bologna , Italy
| | - Evangelos Terpos
- b Department of Clinical Therapeutics , National and Kapodistrian University of Athens School of Medicine , Athens , Greece
| | - Joan Bargay
- c Department of Hematology and Hemotherapy , Hospital Son Llàtzer , Mallorca , Spain
| | - Hermann Einsele
- d Julius-Maximilians-University of Würzburg, and Department of Internal Medicine II , University Hospital Würzburg , Würzburg , Germany
| | - Jim Cavet
- e Consultant Hematologist , Christie National Health Service Foundation Trust , Manchester , UK.,f University of Manchester , Manchester , UK
| | - Richard Greil
- g University Clinic for Internal Medicine III, and Laboratory of Immunological and Molecular Cancer Research (LIMCR), Third Medical Department , Paracelsus Medical University, and Salzburg Cancer Research Institute , Salzburg , Austria
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5
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Büyükkaramikli NC, de Groot S, Fayter D, Wolff R, Armstrong N, Stirk L, Worthy G, Albuquerque de Almeida F, Kleijnen J, Al MJ. Pomalidomide with Dexamethasone for Treating Relapsed and Refractory Multiple Myeloma Previously Treated with Lenalidomide and Bortezomib: An Evidence Review Group Perspective of an NICE Single Technology Appraisal. PHARMACOECONOMICS 2018; 36:145-159. [PMID: 29086363 PMCID: PMC5805808 DOI: 10.1007/s40273-017-0581-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The National Institute for Health and Care Excellence (NICE), as part of the institute's single technology appraisal (STA) process, invited the manufacturer of pomalidomide (POM; Imnovid®, Celgene) to submit evidence regarding the clinical and cost effectiveness of the drug in combination with dexamethasone (POM + LoDEX) for the treatment of relapsed and refractory multiple myeloma (RRMM) after at least two regimens including lenalidomide (LEN) and bortezomib (BOR). Kleijnen Systematic Reviews Ltd (KSR) and Erasmus University Rotterdam were commissioned as the Evidence Review Group (ERG) for this submission. The ERG reviewed the evidence submitted by the manufacturer, validated the manufacturer's decision analytic model, and conducted exploratory analyses in order to assess the robustness and validity of the presented clinical and cost-effectiveness results. This paper describes the company submission, the ERG assessment, and NICE's subsequent decisions. The company conducted a systematic review to identify studies comparing POM with comparators outlined in the NICE scope: panobinostat with bortezomib and dexamethasone (PANO + BOR + DEX), bendamustine with thalidomide and dexamethasone (BTD) and conventional chemotherapy (CC). The main clinical effectiveness evidence was obtained from MM-003, a randomized controlled trial (RCT) comparing POM + LoDEX with high-dose dexamethasone (HiDEX; used as a proxy for CC). Additional data from other studies were also used as nonrandomized observational data sources for the indirect treatment comparison of POM + LoDEX with BTD and PANO + BOR + DEX. Covariate or treatment switching adjustment methods were used for each comparison. The model developed in Microsoft® Excel 2010 using a semi-Markov partitioned survival structure, submitted in the original submission to NICE for TA338, was adapted for the present assessment of the cost effectiveness of POM + LoDEX. Updated evidence from the clinical-effectiveness part was used for the survival modelling of progression-free survival and overall survival. For POM + LoDEX, the patient access scheme (PAS) discount was applied to the POM price. Three separate comparisons were conducted for each comparator, each comparison using a different dataset and adjustment methods. The ERG identified and corrected some errors, and the corrected incremental cost-effectiveness ratios (ICERs) for POM + LoDEX versus each comparator were presented: approximately £45,000 per quality-adjusted life-year (QALY) gained versus BTD, savings of approximately £143,000 per QALY lost versus PANO + BOR + DEX, and approximately £49,000 per QALY gained versus CC. The ERG also conducted full incremental analyses, which revealed that CC, POM + LoDEX and PANO + BOR + DEX were on the cost-effectiveness frontier. The committee's decision on the technology under analysis deemed that POM + LoDEX should be recommended as an option for treating multiple myeloma in adults at third or subsequent relapse of treatments including both LEN and BOR, contingent on the company providing POM with the discount agreed in the PAS.
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Affiliation(s)
- Nasuh C Büyükkaramikli
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Saskia de Groot
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | | | - Lisa Stirk
- Kleijnen Systematic Reviews Ltd, York, UK
| | | | - Fernando Albuquerque de Almeida
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Maiwenn J Al
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
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6
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Beck J, Schwarzer A, Gläser D, Mügge LO, Uhlig J, Heyn S, Kragl B, Mohren M, Hoffmann FA, Lange T, Schliwa T, Zehrfeld T, Becker C, Kreibich U, Winkelmann C, Edelmann T, Andrea M, Bill M, Jentzsch M, Schwind S, Niederwieser D, Pönisch W. Lenalidomide in combination with bendamustine and prednisolone in relapsed/refractory multiple myeloma: results of a phase 2 clinical trial (OSHO-#077). J Cancer Res Clin Oncol 2017; 143:2545-2553. [PMID: 28828689 DOI: 10.1007/s00432-017-2504-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/14/2017] [Indexed: 01/01/2023]
Abstract
INTRODUCTION While lenalidomide monotherapy is established for relapsed and/or refractory multiple myeloma (MM) treatment, combination therapies including lenalidomide are still under investigation in a number of phase 2/3 studies. In the current study, a treatment regime of lenalidomide (Revlimid®), bendamustine and prednisolone (RBP) was tested in patients with relapsed/refractory MM. METHODS In the previously completed phase 1 study RBP with a dose of 75 mg/m2 bendamustine days 1-2, prednisolone 100 mg days 1-4 and 25 mg lenalidomide days 1-21 was well tolerated. RESULTS Between July 2011 and September 2013, 25 patients were included in this analysis. The median number of previous treatments was 1 (range 1-2). Twenty-two patients (88%) responded after at least two cycles of RBP (one sCR, five nCR, eight VGPR and eight PR). The median time to first haematological response was 28 days, and median time to best response was 56 days. Due to increased haematological toxicity a dose reduction in most patients required in subsequent cycles of therapy. The median progression-free and overall survival was 22 and 38 months, respectively. In conclusion RBP is a highly effective therapy for patients with relapsed/refractory MM. In contrast to our phase 1 study, dose reduction was necessary in many patients because of haematological toxicity.
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Affiliation(s)
- Juliane Beck
- Department of Haematology and Oncology, University of Leipzig, Johannisallee 32A, 04103, Leipzig, Germany
| | | | - Dietrich Gläser
- Department of Haematology and Oncology, Klinikum Südstadt Rostock, Rostock, Germany
| | - Lars-Olof Mügge
- Department of Haematology and Oncology, University of Jena, Jena, Germany
| | - Jens Uhlig
- Haematology Practice, Schulstrasse 1, Naunhof, Germany
| | - Simone Heyn
- Department of Haematology and Oncology, University of Leipzig, Johannisallee 32A, 04103, Leipzig, Germany
| | - Brigitte Kragl
- Department of Haematology and Oncology, University of Rostock, Rostock, Germany
| | - Martin Mohren
- Department of Haematology and Oncology, Johanniter Krankenhaus, Stendal, Germany
| | | | - Thoralf Lange
- Department of Haematology and Oncology, Asklepios Hospital, Weissenfels, Germany
| | - Thomas Schliwa
- Department of Haematology and Oncology, University of Leipzig, Johannisallee 32A, 04103, Leipzig, Germany
| | - Thomas Zehrfeld
- Department of Haematology and Oncology, Hospital Johann Kentmann, Torgau, Germany
| | - Cornelia Becker
- Haematology Practice, Biedermannstrasse 84, Leipzig, Germany
| | - Ute Kreibich
- Department of Haematology and Oncology, Heinrich-Braun-Hospital, Zwickau, Germany
| | - Cornelia Winkelmann
- Department of Haematology and Oncology, Paul Gerhardt Stift, Wittenberg, Germany
| | - Thomas Edelmann
- Haematology Practice, Theodor-Heuss-Str. 2, Schkeuditz, Germany
| | - Marc Andrea
- Department of Haematology and Oncology, University of Leipzig, Johannisallee 32A, 04103, Leipzig, Germany
| | - Marius Bill
- Department of Haematology and Oncology, University of Leipzig, Johannisallee 32A, 04103, Leipzig, Germany
| | - Madlen Jentzsch
- Department of Haematology and Oncology, University of Leipzig, Johannisallee 32A, 04103, Leipzig, Germany
| | - Sebastian Schwind
- Department of Haematology and Oncology, University of Leipzig, Johannisallee 32A, 04103, Leipzig, Germany
| | - Dietger Niederwieser
- Department of Haematology and Oncology, University of Leipzig, Johannisallee 32A, 04103, Leipzig, Germany
| | - Wolfram Pönisch
- Department of Haematology and Oncology, University of Leipzig, Johannisallee 32A, 04103, Leipzig, Germany.
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7
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Sonneveld P, De Wit E, Moreau P. How have evolutions in strategies for the treatment of relapsed/refractory multiple myeloma translated into improved outcomes for patients? Crit Rev Oncol Hematol 2017; 112:153-170. [DOI: 10.1016/j.critrevonc.2017.02.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 01/18/2017] [Accepted: 02/09/2017] [Indexed: 10/20/2022] Open
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Naymagon L, Abdul-Hay M. Novel agents in the treatment of multiple myeloma: a review about the future. J Hematol Oncol 2016; 9:52. [PMID: 27363832 PMCID: PMC4929712 DOI: 10.1186/s13045-016-0282-1] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/21/2016] [Indexed: 02/07/2023] Open
Abstract
Multiple myeloma (MM) is a disease that affects plasma cells and can lead to devastating clinical features such as anemia, lytic bone lesions, hypercalcemia, and renal disease. An enhanced understanding of MM disease mechanisms has led to new more targeted treatments. There is now a plethora of treatments available for MM. In this review article, our aim is to discuss many of the novel agents that are being studied or have recently been approved for the treatment of MM. These agents include the following: immunomodulators (pomalidomide), proteasome inhibitors (carfilzomib, marizomib, ixazomib, oprozomib), alkylating agents (bendamustine), AKT inhibitors (afuresertib), BTK inhibitors (ibrutinib), CDK inhibitors (dinaciclib), histone deacetylase inhibitors (panobinostat, rocilinostat, vorinostat), IL-6 inhibitors (siltuximab), kinesin spindle protein inhibitors (filanesib), monoclonal antibodies (daratumumab, elotuzumab, indatuximab, SAR650984), and phosphoinositide 3-kinase (PI3K) inhibitors.
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Affiliation(s)
| | - Maher Abdul-Hay
- Department of Medicine, New York University, New York, USA. .,Perlmutter Cancer Center, New York University, New York, USA. .,NYU School of Medicine, 240 East 38th Street, 19 Floor, New York, NY, 10016, USA.
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Raab MS, Cavo M, Delforge M, Driessen C, Fink L, Flinois A, Gonzalez-McQuire S, Safaei R, Karlin L, Mateos MV, Schoen P, Yong K. Multiple myeloma: practice patterns across Europe. Br J Haematol 2016; 175:66-76. [DOI: 10.1111/bjh.14193] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 04/15/2016] [Indexed: 01/02/2023]
Affiliation(s)
- Marc S. Raab
- Department of Internal Medicine; University of Heidelberg; Heidelberg Germany
| | - Michele Cavo
- “Seràgnoli” Institute of Haematology and Medical Oncology; Bologna University School of Medicine; Bologna Italy
| | | | - Christoph Driessen
- Department of Oncology and Haematology; Kantonsspital St Gallen; St Gallen Switzerland
| | | | | | | | | | | | | | | | - Kwee Yong
- Department of Haematology; University College London; London UK
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10
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Cornell RF, Kassim AA. Evolving paradigms in the treatment of relapsed/refractory multiple myeloma: increased options and increased complexity. Bone Marrow Transplant 2016; 51:479-91. [PMID: 26726946 PMCID: PMC4827007 DOI: 10.1038/bmt.2015.307] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 10/08/2015] [Accepted: 10/22/2015] [Indexed: 12/12/2022]
Abstract
The use of modern therapies such as thalidomide, bortezomib and lenalidomide coupled with upfront high-dose therapy and autologous stem cell transplant (ASCT) has resulted in improved survival in patients with newly diagnosed multiple myeloma (MM). However, patients with relapsed/refractory multiple myeloma (RRMM) often have poorer clinical outcomes and might benefit from novel therapeutic strategies. Emerging therapies, such as deacetylase inhibitors, monoclonal antibodies and new proteasome inhibitors, appear promising and may change the therapeutic landscape in RRMM. A limited number of studies has shown a benefit with salvage ASCT in patients with RRMM, although there remains ongoing debate about its timing and effectiveness. Improvement in transplant outcomes has re-ignited a debate on the timing and possible role for salvage ASCT and allogeneic stem cell transplant in RRMM. As the treatment options for management of patients with RRMM become increasingly complex, physicians must consider both disease- and patient-related factors in choosing the appropriate therapeutic approach, with the goal of improving efficacy while minimizing toxicity.
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Affiliation(s)
- R F Cornell
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - A A Kassim
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
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11
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Cheson BD, Brugger W, Damaj G, Dreyling M, Kahl B, Kimby E, Ogura M, Weidmann E, Wendtner CM, Zinzani PL. Optimal use of bendamustine in hematologic disorders: Treatment recommendations from an international consensus panel - an update. Leuk Lymphoma 2015; 57:766-82. [PMID: 26592922 PMCID: PMC4840280 DOI: 10.3109/10428194.2015.1099647] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Bendamustine has achieved widespread international regulatory approval and is a standard agent for the treatment for chronic lymphocytic leukemia (CLL), indolent non-Hodgkin lymphoma and multiple myeloma. Since approval, the number of indications for bendamustine has expanded to include aggressive non-Hodgkin lymphoma and Hodgkin lymphoma and novel targeted therapies, based on new bendamustine regimens/combinations, are being developed against CLL and lymphomas. In 2010, an international panel of bendamustine experts met and published a set of recommendations on the safe and effective use of bendamustine in patients suffering from hematologic disorders. In 2014, this panel met again to update these recommendations since the clarification of issues including optimal dosing and management of bendamustine-related toxicities. The aim of this report is to communicate the latest consensus on the use of bendamustine, permitting the expansion of its safe and effective administration, particularly in new combination therapies.
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Affiliation(s)
- Bruce D Cheson
- a Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington , DC , USA
| | - Wolfram Brugger
- b Schwarzwald-Baar Clinic, University of Freiburg , Villingen-Schwenningen , Germany
| | - Gandhi Damaj
- c University Hospital, University of Basse-Normandie , Caen , France
| | - Martin Dreyling
- d Medical Clinic, University Hospital of Munich , Munich , Germany
| | - Brad Kahl
- e University of Wisconsin School of Medicine and Public Health , Madison , WI , USA
| | - Eva Kimby
- f Center for Hematology, Department of Medicine Huddinge , Karolinska Institutet , Stockholm , Sweden
| | - Michinori Ogura
- g Department of Hematology , Tokai Central Hospital , Gifu , Japan
| | - Eckhart Weidmann
- h Department of Oncology and Hematology , Krankenhaus Nordwest , Frankfurt , Germany
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12
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Double Relapsed and/or Refractory Multiple Myeloma: Clinical Outcomes and Real World Healthcare Costs. PLoS One 2015; 10:e0136207. [PMID: 26367874 PMCID: PMC4569348 DOI: 10.1371/journal.pone.0136207] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/31/2015] [Indexed: 02/01/2023] Open
Abstract
Double relapsed and/or refractory multiple myeloma (DRMM), MM that is relapsed and/or refractory to bortezomib and lenalidomide, carries a poor prognosis. The healthcare costs of DRMM have not previously been reported. We analyzed detailed medical resource utilization (MRU) costs, drug costs and outcomes for 39 UK patients receiving standard DRMM therapy. Median OS in this cohort was 5.6 months. The mean cost of DRMM treatment plus MRU until death was £23,472 [range: £1,411-£90,262], split between drug costs £11,191 and other resource use costs £12,281. The cost per assumed quality-adjusted life year (QALY) during DRMM was £66,983. These data provide a standard of care comparison when evaluating the cost-effectiveness of new drugs in DRMM.
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Gentile M, Vigna E, Recchia AG, Morabito L, Mendicino F, Giagnuolo G, Morabito F. Bendamustine in multiple myeloma. Eur J Haematol 2015; 95:377-88. [PMID: 26085055 DOI: 10.1111/ejh.12609] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2015] [Indexed: 12/12/2022]
Abstract
The advent of high-dose melphalan with autologous stem-cell transplantation (ASCT), the availability of novel agents such as thalidomide, lenalidomide (immunomodulatory drugs or IMiDs) and bortezomib (proteasome inhibitor) and improvements in supportive care have allowed to increase overall survival in multiple myeloma (MM) patients; nevertheless, MM remains an incurable pathology. For this reason, newer agents are required for continued disease control. Bendamustine is an old drug rediscovered in the last decade. In fact, its unique mechanism of action with structural similarities to both alkylating agents and antimetabolities, but which is not cross-resistant to alkylating agents, has reawakened interest in the use of this drug in the treatment of MM. Studies have proven the safety and efficacy of bendamustine administered alone or in combination with new drugs in both upfront and relapse/refractory settings of MM patients, including those with renal impairment. Moreover, bendamustine has been successfully used as conditioning for autologous stem-cell transplantation. Finally, the use of bendamustine does not compromise peripheral blood stem-cell collection. This drug is generally well tolerated, with the majority of adverse events being due to myelosuppression. Non-haematological adverse events are infrequent and usually mild.
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Affiliation(s)
- Massimo Gentile
- Haematology Unit, Department of Onco-Haematology, A.O. of Cosenza, Cosenza, Italy
| | - Ernesto Vigna
- Haematology Unit, Department of Onco-Haematology, A.O. of Cosenza, Cosenza, Italy
| | - Anna Grazia Recchia
- Haematology Unit, Department of Onco-Haematology, A.O. of Cosenza, Cosenza, Italy
| | - Lucio Morabito
- Medical Oncology & Hematology Unit, Humanitas Cancer Center, Istituto Clinico Humanitas, IRCCS, Milano, Italy
| | - Francesco Mendicino
- Haematology Unit, Department of Onco-Haematology, A.O. of Cosenza, Cosenza, Italy
| | - Giovanna Giagnuolo
- Haematology Unit, Department of Onco-Haematology, A.O. of Cosenza, Cosenza, Italy
| | - Fortunato Morabito
- Haematology Unit, Department of Onco-Haematology, A.O. of Cosenza, Cosenza, Italy
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