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Larsen RF, Jarden M, Minet LR, Frølund UC, Hermann AP, Breum L, Möller S, Abildgaard N. Exercise in newly diagnosed patients with multiple myeloma: A randomized controlled trial of effects on physical function, physical activity, lean body mass, bone mineral density, pain, and quality of life. Eur J Haematol 2024; 113:298-309. [PMID: 38717071 DOI: 10.1111/ejh.14215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 03/26/2024] [Accepted: 04/04/2024] [Indexed: 08/03/2024]
Abstract
Reduced physical function caused by bone destruction, pain, anemia, infections, and weight loss is common in multiple myeloma (MM). Myeloma bone disease challenges physical exercise. Knowledge on the effects and safety of physical exercise in newly diagnosed patients with MM is limited. In a randomized, controlled trial, we studied the effect of a 10-week individualized physical exercise program on physical function, physical activity, lean body mass (LBM), bone mineral density (BMD), quality of life (QoL), and pain in patients newly diagnosed with MM. Lytic bone disease was assessed, and exercise was adjusted accordingly. Primary outcome: knee extension strength. Secondary outcomes: Six-Minute-Walk-Test, 30-s Sit-to-Stand-Test (SST), grip strength, level of physical activity, LBM, BMD, QoL, and pain. Measurements were conducted pre- and post-intervention, and after 6 and 12 months. We included 100 patients, 86 were evaluable; 44 in the intervention group (IG) and 42 in the control group (CG). No statistically significant differences between groups were observed. Knee extension strength declined in the IG (p = .02). SST, aerobic capacity, and global QoL improved in both groups. Pain decreased consistently in the IG regardless of pain outcome. No significant safety concerns of physical exercise in newly diagnosed patients with MM were observed.
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Affiliation(s)
- Rikke F Larsen
- Department of Physiotherapy and Occupational Therapy, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Haematology, Odense University Hospital, Odense, Denmark
| | - Mary Jarden
- Department of Haematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lisbeth R Minet
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Geriatric, Odense University Hospital, Odense, Denmark
- The Competence Centre for Rehabilitation - KCR, Odense University Hospital, Odense, Denmark
| | | | | | - Leif Breum
- Department of Medicine and Endocrinology, Zealand University Hospital, Koge, Denmark
| | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Niels Abildgaard
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Haematology, Odense University Hospital, Odense, Denmark
- The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
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Hevroni G, Korde N. Examining health related quality of life outcomes in multiple myeloma: Past and future perspectives. Semin Oncol 2022; 49:94-102. [DOI: 10.1053/j.seminoncol.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/23/2021] [Accepted: 01/02/2022] [Indexed: 11/11/2022]
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Challenges in the cultural adaptation of the German Myeloma Patient Outcome Scale (MyPOS): an outcome measure to support routine symptom assessment in myeloma care. BMC Cancer 2020; 20:245. [PMID: 32293347 PMCID: PMC7092563 DOI: 10.1186/s12885-020-06730-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/09/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patients with multiple myeloma report more problems with quality of life (QoL) than other haematological malignancies over the course of their incurable illness. The patient-centred Myeloma Patient Outcome Scale (MyPOS) was developed to assess and monitor symptoms and supportive care factors in routine care. Our aim was to translate and culturally adapt the outcome measure to the German context, and to explore its face and content validity. METHODS Translation and cultural adaptation following established guidelines used an exploratory, sequential mixed method study design. Steps included: (1) forward translation to German; (2) backward translation to English; (3) expert review; (4) focus groups with the target population (patients, family members, healthcare professionals) to achieve conceptual equivalence; (5) cognitive interviews using Tourangeau's model with think-aloud technique to evaluate comprehension and acceptability; (6) final review. Results were analysed using thematic analysis. RESULTS Cultural and linguistic differences were noted between the German and English original version. The focus groups (n = 11) and cognitive interviews (n = 9) both highlighted the need for adapting individual items and their answer options to the German healthcare context. Greater individuality regarding need for information with the right to not be informed was elaborated by patients. While the comprehensive nature of the tool was appreciated, item wording regarding satisfaction with healthcare was deemed not appropriate in the German context. Before implementation into routine care, patients' concerns about keeping their MyPOS data confidential need to be addressed as a barrier, whereas the MyPOS itself was perceived as a facilitator/prompt for a patient-centred discussion of QoL issues. CONCLUSION With adaptations to answer options and certain items, the German version of the MyPOS can help monitor symptoms and problems afflicting myeloma patients over the course of the disease trajectory. It can help promote a model of comprehensive supportive and patient-centred care for these patients.
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Larsen RF, Jarden M, Minet LR, Frølund UC, Abildgaard N. Supervised and home-based physical exercise in patients newly diagnosed with multiple myeloma-a randomized controlled feasibility study. Pilot Feasibility Stud 2019; 5:130. [PMID: 31741745 PMCID: PMC6849284 DOI: 10.1186/s40814-019-0518-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 10/15/2019] [Indexed: 01/07/2023] Open
Abstract
Background The study evaluated the feasibility and safety of the exercise intervention and physical test procedures of our ongoing randomized controlled trial, examining the effect of physical exercise in newly diagnosed patients with multiple myeloma. Methods Patients are randomized 1:1 to a control group (usual care) or an intervention group (usual care and exercise) by block randomization with stratification of planned treatment, WHO performance status, and study site. The exercise intervention consists of eight supervised exercise sessions combined with home-based exercise over a 10-week period. Bone disease is systematically evaluated to determine limitations regarding physical testing and/or exercise. Feasibility outcome measures were study eligibility, acceptance, and attrition, and furthermore attendance, adherence, tolerability, and safety to the exercise intervention. Additionally, test completion, pain, and adverse events during the physical test procedures were evaluated. Outcome assessors were blinded to allocation. Results Of 49 patients screened, 30 were included. The median age was 69 years, range 38–90, 77% were males, and 67% had bone disease. Study eligibility was 82%, acceptance 75%, and attrition 20%. Attendance at supervised exercise sessions was 92%, and adherence to supervised exercise sessions and home-based exercise sessions was 99% and 89%, respectively. No serious adverse events attributed to exercise or physical tests were reported. All patients completed the physical tests, except for two patients, where physical test procedures were modified due to bone disease. Discussion The exercise intervention and physical test procedures were feasible and safe in patients with multiple myeloma, even in older patients with multiple myeloma and in patients with myeloma bone disease. Trial registration ClinicalTrials.gov. ID NCT02439112. Registered on May 7, 2015.
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Affiliation(s)
- Rikke Faebo Larsen
- 1Department of Physiotherapy and Occupational Therapy, Zealand University Hospital, Sygehusvej 10, 4000 Roskilde, Denmark.,2Department of Clinical Research, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.,3OPEN, Odense Patient data Explorative Network, Odense University Hospital, J.B. Winsløwvej 9A, 5000 Odense, Denmark
| | - Mary Jarden
- 4Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.,5Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Lisbeth Rosenbek Minet
- 2Department of Clinical Research, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.,6Department of Rehabilitation, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark.,Center for Applied Research, UCL University College, Niels Bohrs Allé 1, 5230 Odense M, Denmark
| | - Ulf Christian Frølund
- 8Department of Hematology, Zealand University Hospital, Sygehusvej 10, 4000 Roskilde, Denmark
| | - Niels Abildgaard
- 2Department of Clinical Research, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.,9Department of Hematology, Odense University Hospital, Kløvervænget 10, 5000 Odense, Denmark.,10The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
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Ramsenthaler C, Gao W, Siegert RJ, Edmonds PM, Schey SA, Higginson IJ. Symptoms and anxiety predict declining health-related quality of life in multiple myeloma: A prospective, multi-centre longitudinal study. Palliat Med 2019; 33:541-551. [PMID: 31060467 DOI: 10.1177/0269216319833588] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patients with multiple myeloma, an incurable haematological cancer, often receive palliative care only late in their trajectory. Criteria for early referral are lacking. AIM To identify which patients might benefit from early integration, by identifying trajectories of health-related quality of life and the determinants for declining or poor Health related quality of life . DESIGN Prospective, longitudinal cohort study. PARTICIPANTS Multiple myeloma patients at all stages (newly diagnosed, first-line or second-line treatment, early or later treatment-free interval, refractory disease) from in- and outpatient units at 14 hospitals in England were recruited. In addition to clinical information and standardised Health related quality of life and psychological aspects, the Myeloma Patient Outcome Scale (MyPOS) measured palliative care concerns. RESULTS A total of 238 patients were recruited, on average 3.5 years ( SD: 3.4) post-diagnosis. Latent mixture growth models identified four Health related quality of life trajectories. Classes 3 and 4 represent trajectories of stable poor Health related quality of life or declining Health related quality of life over an 8-month period. The strongest predictors of poor outcome at the end of follow-up were general symptom level (odds ratio (OR): 1.3, 95% CI: 1.0-1.6, p = 0.028), presence of clinically relevant anxiety (OR: 1.2, 95% confidence interval (CI): 1.0-1.4, p = 0.019), and presence of pain (OR: 1.02, 95% CI: 1.0-1.1, p = 0.018), all being more predictive than demographic or clinical characteristics. CONCLUSION General symptom level, pain and presence of anxiety predict declining Health related quality of life in multiple myeloma. Identification of patients with palliative care needs should focus on assessing patient-reported symptoms and psychosocial well-being for identifying those at risk of deterioration.
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Affiliation(s)
- Christina Ramsenthaler
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,2 Department of Palliative Medicine, University Hospital Munich, Munich, Germany
| | - Wei Gao
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Richard J Siegert
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,3 Department of Psychology, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Polly M Edmonds
- 4 Department of Palliative Care, King's College Hospital NHS Foundation Trust, London, UK
| | - Stephen A Schey
- 5 Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Irene J Higginson
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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Abnormal Plasma Cell Disorders in Refinery Waste Workers. J Clin Med 2018; 7:jcm7080221. [PMID: 30126157 PMCID: PMC6111622 DOI: 10.3390/jcm7080221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 01/19/2023] Open
Abstract
A monoclonal gammopathy of undetermined significance (MGUS) may develop into a multiple myeloma or a correlated lymphoproliferative malignancy with a progress rate of 1% per year. The immune status, occupational-environmental risk factors, and hereditary factors may influence the risk of developing MGUS. We investigated the prevalence of MGUS in 77 refinery waste workers. They were all males, averagely aged 36, with a mean working history of 18.5 years and working in the dump for about 4.2 years. After analyzing the results of standard serum electrophoresis migrations, 16% of cases (n = 12) showed levels beyond the normal ranges. In all 12 samples we observed an increase of gamma component: 67%, IgG; 17%, IgM; 8%, IgA; 8%, oligoclonal. Workers were exposed to hazardous refinery waste. After the biological monitoring of urine samples for metals and t,t-muconic acid, no extra-range values were observed. The multivariate analysis shows, however, that cigarette smoking and residence near industrial sites are significantly (p < 0.001) associated with a high risk of MGUS development; while no association was found with occupational exposure. Additional attention might be paid in particular to these conditions in epidemiological studies and further larger, prospective, population-based researches appear warranted to evaluate the strength of any positive association.
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Vogl DT, Delforge M, Song K, Guo S, Gibson CJ, Ervin-Haynes A, Facon T. Long-term health-related quality of life in transplant-ineligible patients with newly diagnosed multiple myeloma receiving lenalidomide and dexamethasone. Leuk Lymphoma 2017. [PMID: 28641472 DOI: 10.1080/10428194.2017.1334125] [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] [Indexed: 01/25/2023]
Abstract
The FIRST trial demonstrated that continuous therapy with lenalidomide and dexamethasone (Rd) prolongs overall survival (OS) and improves health-related quality of life (HRQoL) during the first 18 months of therapy in newly diagnosed multiple myeloma (NDMM) patients. However, patient-reported HRQoL data were not collected after 18 months. We therefore estimated HRQoL scores based on time-varying data collected during progression-free follow-up after 18 months. During the initial 18 months of Rd, observed changes from baseline were within the 95% confidence interval of the predictive models at 33 of 35 time points across 7 HRQoL scores. Predicted scores after 18 months of therapy showed that observed HRQoL improvements during therapy were maintained or improved. Therefore, the survival gain observed with Rd does not come at a cost of declining HRQoL during continuous therapy beyond 18 months, supporting long-term Rd as a standard of care for initial myeloma therapy.
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Affiliation(s)
- Dan T Vogl
- a Abramson Cancer Center, University of Pennsylvania , Philadelphia , PA , USA
| | - Michel Delforge
- b Campus Gasthuisberg, Universitair Ziekenhuis Leuven , Leuven , Belgium
| | - Kevin Song
- c Vancouver General Hospital , Vancouver , BC , Canada
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Tsukanov J, Fabbro ED. Palliative care and symptom management in amyloidosis: A review. Curr Probl Cancer 2016; 40:220-228. [DOI: 10.1016/j.currproblcancer.2016.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 09/04/2016] [Accepted: 09/14/2016] [Indexed: 12/27/2022]
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Osborne TR, Ramsenthaler C, Schey SA, Siegert RJ, Edmonds PM, Higginson IJ. Improving the assessment of quality of life in the clinical care of myeloma patients: the development and validation of the Myeloma Patient Outcome Scale (MyPOS). BMC Cancer 2015; 15:280. [PMID: 25884627 PMCID: PMC4404617 DOI: 10.1186/s12885-015-1261-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/25/2015] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Multiple myeloma is an incurable cancer with a rising incidence globally. Less toxic treatments are increasingly available, so patients are living longer and treatment decisions are increasingly guided by QOL concerns. There is no QOL assessment tool designed specifically for use in the clinical care of people with myeloma. This study aimed to develop and test the psychometric properties of a new myeloma-specific QOL questionnaire designed specifically for use in the clinical setting - the MyPOS. METHODS The MyPOS was developed using findings from a previously reported literature review and qualitative study. The prototype MyPOS was pretested using cognitive interviews in a purposive sample of myeloma patients and refined prior to field testing. The psychometric properties of the MyPOS were evaluated in a multi-centre, cross sectional survey of myeloma patients recruited from 14 hospital trusts across England. RESULTS The prototype MyPOS contained 33 structured and open questions. These were refined using cognitive interviews with 12 patients, and the final MyPOS contained 30 items taken forward for field-testing. The cross-sectional survey recruited 380 patients for the MyPOS validation. Mean time to complete was 7 minutes 19 seconds with 0.58% missing MyPOS items overall. Internal consistency was high (α = 0.89). Factor analysis confirmed three subscales: Symptoms & Function; Emotional Response and Healthcare Support. MyPOS total scores were higher (worse QOL) in those with active disease compared to those in the stable or plateau phase (F = 11.89, p < 0.001) and were worse in those currently receiving chemotherapy (t = 3.42, p = 0.001). Scores in the Symptoms & Function subscale were higher (worse QOL) in those with worse ECOG performance status (F = 31.33, p < 0.001). Good convergent and discriminant validity were demonstrated. CONCLUSIONS The MyPOS is the first myeloma-specific QOL questionnaire designed specifically for use in the clinical setting. The MyPOS is based on qualitative enquiry and the issues most important to patients. It is a brief, comprehensive and acceptable tool that is reliable and valid on psychometric testing. The MyPOS can now be used to support clinical decision making in the routine care of myeloma patients.
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Affiliation(s)
- Thomas R Osborne
- King's College London Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London, UK.
| | - Christina Ramsenthaler
- King's College London Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London, UK.
| | - Stephen A Schey
- Department of Haematological Medicine, King's College Hospital and King's College London, London, UK.
| | - Richard J Siegert
- King's College London Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London, UK. .,School of Public Health and Psychosocial Studies and School of Rehabilitation and Occupation Studies, Auckland University of Technology, Auckland, New Zealand.
| | - Polly M Edmonds
- King's College London Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London, UK. .,Department of Palliative Care, King's College Hospital, London, UK.
| | - Irene J Higginson
- King's College London Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London, UK.
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Trends in autologous hematopoietic cell transplantation for multiple myeloma in Europe: increased use and improved outcomes in elderly patients in recent years. Bone Marrow Transplant 2014; 50:209-15. [DOI: 10.1038/bmt.2014.255] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 09/19/2014] [Accepted: 09/23/2014] [Indexed: 11/08/2022]
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Osborne TR, Ramsenthaler C, de Wolf-Linder S, Schey SA, Siegert RJ, Edmonds PM, Higginson IJ. Understanding what matters most to people with multiple myeloma: a qualitative study of views on quality of life. BMC Cancer 2014; 14:496. [PMID: 25005145 PMCID: PMC4227056 DOI: 10.1186/1471-2407-14-496] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 06/23/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Multiple myeloma is an incurable haematological cancer that affects physical, psychological and social domains of quality of life (QOL). Treatment decisions are increasingly guided by QOL issues, creating a need to monitor QOL within clinical practice. The development of myeloma-specific QOL questionnaires has been limited by a paucity of research to fully characterise QOL in this group. Aims of the present study are to (1) explore the issues important to QOL from the perspective of people with multiple myeloma, and (2) explore the views of patients and clinical staff on existing QOL questionnaires and their use in clinical practice. METHODS The 'Issues Interviews' were semi-structured qualitative interviews to explore the issues important to QOL in a purposive sample of myeloma patients (n = 20). The 'Questionnaire Interviews' were semi-structured qualitative interviews in a separate purposive sample of myeloma patients (n = 20) to explore views on existing QOL questionnaires and their clinical use. Two patient focus groups (n = 7, n = 4) and a focus group of clinical staff (n = 6) complemented the semi-structured interviews. Thematic content analysis resulted in the development of a theoretical model of QOL in myeloma. RESULTS Main themes important to QOL were Biological Status, Treatment Factors, Symptoms Status, Activity & Participation, Emotional Status, Support Factors, Expectations, Adaptation & Coping and Spirituality. Symptoms had an indirect effect on QOL, only affecting overall QOL if they impacted upon Activity & Participation, Emotional Status or Support Factors. This indirect relationship has implications for the design of QOL questionnaires, which often focus on symptom status. Health-service factors emerged as important but are often absent from QOL questionnaires. Sexual function was important to patients and difficult for clinicians to discuss, so inclusion in clinical QOL tools may flag hidden problems and facilitate better care. Patients and staff expressed preferences for questionnaires to be no more than 2 pages long and to include a mixture of structured and open questions to focus the goals of care on what is most important to patients. CONCLUSION Existing QOL questionnaires developed and validated for use in myeloma do not capture all that is important to patients and may not be well suited to clinical use.
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Affiliation(s)
- Thomas R Osborne
- Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.
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A descriptive study of plasma cell dyscrasias in Egyptian population. J Egypt Natl Canc Inst 2014; 26:67-71. [DOI: 10.1016/j.jnci.2013.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 09/15/2013] [Accepted: 09/17/2013] [Indexed: 11/19/2022] Open
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Multiple myeloma: a descriptive study of 217 Egyptian patients. Ann Hematol 2013; 93:141-5. [PMID: 23892925 DOI: 10.1007/s00277-013-1849-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 07/15/2013] [Indexed: 12/19/2022]
Abstract
Multiple myeloma is a neoplasm of plasma cells that results in the overproduction of light and heavy chain monoclonal immunoglobulins. The incidence rate increases with age, particularly after 40 years, and is higher in men. To determine the clinical and laboratory characteristics and survival of diagnosed Egyptian multiple myeloma patients admitted to the Haemato-Oncology Department between 2000 and 2010. Records of all patients in whom multiple myeloma was diagnosed at the Kasr Al Aini Hospital between 2000 and 2010 were included in this retrospective study. The mean age of patients was 58.5 years (range, 27-80 years). Fifty-nine percent were males. The majority of patients (73 %) had an immunoglobulin G monoclonal band and 70 % were Kappa chain-positive. Mean overall survival was 37.5 months (range, 1-84 months). Survival analysis was statistically insignificant with respect to age, sex, International Staging System and type of treatment (p > 0.05). Our records were largely comparable to those reported in Chinese studies but different from those noted in Western and Arabic countries.
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Félix J, Aragão F, Almeida JM, Calado FJ, Ferreira D, Parreira ABS, Rodrigues R, Rijo JFR. Time-dependent endpoints as predictors of overall survival in multiple myeloma. BMC Cancer 2013; 13:122. [PMID: 23497363 PMCID: PMC3607860 DOI: 10.1186/1471-2407-13-122] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 03/07/2013] [Indexed: 02/01/2023] Open
Abstract
Background Supporting health care sector decisions using time-dependent endpoints (TDEs) such as time to progression (TTP), progression-free survival (PFS), and event-free survival (EFS) remains controversial. This study estimated the quantitative relationship between median TDE and median overall survival (OS) in multiple myeloma (MM) patients. Methods Studies (excluding allogeneic transplantation) published from 1970 to 2011 were systematically searched (PubMed). The nonparametric Spearman’s rank correlation coefficient measured the association between median TDE and OS. The quantitative relationship between TDEs and OS was estimated with a two-step approach to a simultaneous Tobit model. Results We identified 153 studies: 230 treatment arms, 22,696 patients and mean study duration of 3.8 years. Mean of median TDEs was 22.5 months and median OS was 39.1 months. Correlation coefficients of median TTP, PFS, and EFS with median OS were 0.51 (P = 0.003), 0.75 (P < 0.0001), and 0.84 (P < 0.0001), respectively. We estimate a 2.5 month (95% confidence interval, 1.7–3.2) increase in median OS for each additional month reported for median TDEs. There was no evidence that this relationship differed by type of surrogate. Conclusion TDEs predict OS in MM patients; this relationship may be valuable in clinical trial design, drug comparisons, and economic evaluation.
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Affiliation(s)
- Jorge Félix
- Exigo Consultores, Av. Humberto Delgado 33, Alhos Vedros 2860-021, Portugal.
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Osborne TR, Ramsenthaler C, Siegert RJ, Edmonds PM, Schey SA, Higginson IJ. What issues matter most to people with multiple myeloma and how well are we measuring them? A systematic review of quality of life tools. Eur J Haematol 2012; 89:437-57. [PMID: 22985406 DOI: 10.1111/ejh.12012] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Treatment advances in multiple myeloma have increased expected survival from months to years for some patients. Alongside improved survival emerges a need to better understand and measure health-related quality of life (HRQOL), both in research and clinical settings. OBJECTIVES (i) Identify HRQOL tools validated for use in myeloma; (ii) identify issues important to HRQOL from the point of view of patients with myeloma; (iii) describe the measurement properties of each HRQOL tool; (iv) evaluate the content validity of HRQOL tools in terms of their ability to capture all issues important to patients and (v) explore the suitability of each HRQOL tool for use in different settings. METHOD Systematic literature review of six databases with no limits by date or language. RESULTS Thirty-nine studies reported validation of 13 HRQOL instruments. Seven studies identified issues important to HRQOL from the patients' perspective. No instrument was comprehensive to all issues important to patients. The EORTC-QLQ-C30 and MY24 have undergone the most comprehensive psychometric validation. Most validation occurred in trial patients and not clinically representative groups. No studies evaluated clinical utility of tools alongside routine practice. CONCLUSION The best existing HRQOL tools are designed predominantly for use in research. Reliable, valid and responsive tools exist for this purpose, but may miss issues important to patients. The design of HRQOL measures should be guided by intended utility, whether for research or clinical practice, and further validation of HRQOL tools in clinically representative groups is needed. Development and validation of HRQOL tools for clinical use may be of value.
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Affiliation(s)
- Thomas R Osborne
- Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, King's College London, and King's College Hospital, London, UK.
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Noll JE, Williams SA, Purton LE, Zannettino ACW. Tug of war in the haematopoietic stem cell niche: do myeloma plasma cells compete for the HSC niche? Blood Cancer J 2012; 2:e91. [PMID: 22983434 PMCID: PMC3461708 DOI: 10.1038/bcj.2012.38] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In the adult mammal, normal haematopoiesis occurs predominantly in the bone marrow, where primitive haematopoietic stem cells (HSC) and their progeny reside in specialised microenvironments. The bone marrow microenvironment contains specific anatomical areas (termed niches) that are highly specialised for the development of certain blood cell types, for example HSCs. The HSC niche provides important cell–cell interactions and signalling molecules that regulate HSC self-renewal and differentiation processes. These same signals and interactions are also important in the progression of haematological malignancies, such as multiple myeloma (MM). This review provides an overview of the bone marrow microenvironment and its involvement in normal, physiological HSC maintenance and plasma cell growth throughout MM disease progression.
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Affiliation(s)
- J E Noll
- Myeloma Research Laboratory, Bone and Cancer Research Laboratories, Department of Haematology, Centre for Cancer Biology, Adelaide, South Australia, Australia
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Kontodimopoulos N, Samartzis A, Papadopoulos AA, Niakas D. Reliability and validity of the Greek QLQ-C30 and QLQ-MY20 for measuring quality of life in patients with multiple myeloma. ScientificWorldJournal 2012; 2012:842867. [PMID: 22919356 PMCID: PMC3419404 DOI: 10.1100/2012/842867] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 06/10/2012] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the psychometric properties of the Greek EORTC QLQ-C30 and QLQ-MY20 instruments. METHOD A sample of myeloma patients (N = 89) from two tertiary hospitals were surveyed with the QLQ-C30, QLQ-MY20 and various demographic and disease related questions. The previously validated Greek SF-36 instrument was used as a "gold standard" for health-related quality of life (HRQoL) comparisons. Hypothesized scale structure, internal consistency reliability (Cronbach's alpha) and various forms of construct validity (convergent, discriminative, concurrent and known-groups) were assessed. RESULTS Multitrait scaling confirmed scale structure of the QLQ-C30 and QLQ-MY20, with good item convergence (96% and 72%) and discrimination (78% and 58%) rates. Cronbach's α was >0.70 for all but one scale (cognitive functioning). Spearman's correlations between similar QLQ-C30 and SF-36 scales ranged between 0.35-0.80 (P < 0.001). Expected interscale correlations and known-groups comparisons supported construct validity. QLQ-MY20 scales showed comparatively lower correlations with QLQ-C30 functional scales, and higher correlations with conceptually related symptom scales. CONCLUSIONS The observed psychometric properties of the two instruments imply suitability for assessing myeloma HRQoL in Greece. Future studies should focus on generalizability of the results, as well as on specific issues such as longitudinal validity and responsiveness.
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Affiliation(s)
- Nick Kontodimopoulos
- School of Social Sciences, Hellenic Open University, Bouboulinas 57-59, 26222 Patras, Greece.
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19
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Abstract
Multiple myeloma (MM) is a malignancy of terminally differentiated plasma cells characterized by complex genetic aberrations and heterogeneous outcomes. Over the past 25 years, cytogenetic analysis has played a key role in the diagnosis and management of MM. This article reviews the conventional cytogenetics, molecular cytogenetics, and genomic diagnostics of MM and highlights a few recent clinical trials that demonstrate the impact of genetic risk stratification on the treatment of this plasma cell malignancy.
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Affiliation(s)
- Marilyn L Slovak
- Quest Diagnostics Nichols Institute, 14225 Newbrook Drive, Chantilly, VA 20151, USA.
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Kvam AK, Fayers PM, Wisloff F. Responsiveness and minimal important score differences in quality-of-life questionnaires: a comparison of the EORTC QLQ-C30 cancer-specific questionnaire to the generic utility questionnaires EQ-5D and 15D in patients with multiple myeloma. Eur J Haematol 2011; 87:330-7. [PMID: 21668504 DOI: 10.1111/j.1600-0609.2011.01665.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aims of this study were to (i) compare the responsiveness of the EORTC QLQ-C30 cancer-specific questionnaire and the generic questionnaires EQ-5D and 15D used for economic evaluation of healthcare interventions and (ii) determine the minimal important differences (MIDs) in these questionnaires. The MID is the smallest change in a quality-of-life score considered important to patients. METHODS Between 2006 and 2008, 239 patients with multiple myeloma completed the questionnaires at inclusion (T1) and after 3 months (T2). At T2, patients were asked whether they had noticed any change in their quality of life. Responsiveness and MIDs were determined by mean score changes (T2-T1) for patients who, in the interview, stated they had improved, deteriorated, or were unchanged. Responsiveness was also assessed using standardized response means. Wilcoxon tests for pair differences were used to evaluate the statistical significance of the changes. RESULTS Patients who improved had significantly (P < 0.01) higher scores at T2 in all three questionnaires. Patients who deteriorated reported lower scores at T2; however, for the 15D, the differences in score were not statistically significant. The MIDs for the QLQ-C30, EQ-5D, and 15D were 8, 0.08, and 0.03 in patients who improved and 12, 0.10 and 0.02 in patients who deteriorated, respectively. CONCLUSIONS All three questionnaires showed an acceptable responsiveness in patients who improved. However, the 15D did not respond optimally in patients who deteriorate and cannot be recommended for use in patients with myeloma.
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Affiliation(s)
- Ann Kristin Kvam
- Department of Haematology, Oslo University Hospital, Ullevaal Faculty of Medicine, University of Oslo, Oslo, Norway.
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21
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Lenalidomide treatment for patients with multiple myeloma: diagnosis and management of most frequent adverse events. Adv Ther 2011; 28 Suppl 1:11-6. [PMID: 21431627 DOI: 10.1007/s12325-010-0102-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Indexed: 10/18/2022]
Abstract
The introduction of novel antimyeloma therapies, including thalidomide, lenalidomide, and bortezomib, has expanded treatment options for patients with this disease. These compounds have altered the natural history of multiple myeloma, resulting in substantial improvements in patient outcomes. However, like with any other drug, their use is associated with a specific toxicity profile. The major adverse events (AEs) associated with lenalidomide include: hematological toxicities (myelosuppression), mainly neutropenia, venous thromboembolism, gastrointestinal disturbance, skin toxicity, atrial fibrillation, asthenia, and decreased peripheral blood stem cell yield during stem cell collection when lenalidomide is used after a long period of time. These AEs are predictable, consistent, and manageable with patient monitoring, supportive care, and dose adjustment. In this article, using three clinical cases as examples, we discuss the diagnoses and management of the most frequent AEs associated with lenalidomide treatment in patients with multiple myeloma.
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Management of the adverse effects of lenalidomide in multiple myeloma. Adv Ther 2011; 28 Suppl 1:1-10. [PMID: 21431626 DOI: 10.1007/s12325-010-0104-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Indexed: 10/18/2022]
Abstract
The introduction of new agents in the treatment of multiple myeloma, such as thalidomide, bortezomib, or lenalidomide, has represented an important step forward in the management of this disease, with improvement in both treatment response and patient survival. On the other hand, when new drugs are used it is very important to know their associated toxicity, since adequate management of the adverse effects can help to avoid unnecessary treatment interruptions - thereby undoubtedly contributing to improvement in the efficacy of therapy. The present study reviews the main hematological and nonhematological adverse effects potentially associated with the use of lenalidomide in its most common combinations used for the treatment of multiple myeloma, and the recommendations for dealing with such effects.
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Morito N, Yoh K, Maeda A, Nakano T, Fujita A, Kusakabe M, Hamada M, Kudo T, Yamagata K, Takahashi S. A Novel Transgenic Mouse Model of the Human Multiple Myeloma Chromosomal Translocation t(14;16)(q32;q23). Cancer Res 2011; 71:339-48. [DOI: 10.1158/0008-5472.can-10-1057] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Multiple myeloma (MM) is a currently incurable neoplasm of terminally differentiated B cells. The translocation and/or overexpression of c-MAF have been observed in human MM. Although c-MAF might function as an oncogene in human MM, there has been no report thus far describing the direct induction of MM by c-MAF overexpression in vivo. In this study, we have generated transgenic (TG) mice that express c-Maf specifically in the B-cell compartment. Aged c-Maf TG mice developed B-cell lymphomas with some clinical features that resembled those of MM, namely, plasma cell expansion and hyperglobulinemia. Quantitative RT-PCR analysis demonstrated that Ccnd2 and Itgb7, which are known target genes of c-Maf, were highly expressed in the lymphoma cells. This novel TG mouse model of the human MM t(14;16)(q32;q23) chromosomal translocation should serve to provide new insight into the role of c-MAF in tumorigenesis. Cancer Res; 71(2); 339–48. ©2011 AACR.
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Affiliation(s)
- Naoki Morito
- Authors' Affiliations: Departments of 1Nephrology and 2Anatomy and Embryology, Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Keigyou Yoh
- Authors' Affiliations: Departments of 1Nephrology and 2Anatomy and Embryology, Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Atsuko Maeda
- Authors' Affiliations: Departments of 1Nephrology and 2Anatomy and Embryology, Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takako Nakano
- Authors' Affiliations: Departments of 1Nephrology and 2Anatomy and Embryology, Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Akiko Fujita
- Authors' Affiliations: Departments of 1Nephrology and 2Anatomy and Embryology, Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Manabu Kusakabe
- Authors' Affiliations: Departments of 1Nephrology and 2Anatomy and Embryology, Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Michito Hamada
- Authors' Affiliations: Departments of 1Nephrology and 2Anatomy and Embryology, Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takashi Kudo
- Authors' Affiliations: Departments of 1Nephrology and 2Anatomy and Embryology, Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kunihiro Yamagata
- Authors' Affiliations: Departments of 1Nephrology and 2Anatomy and Embryology, Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Satoru Takahashi
- Authors' Affiliations: Departments of 1Nephrology and 2Anatomy and Embryology, Life System Medical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Kvam AK, Wisløff F, Fayers PM. Minimal important differences and response shift in health-related quality of life; a longitudinal study in patients with multiple myeloma. Health Qual Life Outcomes 2010; 8:79. [PMID: 20678240 PMCID: PMC2922103 DOI: 10.1186/1477-7525-8-79] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Accepted: 08/03/2010] [Indexed: 01/22/2023] Open
Abstract
Background We previously reported that changes of 6-17 percent in the EORTC QLQ-C30 scores are regarded important by patients with multiple myeloma and thus may be considered as Minimal Important Differences (MIDs). However, patients' internal standard of measurement may have changed over time (response shift, RS). In the present work, we evaluated whether myeloma patients experience RS and if this could affect the MID-estimates. Methods Between 2006 and 2008, 239 patients with multiple myeloma completed the EORTC QLQ-C30 at baseline (T1) and after three months (T2). At T2, patients were asked if they had noticed any change in the domains pain, fatigue, physical function and global quality of life. They were also asked to give a retrospective judgment of their baseline values on all the four domains. Results We found clear evidence of RS in myeloma patients. However, there were differences in both magnitude and direction between patients who stated that they improved and those who deteriorated. Deteriorating patients retrospectively reported better health-related quality of life at T1 for the domains pain, fatigue and physical function. In these patients, MIDs adjusted for RS were observed to increase up to 12 percentage points. In contrast, for patients stating that they improved, we only found evidence of statistically significant RS in the domain global quality of life. Conclusions MIDs estimated from pre-test/post-test data appeared to be robust against RS in patients reporting improvement over 3-months. This could indicate that RS has a minimal impact on the results in patients who respond to treatment, and that RS may not have an important impact on interpretation of changes reported in clinical trials where an improvement occurs. Although the effect sizes of the RSs were small, RS in deteriorating patients may have an important impact on the interpretation of changes reported in clinical trials. Trial registration The study is registered at clinicaltrials.gov, identifier NCT00290095.
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Affiliation(s)
- Ann K Kvam
- Department of Haematology, Oslo University Hospital, Ullevaal, Norway.
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25
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Put N, Lemmens H, Wlodarska I, Konings P, Moreau Y, Hagemeijer A, Vandenberghe P, Michaux L. Interphase fluorescence in situ hybridization on selected plasma cells is superior in the detection of cytogenetic aberrations in plasma cell dyscrasia. Genes Chromosomes Cancer 2010; 49:991-7. [DOI: 10.1002/gcc.20809] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Clustering of concordant and discordant cancer types in Swedish couples is rare. Eur J Cancer 2010; 47:98-106. [PMID: 20655736 DOI: 10.1016/j.ejca.2010.06.125] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 06/22/2010] [Accepted: 06/23/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Spouses are exposed to common environmental cancer risk factors during adulthood. Investigating the aggregation of cancer in couples might provide valuable insights into cancer development. METHODS The 2008 update of the Swedish Family-Cancer Database includes over 2 million couples with at least one child in common with one single partner. We quantified the contribution of shared adulthood environment by standardised incidence ratios (SIRs) and population attributable fractions (PAFs). Estimated SIRs were used to build an etiological map reflecting the similarity of cancers by adult environmental exposures. RESULTS Increased risks of concordant types amongst spouses were found for lung, upper aerodigestive tract and skin cancers (SIRs from 1.24 to 1.97),which are probably related to shared exposure to smoking and UV radiation. PAFs were low with the highest value of 1.46% for uterus cancer in wives of men affected by prostate cancer. Further analysis, based on all non-sex-specific concordant and discordant types, revealed a clustering of lung, stomach, pancreas and bladder cancers sharing smoking as a risk factor. This aggregation was used as a cut-point to identify further "novel" clusters. CONCLUSION Shared lifestyles including smoking and drinking habits as well as human papilloma virus infection (HPV) might be associated with an excess of cancer incidence amongst spouses. We observed significantly an increased risk for smoking-related cancers such as lung, upper aerodigestive tract and oesophageal cancers. The present population-based study confirms that the lifestyle shared by spouses plays a minor role in cancer causation. Only strong environmental risk factors such as smoking seem to influence cancer development in adulthood. The proposed etiological map based on 24 cancer types identifies novel clusters--for example, non-Hodgkin lymphoma and leukaemia, bone cancer and myeloma--that are not completely explained by established risk factors. Some of the identified clusters relied on reproduced associations between cancer risks amongst husband and wives; however, the role of chance cannot be excluded.
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Impact of high-risk cytogenetics and prior therapy on outcomes in patients with advanced relapsed or refractory multiple myeloma treated with lenalidomide plus dexaméthasone. Leukemia 2010; 24:623-8. [PMID: 20072152 DOI: 10.1038/leu.2009.273] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This retrospective analysis investigated the prognostic value of del(13) and t(4;14) abnormalities and the impact of prior treatment on outcomes in 207 heavily pretreated patients with relapsed or refractory multiple myeloma (MM) treated with lenalidomide plus dexamethasone. Patients with relapsed or refractory MM who had either earlier received thalidomide or bortezomib, or for whom continuation of these agents was contraindicated, and who had fluorescence in situ hybridization data available were included in the analysis. Patients with relapsed or refractory MM who received treatment with lenalidomide plus dexamethasone in the presence of del(13) and t(4;14) chromosomal abnormalities had lower overall response rates (ORRs) and shorter median progression-free survival (PFS) and overall survival (OS) compared with those who did not have these abnormalities. The results also showed that prior treatment with bortezomib was associated with shorter median PFS and OS. Progression during thalidomide therapy was the only significant independent predictor for OS and that the presence of del(13) and hemoglobin levels <10 g per 100 ml were prognostic factors for ORR and PFS, but not OS, in these heavily pretreated relapsed or refractory MM patients treated with lenalidomide plus dexamethasone.
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28
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Heparan sulfate proteoglycans in amyloidosis. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2010; 93:309-34. [PMID: 20807650 DOI: 10.1016/s1877-1173(10)93013-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Amyloidosis is a generic term for a group of diseases characterized by deposits in different organ systems of insoluble materials composed mainly of distinct fibrillar proteins named amyloid. Besides amyloid, heparan sulfate proteoglycan (HSPG), is commonly found in most amyloid deposits, suggesting that HS/HSPG may be functionally involved in the pathogenesis of amyloidosis. HS or HSPG is found to interact with a number of amyloid proteins, displaying a promoting effect on amyloid fibrilization in vitro. In addition, HS is reported to be involved in processing amyloid precursor proteins and mediate amyloid toxicity. Although little is known about the in vivo mechanisms regarding the codeposition of HS with amyloid proteins in different amyloid diseases, experiments carried out in animal models, especially in transgenic mouse model where HS molecular structure is modified, support an active role for HS in amyloidogenesis. Further experimental evidence is required to strengthen these in vivo findings at a molecular level. Animal models that express mutant forms of HS due to knockout of the enzymes involved in glycosaminoglycan (GAG) biosynthesis are expected to provide valuable tools for studying the implications of HS, as well as other GAGs, in amyloid disorders.
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Abstract
This chapter presents the epidemiologic evidence on the association between physical activity and hematologic cancers and related hypothesized biologic mechanisms. Some preliminary indications of a protective role for physical activity for non-Hodgkin's lymphoma, leukemia, multiple myeloma, and Hodgkin's lymphoma exist, but the level of epidemiologic evidence is still insufficient to make any definitive conclusions regarding the nature of these associations. Several plausible biologic mechanisms underlying the possible associations between physical activity and hematologic cancers have been proposed, including enhancement of immune function, reduction in obesity, improvement of antioxidant defense systems, impact on metabolic hormones, and anti-inflammatory effects. Future studies should improve the estimation of physical activity by using more reliable, valid, and comprehensive measurement tools, assessing all components of physical activity (type, intensity, and time period), and conducting intervention studies to evaluate the effect of physical activity on various biomarkers of cancer in order to provide further insight into plausible biologic mechanisms underlying the possible association between physical activity and hematologic cancers.
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Affiliation(s)
- Sai Yi Pan
- Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 785 Carling Avenue, Locator: 6807B, Ottawa, Ontario, K1A 0K9, Canada
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30
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Kvam AK, Fayers P, Wisloff F. What changes in health-related quality of life matter to multiple myeloma patients? A prospective study. Eur J Haematol 2009; 84:345-53. [PMID: 20041946 DOI: 10.1111/j.1600-0609.2009.01404.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the clinical significance of changes in quality-of-life scores in patients with multiple myeloma (MM), we have estimated the minimal important difference (MID) for the health-related quality-of-life instrument, the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30. The MID is the smallest change in a quality-of-life score considered important to patients. METHODS Between 2006 and 2008, 239 patients with MM completed the EORTC QLQ-C30 at inclusion (T1) and after 3 months (T2). At T2, a structured quality-of-life interview was also performed. MIDs were calculated by using mean score changes (T2-T1) for patients who in the interview stated they had improved, deteriorated or were unchanged. MIDs were also estimated by the receiver-operating characteristic (ROC) curve method as well as by calculation effect sizes using standard deviations of baseline scores. RESULTS MIDs varied slightly depending on the method used. Patients stating in the interview that they had 'improved' or 'deteriorated' had a corresponding change in EORTC QLQ-C30 score ranging from 6 to15 (improvement) and from 9 to17 (deterioration) (scale range 0-100). The ROC analysis indicated that changes in score from 7 to17 represent clinically important changes to patients. The effect size method suggested 5-6 to be a small and 11-15 to be a medium change. CONCLUSION Calculation of MIDs as mean score changes or by ROC analysis suggested that a change in the EORTC QLQ-C30 score in the range of approximately 6-17 is considered important by patients with MM. These MIDs are closer to a medium effect size than to a small effect size. Our findings imply that mean score changes smaller than 6 are unlikely to be important to the patients, even if these changes are statistically significant.
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Affiliation(s)
- Ann K Kvam
- Department of Haematology, Oslo University Hospital, Ullevaal, Oslo, Norway.
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31
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Migrino RQ, Mareedu RK, Eastwood D, Bowers M, Harmann L, Hari P. Left ventricular ejection time on echocardiography predicts long-term mortality in light chain amyloidosis. J Am Soc Echocardiogr 2009; 22:1396-402. [PMID: 19880277 DOI: 10.1016/j.echo.2009.09.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Light chain amyloidosis (AL) is associated with high mortality. The aim was to identify echocardiographic parameters that predict AL long-term mortality. METHODS Forty-two subjects with biopsy-proven AL (43% were female; aged 61 +/- 12 years) underwent echocardiography and were followed 29 +/- 16 months (median 29.4 months). Standard echocardiographic and clinical parameters and heart failure (HF) class were tested using univariate/multivariable Cox proportional hazard regression analyses to identify markers of mortality. RESULTS Twenty-three subjects died, with a 1-year mortality of 44%. Univariate predictors of mortality were HF class (P < .001), left ventricular systolic ejection time (ET) (P = .002), alkaline phosphatase (P < .001), and aspartate and alanine aminotransferase (P = .003 each). On multivariable analysis, only HF class (hazard ratio [HR] 4.86; 95% confidence interval [CI], 1.58-14.9; P = .006), ET (10 ms increase; HR 0.87; CI, 0.78-0.97; P = .01), and alkaline phosphatase (10 U/L increase; HR 1.04; CI, 1.01-1.06; P = .01) were prognostic. ET <or= 240 ms had a sensitivity of 61% and a specificity of 90% in predicting 1-year mortality and a sensitivity of 73% and a specificity of 90% in predicting 1-year cardiac mortality. CONCLUSION AL amyloidosis was associated with high long-term mortality. Among echocardiographic and clinical parameters, only ET and alkaline phosphatase had incremental value to HF class in predicting mortality. This may be useful to identify high-risk patients.
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Affiliation(s)
- Raymond Q Migrino
- Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.
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33
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Amyloidosis presenting as bilateral transudative pleural effusions with normal cardiac investigations: a case report. CASES JOURNAL 2009; 2:6963. [PMID: 19829885 PMCID: PMC2740277 DOI: 10.4076/1757-1626-2-6963] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2009] [Accepted: 07/05/2009] [Indexed: 11/11/2022]
Abstract
A 66-year-old man with a diagnosis of monoclonal gammopathy of unknown significance was referred for investigation of bilateral transudative pleural effusions by the cardiology team. Echocardiography, myocardial perfusion scanning and left heart catheterisation were all normal or non diagnostic. Given significant occupational asbestos exposure in his twenties he underwent thoracoscopic pleural biopsy. This showed fibrous inflammation only. He subsequently developed proteinuria and peripheral oedema. Reanalysis of the pleural biopsy specimen for amyloidosis was positive. Pleural disease is an uncommon presentation of systemic amyloidosis. The aetiology of the pleural effusions is unclear and is not simply a consequence of cardiac or renal impairment.
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Kvam AK, Fayers P, Hjermstad M, Gulbrandsen N, Wisloff F. Health-related quality of life assessment in randomised controlled trials in multiple myeloma: a critical review of methodology and impact on treatment recommendations. Eur J Haematol 2009; 83:279-89. [PMID: 19558508 DOI: 10.1111/j.1600-0609.2009.01303.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Patients with multiple myeloma (MM) often have pronounced symptoms and substantially reduced quality of life. The aims of treatment are to control disease, maximise quality of life and prolong survival. Hence, health-related quality of life (HRQOL) should be an important end-point in randomised controlled trials (RCTs) in addition to traditional endpoints. We wanted to evaluate whether trials reporting HRQOL outcomes have influenced clinical decision making and whether HRQOL was assessed robustly according to predefined criteria. METHODS A systematic review identified RCTs in MM with HRQOL assessment as a study end-point. The methodological quality of these studies was assessed according to a checklist developed for evaluating HRQOL outcomes in clinical trials. The impact of the HRQOL results on clinical decision making was assessed, using published clinical guidelines as a reference. RESULTS Fifteen publications presenting RCTs with HRQOL as a study end-point were identified. In 13 trials, the author stated that HRQOL results should influence clinical decision making. We found, however, that the HRQOL data only had a limited impact on published treatment guidelines for bisphosphonates, high-dose treatment, interferon, erythropoiesis-stimulating agents and novel agents. CONCLUSION The present review indicates that the there are still few RCTs in MM including HRQOL as a study end-point. Systematic incorporation of HRQOL measures into clinical trials allows for a comparison of treatment arms that includes the patients' perspective. Before the full impact on clinical decisions can be realised, the quality and methodology of collecting HRQOL data must be further improved and the results rendered more comprehensible to clinicians.
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Affiliation(s)
- Ann Kristin Kvam
- Department of Haematology, Oslo University Hospital, Ullevaal, Oslo, Norway.
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35
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Whole-Body MRI versus PET in assessment of multiple myeloma disease activity. AJR Am J Roentgenol 2009; 192:980-6. [PMID: 19304704 DOI: 10.2214/ajr.08.1633] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The purpose of this study was to compare FDG PET; whole-body MRI; and the reference standard, bone marrow aspiration and biopsy, to determine the best imaging technique for assessment of disease activity in multiple myeloma. SUBJECTS AND METHODS Twenty-four patients (13 women, 11 men; mean age, 67.1 years; range, 44-83 years) with bone marrow biopsy-proven multiple myeloma were included in the study. All patients underwent PET/CT and whole-body MRI within 10 days of each other. Eight patients underwent more than one follow-up PET/CT and whole-body MRI examination, for a total of 34 pairs of images. Activity was defined as lesions with a maximum standardized uptake value greater than 2.5 at PET and as evidence of marrow packing at whole-body MRI. PET and whole-body MRI results were correlated with findings at bone marrow aspiration biopsy. RESULTS PET had a sensitivity of 59%, specificity of 75%, positive predictive value of 81%, and negative predictive value of 50% (p = 0.08). Whole-body MRI had a sensitivity of 68%, specificity of 83%, positive predictive value of 88%, and negative predictive value of 59% (p = 0.01). In 62% of cases, PET and whole-body MRI findings were concordant. When PET and whole-body MRI findings were concordant and positive, no false-positive results were found, yielding a specificity and a positive predictive value of 100% (p = 0.04). CONCLUSION Whole-body MRI performed better than PET in the assessment of disease activity, having a higher sensitivity and specificity. The positive predictive value of whole-body MRI in the assessment of active disease was high at 88%. When used in combination and with concordant findings, PET and whole-body MRI were found to have a specificity and positive predictive value of 100%, which may be of value to clinicians assessing the effectiveness of aggressive and expensive treatment regimens.
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Patriarca F, Petrucci MT, Bringhen S, Baldini L, Caravita T, Corradini P, Corso A, Di Raimondo F, Falcone A, Ferrara F, Morabito F, Musto P, Offidani M, Petrini M, Rizzi R, Semenzato G, Tosi P, Vacca A, Cavo M, Boccadoro M, Palumbo A. Considerations in the treatment of multiple myeloma: a consensus statement from Italian experts. Eur J Haematol 2009; 82:93-105. [DOI: 10.1111/j.1600-0609.2008.01179.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mikhael JR, Belch AR, Prince HM, Lucio MN, Maiolino A, Corso A, Petrucci MT, Musto P, Komarnicki M, Stewart AK. High response rate to bortezomib with or without dexamethasone in patients with relapsed or refractory multiple myeloma: results of a global phase 3b expanded access program. Br J Haematol 2009; 144:169-75. [DOI: 10.1111/j.1365-2141.2008.07409.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Conner TM, Doan QD, Walters IB, LeBlanc AL, Beveridge RA. An Observational, Retrospective Analysis of Retreatment with Bortezomib for Multiple Myeloma. ACTA ACUST UNITED AC 2008; 8:140-5. [DOI: 10.3816/clm.2008.n.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Treatment for patients with myeloma has changed unrecognisably over the last two decades and now includes a sequence of treatments including chemotherapy, biological targeted therapy with or without consideration for high-dose therapy (autologous and allogeneic stem cell transplantation for younger and fit patients). As patients can now expect a doubling of median survival and a 20-30% chance of surviving longer than 10 years, the focus of treatment is shifting to long-term quality of life. This article focuses on future challenges facing clinicians treating myeloma and how best we may optimize our resources.
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Affiliation(s)
- B Sirohi
- Department of Medical Oncology, Royal Marsden NHS Foundation Trust, London, UK
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Birmann BM, Giovannucci E, Rosner B, Anderson KC, Colditz GA. Body mass index, physical activity, and risk of multiple myeloma. Cancer Epidemiol Biomarkers Prev 2007; 16:1474-8. [PMID: 17627013 PMCID: PMC3860750 DOI: 10.1158/1055-9965.epi-07-0143] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Several studies have reported a positive relation of baseline body mass index (BMI) with multiple myeloma, but data on other correlates of energy balance are limited. We undertook the present analyses to further examine the role of energy balance in multiple myeloma etiology in two large prospective cohorts with biennially updated exposure data. We followed members of the Nurses' Health Study and Health Professionals Follow-up Study cohorts from baseline until multiple myeloma diagnosis, death, or 2002. Adult height and current weight were reported at enrollment, and weight every 2 years thereafter. Physical activity was queried at baseline and updated every 2 to 4 years. We computed age-adjusted relative risks (RR) of multiple myeloma for categories of BMI and physical activity using Cox proportional hazards regression. We conducted analyses on each cohort separately and on both cohorts combined. We confirmed 215 incident cases of multiple myeloma in the combined cohort of 136,623 individuals (>2.1 million person-years at risk). BMI was positively associated with multiple myeloma in all analyses. The association was strongest in men with a BMI of >or=30 kg/m2 (versus a BMI of <22.0 kg/m2; RR, 2.4; 95% confidence interval, 1.0-6.0) and modest in overweight (BMI, 25-29.9 kg/m2) and obese (BMI, >or=30 kg/m2) women [versus BMI of <22.0 kg/m2; RR (95% confidence interval), 1.6 (1.0-2.7) and 1.2 (0.7-2.2), respectively]. Physical activity was not significantly related to multiple myeloma risk, although an inverse association was suggested in women. In conclusion, obesity seems to have an etiologic role in multiple myeloma, but the role of other correlates of energy balance remains uncertain.
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Affiliation(s)
- Brenda M Birmann
- Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 181 Longwood Avenue, Boston, MA 02115, USA.
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Abstract
Current standards of care for first-line treatment of multiple myeloma are evolving rapidly because of the introduction of regimens based on novel agents with unique mechanisms of action: the proteasome inhibitor bortezomib and the immunomodulatory drugs thalidomide and lenalidomide. These regimens are becoming increasingly widely used, offering substantially greater benefit to patients in terms of higher response rates and, more importantly, prolonged response durations and survival compared with established standard first-line treatment strategies. A notable aspect of many of these emerging treatment options is the very high rates of complete response (CR) reported, previously only seen with transplantation-based strategies. Achievement of CR is prognostic for improved overall survival; therefore, the higher rates and quality of responses seen with the new regimens might substantially improve patient outcomes versus established standards of care. For example, addition of each of the 3 novel agents to melphalan/prednisone results in higher overall response rates and CR rates, as well as prolonged progression-free and overall survival, compared with melphalan/prednisone alone. Similar substantial improvements in response are seen with addition of the 3 agents to single-agent dexamethasone and the use of bortezomib or thalidomide in VAD (vincristine/doxorubicin/dexamethasone)-like regimens, as induction therapies before stem cell transplantation and in patients not proceeding to transplantation. Ultimately, these novel regimens might obviate the need for stem cell transplantation in a sizeable proportion of patients. The emergence of these new therapeutic options appears likely to significantly alter the first-line treatment paradigm for patients with multiple myeloma.
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Affiliation(s)
- Sundar Jagannath
- St. Vincent's Comprehensive Cancer Center, New York, NY 10011-8202, USA.
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Current Awareness in Hematological Oncology. Hematol Oncol 2007. [DOI: 10.1002/hon.796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Carrasco DR, Sukhdeo K, Protopopova M, Sinha R, Enos M, Carrasco D, Zheng M, Mani M, Henderson J, Pinkus GS, Munshi N, Horner J, Ivanova EV, Protopopov A, Anderson KC, Tonon G, DePinho RA. The differentiation and stress response factor XBP-1 drives multiple myeloma pathogenesis. Cancer Cell 2007; 11:349-60. [PMID: 17418411 PMCID: PMC1885943 DOI: 10.1016/j.ccr.2007.02.015] [Citation(s) in RCA: 308] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Revised: 12/01/2006] [Accepted: 02/14/2007] [Indexed: 12/11/2022]
Abstract
Multiple myeloma (MM) evolves from a highly prevalent premalignant condition termed MGUS. The factors underlying the malignant transformation of MGUS are unknown. We report a MGUS/MM phenotype in transgenic mice with Emu-directed expression of the XBP-1 spliced isoform (XBP-1s), a factor governing unfolded protein/ER stress response and plasma-cell development. Emu-XBP-1s elicited elevated serum Ig and skin alterations. With age, Emu-xbp-1s transgenics develop features diagnostic of human MM, including bone lytic lesions and subendothelial Ig deposition. Furthermore, transcriptional profiles of Emu-xbp-1s lymphoid and MM cells show aberrant expression of known human MM dysregulated genes. The similarities of this model with the human disease, coupled with documented frequent XBP-1s overexpression in human MM, serve to implicate XBP-1s dysregulation in MM pathogenesis.
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Affiliation(s)
- Daniel R. Carrasco
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Corresponding author
| | - Kumar Sukhdeo
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
| | - Marina Protopopova
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
- Center for Applied Cancer Science, Belfer Foundation Institute for Innovative Cancer Science, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
| | - Raktim Sinha
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
| | - Miriam Enos
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
| | - Daniel E. Carrasco
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
| | - Mei Zheng
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Mala Mani
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
| | - Joel Henderson
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Geraldine S. Pinkus
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Nikhil Munshi
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
- The Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
| | - James Horner
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
| | - Elena V. Ivanova
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
- Center for Applied Cancer Science, Belfer Foundation Institute for Innovative Cancer Science, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
| | - Alexei Protopopov
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
- Center for Applied Cancer Science, Belfer Foundation Institute for Innovative Cancer Science, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
| | - Kenneth C. Anderson
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
- Center for Applied Cancer Science, Belfer Foundation Institute for Innovative Cancer Science, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
- The Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA
| | - Giovanni Tonon
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
| | - Ronald A. DePinho
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
- Center for Applied Cancer Science, Belfer Foundation Institute for Innovative Cancer Science, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
- Departments of Medicine and Genetics, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA 02115, USA
- Corresponding author
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