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Lopez-Muñoz N, Hernández-Ibarburu G, Alonso R, Sanchez-Pina JM, Ayala R, Calbacho M, Cuellar C, Cedena MT, Jimenez A, Iñiguez R, Pedrera M, Cruz J, Meloni L, Pérez-Rey D, Serrano P, de la Cruz J, Martinez-Lopez J. Large-scale real-life analysis of survival and usage of therapies in multiple myeloma. J Hematol Oncol 2023; 16:76. [PMID: 37468911 PMCID: PMC10357768 DOI: 10.1186/s13045-023-01474-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 06/26/2023] [Indexed: 07/21/2023] Open
Abstract
Survival in multiple myeloma has improved significantly in recent years, especially in young patients. We reviewed the evolution of the survival of patients with MM in three groups based on age at MM diagnosis over three time periods between 1999 and 2020 at our 12 de Octubre Hospital institution (H12O). Then, to confirm our results, we used data from TriNetx, a global health research platform that includes patients from Europe to US. Finally, we analysed differences in the patterns of treatment between networks across the world. Kaplan‒Meier analysis was used to estimate survival probabilities, and between-group differences were tested using the log-rank test and hazard ratio. For patients from H12O, the median OS was 35.61, 55.59 and 68.67 months for the 1999-2009, 2010-2014 and 2015-2020 cohorts, respectively (p = 0.0001). Among all patients included in the EMEA network, the median OS was 20.32 months versus 34.75 months from 1999-2009 versus 2010-2014. The median OS from the 2010-2014 versus 2015-2020 time cohorts was 34.75 months versus 54.43 months, respectively. In relation to the US cohort, the median OS from before 2010 versus 2010-2014 was not reached in either time cohort and neither when comparing the 2010-2014 versus 2015-2019 time cohorts. Bortezomib is the most commonly used drug in the EMEA cohort, while lenalidomide is the most commonly used drug in the US cohort. This large-scale study based on real-world data confirms the previous finding that MM patients have increased their survival in the last two decades.
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Affiliation(s)
- N Lopez-Muñoz
- Hematology Department, Hospital 12 de Octubre, CNIO, Complutense University, Madrid, Spain
| | | | - R Alonso
- Hematology Department, Hospital 12 de Octubre, CNIO, Complutense University, Madrid, Spain
| | - J M Sanchez-Pina
- Hematology Department, Hospital 12 de Octubre, CNIO, Complutense University, Madrid, Spain
| | - R Ayala
- Hematology Department, Hospital 12 de Octubre, CNIO, Complutense University, Madrid, Spain
| | - M Calbacho
- Hematology Department, Hospital 12 de Octubre, CNIO, Complutense University, Madrid, Spain
| | - C Cuellar
- Hematology Department, Hospital 12 de Octubre, CNIO, Complutense University, Madrid, Spain
| | - M T Cedena
- Hematology Department, Hospital 12 de Octubre, CNIO, Complutense University, Madrid, Spain
| | - A Jimenez
- Hematology Department, Hospital 12 de Octubre, CNIO, Complutense University, Madrid, Spain
| | - R Iñiguez
- Hematology Department, Hospital 12 de Octubre, CNIO, Complutense University, Madrid, Spain
| | - M Pedrera
- Data Science Group, Hospital 12 de Octubre, Madrid, Spain
| | - J Cruz
- Data Science Group, Hospital 12 de Octubre, Madrid, Spain
| | - L Meloni
- TriNetX Europe NV, Sint-Martens-Latem, Belgium
| | - D Pérez-Rey
- Biomedical Informatics Group, Universidad Politécnica de Madrid, Madrid, Spain
| | - P Serrano
- Data Science Group, Hospital 12 de Octubre, Madrid, Spain
| | - J de la Cruz
- Research Institute imas12, Hospital 12 de Octubre, Madrid, Spain
| | - J Martinez-Lopez
- Hematology Department, Hospital 12 de Octubre, CNIO, Complutense University, Madrid, Spain.
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de la Rubia J, Alonso R, Clavero ME, Askari E, García A, Antón C, Fernández M, Escalante F, García A, Rios-Tamayo R, Conesa V, Bermúdez MA, Merchán B, Velasco AE, Blanchard MJ, Sampol A, Gainza E, Hernández PM, Alegre A. Belantamab Mafodotin in Patients with Relapsed/Refractory Multiple Myeloma: Results of the Compassionate Use or the Expanded Access Program in Spain. Cancers (Basel) 2023; 15:cancers15112964. [PMID: 37296925 DOI: 10.3390/cancers15112964] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/23/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
Belantamab-mafodotin (belamaf) is a novel antibody-drug conjugate targeting B-cell maturation antigen that showed anti-myeloma activity in patients with relapsed and refractory multiple myeloma (RRMM). We performed an observational, retrospective, and multicenter study aimed to assess the efficacy and safety of single-agent belamaf in 156 Spanish patients with RRMM. The median number of prior therapy lines was 5 (range, 1-10), and 88% of patients were triple-class refractory. Median follow-up was 10.9 months (range, 1-28.6). The overall response rate was 41.8% (≥CR 13.5%, VGPR 9%, PR 17.3%, MR 2%). The median progression-free survival was 3.61 months (95% CI, 2.1-5.1) and 14.47 months (95% CI, 7.91-21.04) in patients achieving at least MR (p < 0.001). Median overall survival in the entire cohort and in patients with MR or better was 11.05 months (95% CI, 8.7-13.3) and 23.35 (NA-NA) months, respectively (p < 0.001). Corneal events (87.9%; grade ≥ 3, 33.7%) were the most commonly adverse events, while thrombocytopenia and infections occurred in 15.4% and 15% of patients, respectively. Two (1.3%) patients discontinued treatment permanently due to ocular toxicity. Belamaf showed a noticeably anti-myeloma activity in this real-life series of patients, particularly among those achieving MR or better. The safety profile was manageable and consistent with prior studies.
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Affiliation(s)
- Javier de la Rubia
- Hospital Universitario y Politécnico La Fe & Universidad Católica de Valencia, Centro de Investigación Biomédica en Red de Cáncer, CIBERONC CB16/12/00284, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Department of Hematology, University Hospital La Fe and Universidad Católica de Valencia, Avda. Fernando Abril Martorell, 106, 46026 Valencia, Spain
| | | | | | | | | | | | | | | | - Ana García
- Hospital Dr. Peset, 46017 Valencia, Spain
| | | | | | | | - Beatriz Merchán
- Hospital Universitario de Guadalajara, 19002 Guadalajara, Spain
| | | | | | | | | | | | - Adrián Alegre
- Spain for the Spanish Myeloma Group, Hospital Universitario La Princesa, 28006 Madrid, Spain
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[Efficacy and safety of autologous hematopoietic stem cell transplantation in elderly multiple myeloma patients: a single center retrospective study]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:141-145. [PMID: 35381675 PMCID: PMC8980643 DOI: 10.3760/cma.j.issn.0253-2727.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objective: To evaluate the efficacy and safety of autologous hematopoietic stem cell transplantation (auto-HSCT) in elderly patients (≥65 years old) with multiple myeloma (MM) . Methods: From June 1, 2006 to July 31, 2020, 22 MM patients (≥65 years old) who were diagnosed in the First Affiliated Hospital, Sun Yat-sen University and received novel drug induction followed by auto-HSCT were analyzed retrospectively. These patients were evaluated for important organ functions before transplantation, and the International Myeloma Working Group frail score was used in 2016 to screen out transplant-eligible patients. Results: The median (interquartile range, IQR) age at the time of transplantation of the 22 patients was 66.75 (IQR 4.50) years. A total of 20 patients received stem cell mobilization. The median number of mononuclear cells collected was 4.53×10(8)/kg, that of CD34(+) cells was 3.37×10(6)/kg, and the median number of apheresis procedures performed was 2. After stem cell transfusion, the median time of neutrophil implantation was 11 days, that of platelet implantation was 13 days, and the treatment-related mortality was 0 at 100 days after transplantation. The median follow-up was 48.7 months. The median time to progression time was not reached, and the median overall survival time was 111.8 months. Conclusion: Auto-HSCT is a safe and effective treatment for selected elderly patients of 65 years or older with MM.
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Gordan LN, Marks SM, Xue M, Nagovski N, Lambert JH, Smith RE. Daratumumab utilization and cost analysis among patients with multiple myeloma in a US community oncology setting. Future Oncol 2021; 18:301-309. [PMID: 34709061 DOI: 10.2217/fon-2021-1072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: The introduction of daratumumab into the treatment of multiple myeloma has improved outcomes in patients; however, community oncologists often dose more frequently than the US FDA-approved label. Materials and methods: Integra analyzed its database to elucidate daratumumab treatment patterns and the impact of increased utilization on the cost of care for multiple myeloma. Results: Following week 24, 671 (65%) of 1037 patients remained on daratumumab-containing regimens, with 330 patients continuing more frequent treatments than the expected once-every-4-weeks dosing described in the standard dosing schedule. Patients received an average of 14% more daratumumab doses than the FDA-approved label indicates, increasing the 1-year daratumumab costs by an estimated US$31,353. Conclusion: Daratumumab is utilized more frequently than the FDA-recommended dosing, leading to higher multiple myeloma treatment costs.
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Affiliation(s)
| | - Stanley M Marks
- University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, PA, USA
| | - Mei Xue
- Integra PrecisionQ, West Palm Beach, FL, USA
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Ocio EM, Montes-Gaisán C, Bustamante G, Garzón S, González E, Pérez E, Sirvent M, Arguiñano JM, González Y, Ríos R, de Miguel D, Grande M, Fernández A, Naves A, Rosiñol L. Clinical and Sociodemographic Characteristics of Patients With Relapsed and/or Refractory Multiple Myeloma and Their influence on Treatment in the Real-World Setting in Spain: The CharisMMa Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:e241-e249. [PMID: 34774462 DOI: 10.1016/j.clml.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/21/2021] [Accepted: 10/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Treatment of relapsed and/or refractory multiple myeloma (RRMM) should be established based on multiple factors, including previous treatment and the sociodemographic/clinical characteristics of the patients. However, patients enrolled in randomized-controlled trials often do not mirror the scenario encountered in real-world practice, thus challenging therapeutic decisions in day-to-day practice. PATIENTS AND METHODS This observational, cross-sectional, multicenter study aimed to investigate the sociodemographic and clinical characteristics of patients with RRMM treated in routine practice in Spain and their influence on treatment regimens. RESULTS The study included 276 RRMM patients (median age 69 years; no gender predominance). Seventy-four percent of patients had CRAB features at the time of study inclusion, 65.9% bone lesions, 28.7% high-risk cytogenetics, and 27.0% were at ISS stage III; 65.1% were retired and lived in urban areas (75.7%) with their relatives (85.8%); 28.7% had some dependence degree. Patients had experienced their last relapse in a median of 1.61 months before enrollment and had received a median of 2 treatment lines (range 1-10). Second-and third-line therapies were mostly based on immunomodulatory drugs, followed by proteasome inhibitors (PIs), whereas monoclonal antibodies prevailed in later treatment lines. The presence of extramedullary plasmacytomas, the absence of osteopenia, and being in the second or third treatment line (vs. later lines) significantly increased the odds of receiving PIs. CONCLUSIONS RRMM treatment in the real-world setting is highly heterogeneous and is primarily influenced by the number of previous lines. The consideration of patients' clinical and sociodemographic characteristics may support clinicians in making therapeutic decisions.
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Affiliation(s)
- Enrique M Ocio
- Complejo Hospitalario de Salamanca (IBSAL), Universidad de Salamanca, Salamanca, Spain; Hospital Universitario Marqués de Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain
| | - Carmen Montes-Gaisán
- Hospital Universitario Marqués de Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain
| | | | | | | | - Ernesto Pérez
- Bioaraba, [Grupo diagnóstico y terapéutica oncológica], Vitoria-Gasteiz, Spain; Osakidetza, [OSI Araba], Hospital Universitario Araba, [Servicio de hematología], Vitoria-Gasteiz, Spain
| | | | | | | | - Rafael Ríos
- Hospital Virgen de las Nieves, Granada, Spain
| | | | - Marta Grande
- Takeda Farmacéutica España, Madrid, Spain; Universidad de Alcalá, Madrid, Spain
| | | | | | - Laura Rosiñol
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain.
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Ye C, Chen W, Gao Q, Chen Y, Song X, Zheng S, Liu J. Secondary Immunodeficiency and Hypogammaglobulinemia with IgG Levels of <5 g/L in Patients with Multiple Myeloma: A Retrospective Study Between 2012 and 2020 at a University Hospital in China. Med Sci Monit 2021; 27:e930241. [PMID: 34238914 PMCID: PMC8276618 DOI: 10.12659/msm.930241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Infections are the main cause of mortality and morbidity in multiple myeloma (MM) patients. However, adult immunodeficiency specialists in China are lacking, and the care of secondary immunodeficiency (SID) and the prognostic role of hypogammaglobulinemia in MM is unknown. Material/Methods MM patients (295) were retrospectively analyzed between January 2012 and 2020 in Zhejiang Provincial People’s Hospital, Hangzhou Medical College. MM patients with immunoglobulin (Ig) G <5 g/L were defined as SID patients. The care of these patients and the prognostic role of IgG <5 g/L were analyzed. Results Forty-five of 295 MM patients with IgG <5 g/L were defined as SID patients. These 45 patients mainly had recurrent infections, especially pulmonary bacterial infections; 2 patients had them 5 times/year. The median survival time was significantly shorter in MM patients with SID (24 vs 66 months). More importantly, the multivariate and univariate analysis revealed that IgG <5 g/L was an independent prognostic factor for MM patients. Conclusions Ig replacement therapy or prophylactic antibiotics for MM patients with SID were lacking in this single retrospective study. IgG <5 g/L could be a prognostic marker for MM patients.
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Affiliation(s)
- Chunmei Ye
- College of Medical Technology, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China (mainland).,Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China (mainland)
| | - Weiwei Chen
- Department of Anesthesiology, Xinchang Hospital Affiliated to Wenzhou Medical University, Xinchang, Zhejiang, China (mainland)
| | - Qi Gao
- College of Medical Technology, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China (mainland).,Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China (mainland)
| | - Yanxia Chen
- Department of Rheumatology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China (mainland)
| | - Xiaolu Song
- Department of Hematology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China (mainland)
| | - Sujie Zheng
- Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China (mainland)
| | - Jinlin Liu
- Department of Clinical Laboratory, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China (mainland)
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7
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Zheleznyak A, Mixdorf M, Marsala L, Prior J, Yang X, Cui G, Xu B, Fletcher S, Fontana F, Lanza G, Achilefu S. Orthogonal targeting of osteoclasts and myeloma cells for radionuclide stimulated dynamic therapy induces multidimensional cell death pathways. Theranostics 2021; 11:7735-7754. [PMID: 34335961 PMCID: PMC8315072 DOI: 10.7150/thno.60757] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/09/2021] [Indexed: 12/13/2022] Open
Abstract
Rationale: Multiple myeloma (MM) is a multifocal malignancy of bone marrow plasma cells, characterized by vicious cycles of remission and relapse that eventually culminate in death. The disease remains mostly incurable largely due to the complex interactions between the bone microenvironment (BME) and MM cells (MMC). In the “vicious cycle” of bone disease, abnormal activation of osteoclasts (OCs) by MMC causes severe osteolysis, promotes immune evasion, and stimulates the growth of MMC. Disrupting these cancer-stroma interactions would enhance treatment response. Methods: To disrupt this cycle, we orthogonally targeted nanomicelles (NM) loaded with non-therapeutic doses of a photosensitizer, titanocene (TC), to VLA-4 (α4ß1, CD49d/CD29) expressing MMC (MM1.S) and αvß3 (CD51/CD61) expressing OC. Concurrently, a non-lethal dose of a radiopharmaceutical, 18F-fluorodeoxyglucose ([18F]FDG) administered systemically interacted with TC (radionuclide stimulated therapy, RaST) to generate cytotoxic reactive oxygen species (ROS). The in vitro and in vivo effects of RaST were characterized in MM1.S cell line, as well as in xenograft and isograft MM animal models. Results: Our data revealed that RaST induced non-enzymatic hydroperoxidation of cellular lipids culminating in mitochondrial dysfunction, DNA fragmentation, and caspase-dependent apoptosis of MMC using VLA-4 avid TC-NMs. RaST upregulated the expression of BAX, Bcl-2, and p53, highlighting the induction of apoptosis via the BAK-independent pathway. The enhancement of multicopper oxidase enzyme F5 expression, which inhibits lipid hydroperoxidation and Fenton reaction, was not sufficient to overcome RaST-induced increase in the accumulation of irreversible function-perturbing α,ß-aldehydes that exerted significant and long-lasting damage to both DNA and proteins. In vivo, either VLA-4-TC-NM or αvß3-TC-NMs RaST induced a significant therapeutic effect on immunocompromised but not immunocompetent MM-bearing mouse models. Combined treatment with both VLA-4-TC-NM and αvß3-TC-NMs synergistically inhibited osteolysis, reduced tumor burden, and prevented rapid relapse in both in vivo models of MM. Conclusions: By targeting MM and bone cells simultaneously, combination RaST suppressed MM disease progression through a multi-prong action on the vicious cycle of bone cancer. Instead of using the standard multidrug approach, our work reveals a unique photophysical treatment paradigm that uses nontoxic doses of a single light-sensitive drug directed orthogonally to cancer and bone cells, followed by radionuclide-stimulated generation of ROS to inhibit tumor progression and minimize osteolysis in both immunocompetent murine and immunocompromised human MM models.
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Cejalvo MJ, Bustamante G, González E, Vázquez-Álvarez J, García R, Ramírez-Payer Á, Pérez-Persona E, Abella E, Garzón S, García A, Jarque I, González MS, Sampol A, Motlló C, Martí JM, Alcalá M, Duro R, González Y, Sastre JL, Sarrà J, Lostaunau G, López R, de la Rubia J. Treatment patterns and outcomes in real-world transplant-ineligible patients newly diagnosed with multiple myeloma. Ann Hematol 2021; 100:1769-1778. [PMID: 33885924 DOI: 10.1007/s00277-021-04529-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Despite the significant proportion of older patients with newly diagnosed multiple myeloma (MM), most clinical trials driving therapeutic decisions in routine practice include younger and presumably healthier patients than those in the real world. Furthermore, longitudinal studies suggest that elderly, transplant-ineligible patients with MM are not benefitting enough from new anti-MM agents. We retrospectively analyzed the profile of and treatment patterns and outcomes in 675 transplant-ineligible patients with MM who started frontline therapy in routine practice. The mean (SD) age was 75.6 (6.7) years; 152 (47.4%) had Eastern Cooperative Oncology Group performance status (ECOG PS) 2-4, and 73 (25.1%) had high cytogenetic risk. The most frequent frontline therapy was non-VMP bortezomib-based regimens (n=207; 30.7%), which were more frequent among patients with ECOG PS 0/1 and higher risk (e.g., international staging system (ISS) stage III, severely impaired glomerular filtrate rate (GFR), high lactate dehydrogenase (LDH), and high-risk cytogenetics); 185 patients (27.4%) started an attenuated (lite) VMP regimen, and 159 (23.6%) a VMP (VISTA) regimen. Median progression-free survival and overall survival (OS) were 15.3 months (95%CI 14.0-16.9) and 33.5 months (95%CI 29.1-37.2), respectively; 405 patients (78.2%) achieved partial response or better. Age, ECOG PS, ISS stage, serum LDH, GFR, cytogenetic risk, and treatment regimen significantly influenced OS. In this study, a remarkable proportion of transplant-ineligible patients with MM were older, frontline regimens were highly heterogeneous, and patients at higher risk often received less efficacious combinations. These findings suggest that clinicians have limited objective criteria for therapeutic decisions for this patient group.
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Affiliation(s)
- María José Cejalvo
- Department of Hematology, Hospital Universitario Doctor Peset, Av. de Gaspar Aguilar, 90 46017, Valencia, Spain
| | - Gabriela Bustamante
- Department of Hematology, Institut Català d'Oncologia, Hospital Duran i Reynals, Barcelona, Spain
| | - Esther González
- Department of Hematology, Hospital de Cabueñes, Gijón, Spain
| | | | - Ricarda García
- Department of Hematology, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Ángel Ramírez-Payer
- Department of Hematology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Eugenia Abella
- Department of Hematology, Hospital del Mar, Barcelona, Spain
| | - Sebastián Garzón
- Department of Hematology, Hospital de Jerez, Jerez de la Frontera, Spain
| | - Antoni García
- Department of Hematology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Isidro Jarque
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia & CIBERONC, Instituto de Salud Carlos III, Valencia, Spain
| | | | - Antonia Sampol
- Department of Hematology, Hospital Son Espases, Palma de Mallorca, Spain
| | | | - Josep María Martí
- Department of Hematology, Hospital Mútua de Terrassa, Terrassa, Spain
| | - Magdalena Alcalá
- Department of Hematology, Hospital Universitario Carlos Haya, Málaga, Spain
| | - Rafael Duro
- Department of Hematology, Hospital Universitario Virgen de la Macarena, Sevilla, Spain
| | - Yolanda González
- Department of Hematology, Hospital Universitario de Girona Doctor Josep Trueta, Girona, Spain
| | - José Luis Sastre
- Department of Hematology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Josep Sarrà
- Department of Hematology, Hospital Universitario Joan XXIII, Tarragona, Spain
| | | | - Rocío López
- Celgene S.L.U., Bristol-Myers Squibb Company, Madrid, Spain
| | - Javier de la Rubia
- Department of Hematology, Hospital Universitario Doctor Peset, Av. de Gaspar Aguilar, 90 46017, Valencia, Spain. .,Departamento de Medicina Interna y Odontología, Universidad Católica de Valencia, Valencia, Spain.
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9
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Bergin K, Wellard C, Moore E, McQuilten Z, Blacklock H, Harrison SJ, Ho PJ, King T, Quach H, Mollee P, Walker P, Wood E, Spencer A. The Myeloma Landscape in Australia and New Zealand: The First 8 Years of the Myeloma and Related Diseases Registry (MRDR). CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e510-e520. [PMID: 33785297 DOI: 10.1016/j.clml.2021.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/12/2021] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Real-world multiple myeloma (MM) data are scarce, with most data originating from clinical trials. The Myeloma and Related Diseases Registry (MRDR) is a prospective clinical-quality registry of newly diagnosed cases of plasma cell disorders established in 2012 and operating at 44 sites in Australia and New Zealand as of April 2020. METHODS We reviewed all patients enrolled onto the MRDR between June 2012 and April 2020. Baseline characteristics, treatment, and outcome data were reviewed for MM patients with comparisons made by chi-square tests (categorical variables) and rank sum tests (continuous variables). Kaplan-Meier analysis was used to estimate progression-free survival and overall survival (OS). RESULTS As of April 2020, a total of 2405 MM patients were enrolled (median age, 67 years, with 40% aged > 70 years). High-risk features were present in 13% to 31% of patients: fluorescence in-situ hybridization (FISH) ≥ 1 of t(4;14), t(14;16), or del(17p) 18%, International Staging System (ISS)-3 31%, and Revised ISS (R-ISS)-3 13%. Cytogenetic/FISH analyses were performed in 50% and 68% of patients, respectively, with an abnormal karyotype result in 34%. Bortezomib-containing therapy was the most common first-line therapy (79.3%, n = 1706). Patients not receiving bortezomib were older (median age, 76 vs 65 years, P < .001) with inferior performance status (Eastern Cooperative Oncology Group performance status ≥ 2, 41% vs 18%, P < .001). Median progression-free survival and OS were 30.8 and 65.8 months, respectively. Younger patients had superior OS (76.3 vs 46.7 months, P < .001, < 70 and ≥ 70 years, respectively). R-ISS score was available in 50.7% (n = 1220) of patients, and higher R-ISS was associated with inferior OS (R-ISS-1 vs R-ISS-2 vs R-ISS-3: not reached vs 68.1 months vs 33.2 months, respectively, P < .001). CONCLUSION Clinical registries provide a more complete picture of MM diagnosis and treatment, and highlight the challenges of adhering to best practices in a real-world context.
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Affiliation(s)
- Krystal Bergin
- Department of Haematology, Alfred Health-Monash University, Melbourne, Victoria, Australia
| | - Cameron Wellard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Elizabeth Moore
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zoe McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Hilary Blacklock
- Clinical Haematology, Middlemore Hospital, Middlemore, Auckland, New Zealand
| | - Simon J Harrison
- Clinical Haematology, Peter MacCallum Cancer Center, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, Melbourne University, Parkville, Melbourne, Victoria, Australia; Clinical Haematology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - P Joy Ho
- Royal Prince Alfred Hospital, Camperdown, and University of Sydney, Sydney, New South Wales, Australia
| | - Tracy King
- Royal Prince Alfred Hospital, Camperdown, and University of Sydney, Sydney, New South Wales, Australia
| | - Hang Quach
- Clinical Haematology, University of Melbourne and St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Peter Mollee
- Clinical Haematology, Princess Alexandra Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Patricia Walker
- Clinical Haematology, Peninsula Health, Frankston, Victoria, Australia
| | - Erica Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Spencer
- Department of Haematology, Alfred Health-Monash University, Melbourne, Victoria, Australia.
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Abstract
Multiple myeloma is the second most common haematological malignancy in high-income countries, and typically starts as asymptomatic precursor conditions-either monoclonal gammopathy of undetermined significance or smouldering multiple myeloma-in which initiating genetic abnormalities, such as hyperdiploidy and translocations involving the immunoglobulin heavy chain, are already present. The introduction of immunomodulatory drugs, proteasome inhibitors, and CD38-targeting antibodies has extended survival, but ultimately the majority of patients will die from their disease, and some from treatment-related complications. Disease progression and subsequent relapses are characterised by subclonal evolution and increasingly resistant disease. Patients with multiple myeloma usually have hypercalcaemia, renal failure, anaemia, or osteolytic bone lesions-and a detailed diagnostic investigation is needed to differentiate between symptomatic multiple myeloma that requires treatment, and precursor states. Risk stratification using both patient-specific (eg, performance status) and disease-specific (eg, presence of high-risk cytogenetic abnormalities) is important for prognosis and to define the best treatment strategy. Current research strategies include the use of minimal residual disease assays to guide therapy, refining immunotherapeutic approaches, and intercepting disease early in smouldering multiple myeloma.
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Affiliation(s)
- Niels W C J van de Donk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Hematology, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Charlotte Pawlyn
- The Institute of Cancer Research, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Kwee L Yong
- University College London Cancer Institute, London, UK.
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11
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Akizuki K, Matsuoka H, Toyama T, Kamiunten A, Sekine M, Shide K, Kameda T, Kawano N, Maeda K, Takeuchi M, Kawano H, Sato S, Ishizaki J, Tahira Y, Shimoda H, Hidaka T, Yamashita K, Kubuki Y, Shimoda K. Real-World Data on Clinical Features, Outcomes, and Prognostic Factors in Multiple Myeloma from Miyazaki Prefecture, Japan. J Clin Med 2020; 10:jcm10010105. [PMID: 33396800 PMCID: PMC7795356 DOI: 10.3390/jcm10010105] [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: 11/04/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 11/16/2022] Open
Abstract
The prognosis of multiple myeloma (MM) has improved with the introduction of novel agents. These data are largely derived from clinical trials and might not reflect real-world patient outcomes accurately. We surveyed real-world data from 284 patients newly diagnosed with MM between 2010 and 2018 in Miyazaki Prefecture. The median follow-up period was 32.8 months. The median age at diagnosis was 71 years, with 68% of patients aged >65 years. The International Staging System (ISS) stage at diagnosis was I in 18.4% of patients, II in 34.1%, and III in 47.5%. Bortezomib-containing regimens were preferred as initial treatment; they were used in 147 patients (51.8%). In total, 80% of patients were treated with one or more novel agents (thalidomide, lenalidomide, or bortezomib). Among 228 patients who were treated with novel agents as an initial treatment, the overall response rate (partial response (PR) or better) to initial treatment was 78.4%, and the median time to next treatment (TTNT) was 11.6 months. In the multivariate analysis, PR or better responses to initial treatment were independently favorable prognostic factors for TTNT. The median survival time after initial therapy for patients with novel agents was 56.4 months and 3-year overall survival (OS) was 70.4%. In multivariate analysis, ISS stage I/II disease and PR or better response to initial treatment, and autologous stem cell transplantation (ASCT) were identified as independent prognostic factors for overall survival (OS).
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Affiliation(s)
- Keiichi Akizuki
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan; (K.A.); (A.K.); (M.S.); (K.S.); (T.K.); (Y.T.); (H.S.); (T.H.); (Y.K.)
| | - Hitoshi Matsuoka
- Department of Internal Medicine, Koga General Hospital, 1749-1 Sudaki, Ikeuchi Machi, Miyazaki 880-0041, Japan; (H.M.); (M.T.); (H.K.)
| | - Takanori Toyama
- Department of Internal Medicine, Miyazaki Prefectural Nobeoka Hospital, 2-1-10 Shinkouji, Nobeoka 882-0835, Japan;
| | - Ayako Kamiunten
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan; (K.A.); (A.K.); (M.S.); (K.S.); (T.K.); (Y.T.); (H.S.); (T.H.); (Y.K.)
| | - Masaaki Sekine
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan; (K.A.); (A.K.); (M.S.); (K.S.); (T.K.); (Y.T.); (H.S.); (T.H.); (Y.K.)
| | - Kotaro Shide
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan; (K.A.); (A.K.); (M.S.); (K.S.); (T.K.); (Y.T.); (H.S.); (T.H.); (Y.K.)
| | - Takuro Kameda
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan; (K.A.); (A.K.); (M.S.); (K.S.); (T.K.); (Y.T.); (H.S.); (T.H.); (Y.K.)
| | - Noriaki Kawano
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, 5-30 Kitatakamatsu, Miyazaki 880-8510, Japan; (N.K.); (K.Y.)
| | - Kouichi Maeda
- Department of Internal Medicine, Miyakonojo Medical Center, 5033-1 Iwayoshi-cho, Miyakonojo 880-8510, Japan;
| | - Masanori Takeuchi
- Department of Internal Medicine, Koga General Hospital, 1749-1 Sudaki, Ikeuchi Machi, Miyazaki 880-0041, Japan; (H.M.); (M.T.); (H.K.)
| | - Hiroshi Kawano
- Department of Internal Medicine, Koga General Hospital, 1749-1 Sudaki, Ikeuchi Machi, Miyazaki 880-0041, Japan; (H.M.); (M.T.); (H.K.)
| | - Seiichi Sato
- Fujimoto General Hospital, 17-1 Hayasuzumachi, Miyakonojo 885-0055, Japan;
| | - Junzo Ishizaki
- Department of Internal Medicine, Miyazaki Aisenkai Nichinan Hospital, 3649-2 Kazeta, Nichinan 887-0034, Japan;
| | - Yuki Tahira
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan; (K.A.); (A.K.); (M.S.); (K.S.); (T.K.); (Y.T.); (H.S.); (T.H.); (Y.K.)
| | - Haruko Shimoda
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan; (K.A.); (A.K.); (M.S.); (K.S.); (T.K.); (Y.T.); (H.S.); (T.H.); (Y.K.)
| | - Tomonori Hidaka
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan; (K.A.); (A.K.); (M.S.); (K.S.); (T.K.); (Y.T.); (H.S.); (T.H.); (Y.K.)
| | - Kiyoshi Yamashita
- Department of Internal Medicine, Miyazaki Prefectural Miyazaki Hospital, 5-30 Kitatakamatsu, Miyazaki 880-8510, Japan; (N.K.); (K.Y.)
| | - Yoko Kubuki
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan; (K.A.); (A.K.); (M.S.); (K.S.); (T.K.); (Y.T.); (H.S.); (T.H.); (Y.K.)
| | - Kazuya Shimoda
- Department of Gastroenterology and Hematology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki 889-1692, Japan; (K.A.); (A.K.); (M.S.); (K.S.); (T.K.); (Y.T.); (H.S.); (T.H.); (Y.K.)
- Correspondence: ; Tel.: +81-985-85-9121; Fax: +81-985-85-5194
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12
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Maouche N, Kishore B, Jenner MW, Boyd K, Bhatti Z, Bird SA, Chander G, Robinson R, Vallance GD, Offer M, Kothari J, Peniket A, Aitchison R, Dungarwalla M, Collings F, Bygrave C, Ramasamy K. Ixazomib, lenalidomide, and dexamethasone is effective and well tolerated in multiply relapsed (≥2nd relapse) refractory myeloma: a multicenter real world UK experience. Leuk Lymphoma 2020; 62:1396-1404. [PMID: 33356703 DOI: 10.1080/10428194.2020.1864355] [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: 12/13/2022]
Abstract
There are limited real world data on ixazomib, lenalidomide, and dexamethasone (IRd) in multiply relapsed myeloma. We analyzed outcomes of 116 patients who received IRd predominantly at second and subsequent relapse including those refractory to proteasome inhibitors (PIs). With a median follow up 16.3 months, the overall response rate was 66.9%; median progression-free survival (PFS) was 17.7 months with median overall survival (OS) not reached (NR). PFS and OS were significantly shorter in advanced disease (PFS; 12.6 vs. 21.2 months (p = .01), OS; 15.9 months vs. NR (p = .01) for ISS3 vs. ISS 1&2, respectively). PFS and OS were significantly shorter in clinical high risk (CHR) compared to standard risk (SR) patients (PFS; 9.3 months vs. NR (p = .001), OS; 11.5 months vs. NR (p < .001), respectively). There was a trend toward shorter PFS in PI-refractory patients 13.7 vs. 19.6 months for non-PI refractory (p = .2). The triplet combination was generally well tolerated.
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Affiliation(s)
- Nadjoua Maouche
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bhuvan Kishore
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Matthew W Jenner
- Department of Haematology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kevin Boyd
- Department of Haemato-Oncology, The Royal Marsden Hospital, Sutton, UK
| | - Zara Bhatti
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sarah Anne Bird
- Department of Haemato-Oncology, The Royal Marsden Hospital, Sutton, UK
| | - Gurvin Chander
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rebecca Robinson
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Grant D Vallance
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mark Offer
- Department of Haematology, Frimley Health NHS Foundation Trust, Frimley, UK
| | - Jaimal Kothari
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andy Peniket
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robin Aitchison
- Department of Haematology, Buckinghamshire Healthcare NHS Trust, Bucks, UK
| | - Moez Dungarwalla
- Department of Haematology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Freya Collings
- Department of Haematology, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Ceri Bygrave
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - Karthik Ramasamy
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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13
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Ixazomib-based frontline therapy in patients with newly diagnosed multiple myeloma in real-life practice showed comparable efficacy and safety profile with those reported in clinical trial: a multi-center study. Ann Hematol 2020; 99:2589-2598. [PMID: 32892275 PMCID: PMC7474576 DOI: 10.1007/s00277-020-04234-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023]
Abstract
The induction therapy containing ixazomib, an oral proteasome inhibitor, has shown favorable efficacy and safety in clinical trials, but its experience in real-life remains limited. In routine practice, few patients received ixazomib-based induction therapy due to reasons including (1) patients’ preference on oral regimens, (2) concerns on adverse events (AEs) of other intravenous/subcutaneous regimens, (3) requirements for less center visits, and (4) fears of COVID-19 and other infectious disease exposures. With the aim of assessing the real-life effectiveness and safety of ixazomib-based induction therapy, we performed this multi-center, observational study on 85 newly diagnosed multiple myeloma (NDMM) patients from 14 medical centers. Ixazomib-based regimens included ixazomib-lenalidomide-dexamethasone (IRd) in 44.7% of patients, ixazomib-dexamethasone (Id) in 29.4%, and Id plus another agent (doxorubicin, cyclophosphamide, thalidomide, or daratumumab) in 25.9%. Different ixazomib-based therapies were applied due to (1) financial burdens or limitations on local health insurance coverage, (2) concerns on treatment tolerance, and (3) drug accessibility issue. Ten patients received ixazomib maintenance. The median age was 67 years; 43.5% had ISS stage III disease; 48.2% had an Eastern Cooperative Oncology Group performance score ≥ 2; and 17.6% with high-risk cytogenetic abnormalities. Overall response rate for all 85 patients was 95.3%, including 65.9% very good partial response or better and 29.5% complete responses. The median time to response was 30 days. The response rate was similar across different ixazomib-based regimens. Median progression-free survival was not reached. Severe AEs (≥ grade 3) were reported in 29.4% of patients. No grade 3/4 peripheral neuropathy (PN) occurred. Patients received a median of 6 (range 1–20) cycles of ixazomib treatment; 56.6% remained on treatment at data cutoff; 15.3% discontinued treatment due to intolerable AEs. These results support that the ixazomib-based frontline therapy was highly effective with acceptable toxicity in routine practice and the ixazomib oral regimens could be good alternative options for NDMM patients.
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14
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Wenthe J, Naseri S, Hellström AC, Wiklund HJ, Eriksson E, Loskog A. Immunostimulatory oncolytic virotherapy for multiple myeloma targeting 4-1BB and/or CD40. Cancer Gene Ther 2020; 27:948-959. [PMID: 32355275 PMCID: PMC7725669 DOI: 10.1038/s41417-020-0176-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/02/2020] [Accepted: 04/15/2020] [Indexed: 12/20/2022]
Abstract
Multiple myeloma (MM) is a plasma cell malignancy that is characterized by immune dysregulation. MM is commonly treated with immunomodulating agents, but still remains incurable. Herein, we proposed and evaluated immunostimulatory Lokon oncolytic adenoviruses (LOAd) for MM treatment. LOAd viruses are serotype 5/35 chimera, which enables infection of hematopoietic cells. Oncolysis is restricted to cells with a dysregulated retinoblastoma protein pathway, which is frequently observed in MM. Further, LOAd viruses are armed with human immunostimulatory transgenes: trimerized membrane-bound CD40L (LOAd700, LOAd703) and 4-1BBL (LOAd703). LOAd viruses were assessed in a panel of MM cell lines (ANBL-6, L363, LP-1, OPM-2, RPMI-8226, and U266-84). All cells were sensitive to infection, leading to viral replication and cell killing as analyzed by quantitative PCR and viability assay. Transgene expression was verified post infection with flow cytometry. Cell phenotypes were further altered with a downregulation of markers connected to MM progression (ICAM-1, CD70, CXCL10, CCL2, and sIL-2Rα) and an upregulation of the death receptor Fas. In a co-culture of immune and MM cells, LOAd viruses promoted activation of cytotoxic T cells as seen by higher CD69, CD107a, and IFNγ expression. This was most prominent with LOAd703. In conclusion, LOAd viruses are of interest for MM therapy.
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Affiliation(s)
- Jessica Wenthe
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden.
| | - Sedigheh Naseri
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Ann-Charlotte Hellström
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Helena Jernberg Wiklund
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Emma Eriksson
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Angelica Loskog
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden.,Lokon Pharma AB, Uppsala, Sweden
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15
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Real-world effectiveness and safety of ixazomib-lenalidomide-dexamethasone in relapsed/refractory multiple myeloma. Ann Hematol 2020; 99:1049-1061. [PMID: 32236735 DOI: 10.1007/s00277-020-03981-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 03/01/2020] [Indexed: 01/31/2023]
Abstract
Real-world data on regimens for relapsed/refractory multiple myeloma (RRMM) represent an important component of therapeutic decision-making. This multi-centric, retrospective, observational study conducted by the treating physicians evaluated the effectiveness and safety of ixazomib-lenalidomide-dexamethasone (IRd) in 155 patients who received ixazomib via early access programs in Greece, the UK, and the Czech Republic. Median age was 68 years; 17% had an Eastern Cooperative Oncology Group performance status ≥ 2; median number of prior therapies was 1 (range 1-7); 91%, 47%, and 17% had received prior bortezomib, thalidomide, and lenalidomide, respectively. Median duration of exposure to ixazomib was 9.6 months. Overall response rate was 74%, including 35% very good partial response or better (16% complete response). Median progression-free survival (PFS) was 27.6 months (27.6 and 19.9 months in patients with 1 or > 1 prior lines, respectively). IRd treatment for ≥ 6 months was associated with longer PFS (hazard ratio 0.06). Fourteen patients (9%) discontinued IRd due to adverse events/toxicity in the absence of disease progression. Peripheral neuropathy was reported in 35% of patients (3% grades 3-4). These findings support the results of the phase III TOURMALINE-MM1 trial in a broader real-world RRMM population.
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16
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Hock BD, Mulholland KS, Ganly P, McKenzie JL, Pearson JF, MacPherson SA. Impact of increased access to novel agents on the survival of multiple myeloma patients treated at a single New Zealand centre. Intern Med J 2020; 49:598-606. [PMID: 30411451 DOI: 10.1111/imj.14155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 10/11/2018] [Accepted: 10/29/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The impact of changes in novel agent (NA) usage on the survival of multiple myeloma (MM) patients in real-world hospital settings is unclear. In New Zealand (NZ) in 2011, frontline bortezomib became available and thalidomide availability was expanded. AIM This retrospective study analyses the impact these change had on the survival of MM patients treated at a NZ hospital. METHODS Clinical and overall survival (OS) data were collected on MM patients who were treated at Christchurch Hospital during 2000-2009 (pre-cohort, n = 337) and 2011-2017 (post-cohort, n = 343). Outcomes were compared using pre-cohort data truncated at 2011. RESULTS Patients in the post-cohort had significant increases (P < 0.001) in not only NA usage (85 vs 55%) and OS (median = 56 vs 44 months) but also the proportion (74 vs 49%) of young patients (age < 70) who received an autologous stem cell transplant (ASCT). Separate analysis of older patients demonstrated that those in the post-cohort had significantly longer OS (median OS 28 vs 17, P < 0.001) although 5-year relative survival remained less than 50%. Separate analysis of young patients demonstrated that those in the post-cohort had significantly increased initial OS with the survival curves converging at 5 years. Although ASCT-treated patients had similar OS in each cohort, their progression-free survival (PFS) was significantly increased in the post-cohort (median 40 vs 20 months, P < 0.0001). CONCLUSION In the setting of a NZ hospital the increased availability of NA was associated with a significant improvement in both the OS of older patients and the PFS of ASCT patients.
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Affiliation(s)
- Barry D Hock
- Haematology Research Group, Christchurch Hospital and Department of Pathology and Biomedical Science, Christchurch, New Zealand
| | | | - Peter Ganly
- Haematology Department, Christchurch Hospital, Christchurch, New Zealand
| | - Judith L McKenzie
- Haematology Research Group, Christchurch Hospital and Department of Pathology and Biomedical Science, Christchurch, New Zealand
| | - John F Pearson
- Biostatistics and Computational Biology Unit, Christchurch, New Zealand
| | - Sean A MacPherson
- Haematology Research Group, Christchurch Hospital and Department of Pathology and Biomedical Science, Christchurch, New Zealand.,Haematology Department, Christchurch Hospital, Christchurch, New Zealand
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17
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Goto D, Khairnar R, Yared JA, Yong C, Romanus D, Onukwugha E, Slejko JF. Utilization of novel systemic therapies for multiple myeloma: A retrospective study of front-line regimens using the SEER-Medicare data. Cancer Med 2020; 9:626-639. [PMID: 31801177 PMCID: PMC6970041 DOI: 10.1002/cam4.2698] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/20/2019] [Accepted: 10/13/2019] [Indexed: 11/17/2022] Open
Abstract
The landscape of treatment for multiple myeloma (MM) has significantly changed over the last decade due to novel agents that have shown superiority in efficacy such as proteasome inhibitors (PIs) and immunomodulatory drugs (IMiDs) over traditional therapies. However, the real-world utilization of these new agents has not been studied well. This study evaluated year-to-year changes in treatment choices in a cohort of patients aged 66 or older in the Surveillance, Epidemiology, and End Results (SEER) registry linked with Medicare claims (SEER-Medicare) data who were diagnosed with MM between 2007 and 2011. We identified 2477 symptomatic newly diagnosed patients who were followed for 6 months or more postdiagnosis and treated with systemic therapies but not with stem cell transplantation. Symptomatic patients were identified by evidence of hypercalcemia, renal failure, anemia, or bone lesions (CRAB criteria). The minimum follow-up was imposed to ensure sufficient data to characterize treatment. Our analysis found that the proportion of treated patients increased from 75% in the 2007 cohort to 79% in the 2011 cohort. The share of PI-based regimens including PI plus alkylating agents, PI plus IMiD, and PI-only increased from 9% to 21%, 3% to 11%, and 16% to 22%, respectively, between 2007 and 2011. These findings translate to the share of PI-based regimens having increased from 28% to 55% and that of IMiDs-based regimens (excluding PI plus IMiD) having decreased from 43% to 27%. In conclusion, while the usage of PIs among elderly MM patients increased significantly replacing IMiD-based regimens (with or without alkylating agents but not with PI) between 2007 and 2011, this significant shift did not increase the proportion of treated patients.
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Affiliation(s)
| | - Rahul Khairnar
- Department of Pharmaceutical Health Services ResearchUniversity of Maryland School of PharmacyBaltimoreMDUSA
| | - Jean A. Yared
- Department of MedicineUniversity of Maryland School of MedicineBaltimoreMDUSA
| | | | - Dorothy Romanus
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company LimitedCambridgeMAUSA
| | - Eberechukwu Onukwugha
- Department of Pharmaceutical Health Services ResearchUniversity of Maryland School of PharmacyBaltimoreMDUSA
| | - Julia F. Slejko
- Department of Pharmaceutical Health Services ResearchUniversity of Maryland School of PharmacyBaltimoreMDUSA
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18
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Schaffel R. Induction therapy and stem-cell mobilization in myeloma, look at the past to plan the future. Hematol Transfus Cell Ther 2019; 41:283-284. [PMID: 31640937 PMCID: PMC6978529 DOI: 10.1016/j.htct.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 09/17/2019] [Indexed: 11/09/2022] Open
Affiliation(s)
- Rony Schaffel
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.
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19
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Multiple myeloma in elderly patients—a Portuguese multicentric real-life study. Ann Hematol 2019; 98:1689-1701. [DOI: 10.1007/s00277-019-03640-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 02/13/2019] [Indexed: 01/25/2023]
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20
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Rajput S, Minhas K, Azam I, Shaikh U, Hussain A, Lalani EN. LMP1 expression in bone marrow trephines of patients with multiple myeloma confers a survival advantage. Leuk Lymphoma 2019; 60:1991-2001. [PMID: 30912465 DOI: 10.1080/10428194.2018.1563697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Multiple myeloma (MM) is a heterogeneous disease of the bone marrow (BM). Its association with Epstein-Barr virus (EBV) remains enigmatic. Aim of our study was to determine expression of latent membrane protein 1 (LMP1), aldehyde dehydrogenase 1 (ALDH1), CD117 and their association with 5-year survival in MM patients. Seven percent of cases expressed LMP1 in MM cells with no association with survival. Whereas, LMP1 expression in CD138- non-neoplastic cells was observed in 80% of the cases, conferring a survival advantage of 1.75 years (mean 3.75 ± 0.28, 95% CI 3.19-4.3). LMP1 in CD138- non-neoplastic cells was associated with CD117 expression in MM cells. Combinatorial analysis of LMP1 and CD117 stratified patients into good prognostic group LMP1+/CD117- (mean survival 4.16 ± 0.39 years) and a worst prognostic group; LMP1-/CD117+ (mean survival 1.02 ± 0.29 years). Our study showed that LMP1 expression in CD138- non-neoplastic cells of BM in MM patients confers a survival advantage.
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Affiliation(s)
- Sheerien Rajput
- a Centre for Regenerative Medicine and Stem Cell Research, Aga Khan University , Karachi , Pakistan.,b Department of Pathology and Laboratory Medicine , Aga Khan University , Karachi , Pakistan
| | - Khurram Minhas
- b Department of Pathology and Laboratory Medicine , Aga Khan University , Karachi , Pakistan
| | - Iqbal Azam
- c Department of Community Health Sciences , Aga Khan University , Karachi , Pakistan
| | - Usman Shaikh
- b Department of Pathology and Laboratory Medicine , Aga Khan University , Karachi , Pakistan
| | - Azhar Hussain
- a Centre for Regenerative Medicine and Stem Cell Research, Aga Khan University , Karachi , Pakistan
| | - El-Nasir Lalani
- a Centre for Regenerative Medicine and Stem Cell Research, Aga Khan University , Karachi , Pakistan.,b Department of Pathology and Laboratory Medicine , Aga Khan University , Karachi , Pakistan
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Liu XP, Yin XH, Meng XY, Yan XH, Wang F, He L. Development and Validation of a 9-Gene Prognostic Signature in Patients With Multiple Myeloma. Front Oncol 2019; 8:615. [PMID: 30671382 PMCID: PMC6331463 DOI: 10.3389/fonc.2018.00615] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/29/2018] [Indexed: 01/21/2023] Open
Abstract
Background: Multiple myeloma (MM) is one of the most common types of hematological malignance, and the prognosis of MM patients remains poor. Objective: To identify and validate a genetic prognostic signature in patients with MM. Methods: Co-expression network was constructed to identify hub genes related with International Staging System (ISS) stage of MM. Functional analysis of hub genes was conducted. Univariate Cox proportional hazard regression analysis was conducted to identify genes correlated with the overall survival (OS) of MM patients. Least absolute shrinkage and selection operator (LASSO) penalized Cox proportional hazards regression model was used to minimize overfitting and construct a prognostic signature. The prognostic value of the signature was validated in the test set and an independent validation cohort. Results: A total of 758 hub genes correlated with ISS stage of MM patients were identified, and these hub genes were mainly enriched in several GO terms and KEGG pathways involved in cell proliferation and immune response. Nine hub genes (HLA-DPB1, TOP2A, FABP5, CYP1B1, IGHM, FANCI, LYZ, HMGN5, and BEND6) with non-zero coefficients in the LASSO Cox regression model were used to build a 9-gene prognostic signature. Relapsed MM and ISS stage III MM was associated with high risk score calculated based on the signature. Patients in the 9-gene signature low risk group was significantly associated with better clinical outcome than those in the 9-gene signature high risk group in the training set, test, and validation set. Conclusions: We developed a 9-gene prognostic signature that might be an independent prognostic factor in patients with MM.
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Affiliation(s)
| | | | | | - Xin-Hui Yan
- Department of Cardiology, the First Hospital of Lanzhou University, Lanzhou, China
| | - Fan Wang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Li He
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
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22
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Richardson PG, Zweegman S, O’Donnell EK, Laubach JP, Raje N, Voorhees P, Ferrari RH, Skacel T, Kumar SK, Lonial S. Ixazomib for the treatment of multiple myeloma. Expert Opin Pharmacother 2018; 19:1949-1968. [DOI: 10.1080/14656566.2018.1528229] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Paul G. Richardson
- Division of Hematologic Malignancy, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Sonja Zweegman
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Jacob P. Laubach
- Division of Hematologic Malignancy, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Noopur Raje
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Peter Voorhees
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Renda H. Ferrari
- Global Medical Affairs, Millennium Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Tomas Skacel
- Global Medical Affairs, Millennium Pharmaceuticals, Inc, Cambridge, MA, USA
| | | | - Sagar Lonial
- Hematology & Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
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23
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Zheleznyak A, Shokeen M, Achilefu S. Nanotherapeutics for multiple myeloma. WILEY INTERDISCIPLINARY REVIEWS. NANOMEDICINE AND NANOBIOTECHNOLOGY 2018; 10:e1526. [PMID: 29701006 PMCID: PMC6185771 DOI: 10.1002/wnan.1526] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 03/19/2018] [Accepted: 03/23/2018] [Indexed: 01/11/2023]
Abstract
Multiple myeloma (MM) is an age-related hematological malignancy with an estimated 30,000 new cases and 13,000 deaths per year. A disease of antibody-secreting malignant plasma B-cells that grow primarily in the bone marrow (BM), MM causes debilitating fractures, anemia, renal failure, and hypercalcemia. In addition to the abnormal genetic profile of MM cells, the permissive BM microenvironment (BMM) supports MM pathogenesis. Although advances in treatment options have significantly enhanced survival in MM patients, transient perfusion of small-molecule drugs in the BM does not provide sufficient residence to enhance MM cell-drug interaction, thus allowing some myeloma cells to escape the first line of treatment. As such, there remains a crucial need to develop advanced drug delivery systems that can navigate the complex BMM and effectively reach the myeloma cells. The high vascular density and spongy nature of bone structure suggest that nanoparticles (NPs) can serve as smart drug-delivery systems capable of extravasation and retention in various BM compartments to exert a durable therapeutic effect. In this focus article, we first summarize the pathophysiology of MM, emphasizing how the BM niche presents serious challenges for effective treatment of MM with small-molecule drugs. We then pivot to current efforts to develop NP-based drug carriers and intrinsically therapeutic nanotherapeutics. The article concludes with a brief perspective on the opportunities and challenges in developing and translating nanotherapeutics to improve the treatment outcomes of MM patients. This article is categorized under: Therapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease.
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Affiliation(s)
| | - Monica Shokeen
- Departments of Radiology, and Biomedical Engineering, Washington University, St. Louis, MO, USA
| | - Samuel Achilefu
- Departments of Radiology, Biomedical Engineering, and Biochemistry & Molecular Biophysics, Washington University, St. Louis, MO, USA
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24
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Marini C, Maia T, Bergantim R, Pires J, Aguiar E, Guimarães JE, Trigo F. Real-life data on safety and efficacy of autologous stem cell transplantation in elderly patients with multiple myeloma. Ann Hematol 2018; 98:369-379. [PMID: 30368589 PMCID: PMC6342895 DOI: 10.1007/s00277-018-3528-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 10/17/2018] [Indexed: 12/22/2022]
Abstract
Autologous stem cell transplantation (ASCT) is still debatable in treatment of patients over 65 years with multiple myeloma (MM). We performed a retrospective analysis of newly diagnosed MM patients who underwent ASCT between January 2010 and July 2016. A non-transplanted group with similar clinical characteristics, aged 65-70 years old, diagnosed and treated in the same timeline was used for comparison. We analyzed a total of 155 patients, 132 of which underwent ASCT (≤ 65 years, n = 103, median 56 years; > 65 years, n = 29, median 67 years) and 23 non-transplanted (median 68 years). Conditioning consisted of melphalan 200 mg/m2 (MEL200) in younger patients and melphalan 140 mg/m2 (MEL140) in half of elderly patients. Stratifying by age, there were no statistically significant differences concerning transplant-related myelotoxicity and non-hematopoietic toxicity; however, elderly patients conditioned with MEL200 had higher needs of transfusional support and more days of intravenous antibiotics. Those patients also had higher needs of transfusional support, higher grade of mucositis (p = 0.028), and more days of intravenous antibiotics (p = 0.019) than the elderly transplanted with MEL140. Global transplant-related mortality was 3.8%. Survival was not influenced by age. Non-transplanted elderly patients had comparable disease features, and induction response was similar in both groups (before ASCT in the transplanted cohort). Survival of transplanted elderly patients was superior to non-transplanted (OS, 59 months vs 30 months, p = 0.037; EFS, 45 months vs 27 months, p = 0.014). Selected elderly patients when transplanted have similar disease response and survival as younger patients. A higher dose of melphalan has more toxicity, but it is globally a well-tolerated procedure.
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Affiliation(s)
| | - Tânia Maia
- Centro Hospitalar de São João, Porto, Portugal
| | - Rui Bergantim
- Centro Hospitalar de São João, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Jorge Pires
- Centro Hospitalar de São João, Porto, Portugal
| | | | - José Eduardo Guimarães
- Centro Hospitalar de São João, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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25
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Knauf W, Aldaoud A, Hutzschenreuter U, Klausmann M, Dille S, Wetzel N, Jänicke M, Marschner N. Survival of non-transplant patients with multiple myeloma in routine care differs from that in clinical trials-data from the prospective German Tumour Registry Lymphatic Neoplasms. Ann Hematol 2018; 97:2437-2445. [PMID: 30069704 PMCID: PMC6208687 DOI: 10.1007/s00277-018-3449-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/17/2018] [Indexed: 11/29/2022]
Abstract
Despite increasing treatment options, multiple myeloma (MM) remains incurable for most patients. Data on improvement of outcomes are derived from selected patient populations enrolled in clinical trials and might not be conferrable to all patients. Therefore, we assessed the trial eligibility, sequential treatment, and survival of non-transplant patients with MM treated in German routine care. The prospective clinical cohort study TLN (Tumour Registry Lymphatic Neoplasms) recruited 285 non-transplant patients with symptomatic MM at start of first-line treatment in 84 centres from 2009 to 2011. Demographic and clinical data were collected until August 2016. Trial-ineligibility was determined by presence of at least one of the common exclusion criteria: heart/renal failure, liver/renal diseases, polyneuropathy, HIV positivity. All other patients were considered potentially trial-eligible. Thirty percent of the patients in our study were classified as trial-ineligible. Median first-line progression-free survival (PFS) and overall survival (OS) of trial-ineligible patients were inferior to that of potentially trial-eligible patients: PFS 16.2 months (95% CI (confidence interval) 11.1–20.4) vs. 27.3 months (95% CI 23.3–33.0); OS 34.2 months (95% CI 21.6–48.1) vs. 58.6 months (95% CI 48.6–64.4). A high percentage of non-transplant patients with MM in German routine care would be ineligible for participation in clinical trials. Despite similar treatment algorithms, their first-line PFS and OS were shorter than those of potentially trial-eligible patients; the survival data of the latter were similar to results from clinical trials. Physicians should be aware of the fact that results from clinical trials may not mirror “real world” patient outcomes when discussing outcome expectations with patients. Trial registration: Clinicaltrials.gov identifier: NCT00889798.
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Affiliation(s)
- Wolfgang Knauf
- Joint Outpatient-Centre for Oncology, Frankfurt a. M., Germany
| | - Ali Aldaoud
- Joint Outpatient-Centre for Haematology and Oncology, Leipzig, Germany
| | | | - Martine Klausmann
- Joint Outpatient-Centre for Haematology and Oncology, Aschaffenburg, Germany
| | | | - Natalie Wetzel
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
| | - Martina Jänicke
- Clinical Epidemiology and Health Economics, iOMEDICO, Freiburg, Germany
| | - Norbert Marschner
- Outpatient-Centre for Interdisciplinary Oncology and Haematology, Wirthstrasse 11c, 79110, Freiburg, Germany.
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26
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Abstract
Multiple myeloma treatment has changed tremendously over recent years leading to overall improvement in patient outcomes. With therapeutic advancements, patient care has become increasingly complex and variability is seen in healthcare delivery as well as outcomes when various patient subgroups are analyzed based on sociodemographic factors. It is imperative to understand this variability so that while overall the outcomes get better, specific focus is placed on subgroups that may remain disadvantaged and may not be able to fully access the advancements in therapeutics. Research in multiple myeloma has specifically looked at several such patient subgroups based on socioeconomic status, age, race/ethnicity, insurance carrier, and geographic location that may affect healthcare utilization and patient outcomes. Exploring and understanding these would certainly help address disparities and lead to further equity in healthcare access and, hopefully, patient outcomes.
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27
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Savvidou OD, Bolia IK, Chloros GD, Papanastasiou J, Koutsouradis P, Papagelopoulos PJ. Denosumab: Current Use in the Treatment of Primary Bone Tumors. Orthopedics 2017; 40:204-210. [PMID: 28732103 DOI: 10.3928/01477447-20170627-04] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Denosumab, a human monoclonal antibody that inhibits bone resorption by binding on the receptor activator of the nuclear factor kappa-β ligand, has recently emerged as an additional option in the treatment of musculoskeletal osteolytic tumors. This article focuses on the recent literature regarding the effectiveness of denosumab in the management of giant cell tumor, multiple myeloma, aneurysmal bone cyst, and osteosarcoma. The mechanism of action of denosumab in the management of these tumors and the associated side effects are discussed in detail. [ Orthopedics. 2017; 40(4):204-210.].
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