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Soekojo CY, Chng WJ. Treatment Horizon in Multiple Myeloma. Eur J Haematol Suppl 2022; 109:425-440. [PMID: 35880395 DOI: 10.1111/ejh.13840] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/23/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This paper reviews current and emerging therapies for MM. METHODS Narrative review RESULTS: Multiple myeloma (MM) is a complex, heterogenous condition, and in recent years there has been an expansion in the number and range of treatments. Several new treatment approaches, including enhanced monoclonal antibodies, antibody-drug conjugates (ADC), bispecific T-cell engagers (BiTE) and chimeric antigen-T-cell therapy (CAR-T) are under development. CONCLUSIONS The emergence of new treatments that aim to tackle MM-associated immune dysfunction has led to improvements in overall survival.
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Affiliation(s)
- Cinnie Yentia Soekojo
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, National University Health System
| | - Wee Joo Chng
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, National University Health System
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2
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Pasvolsky O, Yeshurun M, Fraser R, Estrada-Merly N, Rozovski U, Shargian L, Assal A, Banerjee R, Bumma N, Gale RP, Hagen P, Holmberg L, Hossain NM, Lazarus HM, Lee C, Mian H, Miller KC, Nathan S, Nagler A, Nishihori T, Parrondo RD, Patel S, Schroeder MA, Usmani SZ, Wang T, Wirk B, Kumar S, Shah N, Qazilbash MH, D’Souza A. Maintenance therapy after second autologous hematopoietic cell transplantation for multiple myeloma. A CIBMTR analysis. Bone Marrow Transplant 2022; 57:31-37. [PMID: 34608275 PMCID: PMC8764606 DOI: 10.1038/s41409-021-01455-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023]
Abstract
The role of maintenance therapy after high-dose chemotherapy and first autologous transplantation in multiple myeloma (MM) is well established. We explored the effect of maintenance therapy on outcomes after salvage second autologous hematopoietic cell transplant (AHCT2) using the Center for International Blood and Marrow Transplant Research registry. Outcomes of interest included non-relapse mortality (NRM), relapse/progression (REL), progression-free and overall survival (PFS, OS). Of 522 patients who underwent AHCT2 between 2010 and 2018, 342 received maintenance therapy and 180 did not. Maintenance regimens included lenalidomide (42%), pomalidomide (13%), and bortezomib (13%). Median follow up was 58 months in the maintenance group and 61.5 months in the no-maintenance group. Univariate analysis showed superior outcomes at 5 years in maintenance compared to the no-maintenance group: NRM 2 (0.7-3.9)% vs 9.9 (5.9-14.9)%, (p < 0.01), REL 70.2 (64.4-75.8)% vs 80.3 (73.6-86.3)% (p < 0.01), PFS 27.8 (22.4-33.5)% vs. 9.8 (5.5-15.2)% (p < 0.01), and OS 54 (47.5-60.5)% vs 30.9 (23.2-39.2)% (p < 0.01), respectively. Use of maintenance therapy retained its association with improved outcomes in multivariate analysis. There was no difference in second cancers in the two groups (p = 0.39). We conclude that maintenance after AHCT2 is associated with improved 5-year outcomes.
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Affiliation(s)
- Oren Pasvolsky
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikvah, Israel;,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Yeshurun
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikvah, Israel;,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raphael Fraser
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI;,Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Noel Estrada-Merly
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Uri Rozovski
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikvah, Israel
| | - Liat Shargian
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikvah, Israel
| | - Amer Assal
- Columbia University Irving Medical Center, Department of Medicine, Bone Marrow Transplant and Cell Therapy Program, New York, NY
| | - Rahul Banerjee
- Division of Hematology-Oncology, University of California San Francisco, San Francisco, CA
| | - Naresh Bumma
- Ohio State Medical Center, James Cancer Center, Columbus , OH
| | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK
| | | | | | - Nasheed M. Hossain
- Department of Medicine, Division of Hematology/Oncology, Stem Cell Transplant Program – Loyola University Chicago Stritch School of Medicine, Maywood, IL
| | - Hillard M. Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Cindy Lee
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Hira Mian
- McMaster University, Hamilton, ON, Canada
| | | | - Sunita Nathan
- Section of Bone Marrow Transplant and Cell Therapy, Rush University Medical Center, Chicago, IL
| | - Arnon Nagler
- Hematology Division and BMT, Chaim Sheba Medical Center, Tel Hashomer, Israel;,Tel Aviv University, Tel Aviv, Israel
| | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Ricardo D Parrondo
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonsville, FL
| | - Sagar Patel
- Blood and Marrow Transplant Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Mark A. Schroeder
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Saad Z. Usmani
- Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC
| | - Trent Wang
- Division of Transplantation and Cellular Therapy, University of Miami, Miami, FL
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, PA
| | | | - Nina Shah
- Division of Hematology-Oncology, University of California San Francisco, San Francisco, CA
| | | | - Anita D’Souza
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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Moreau P, Hulin C, Perrot A, Arnulf B, Belhadj K, Benboubker L, Béné MC, Zweegman S, Caillon H, Caillot D, Corre J, Delforge M, Dejoie T, Doyen C, Facon T, Sonntag C, Fontan J, Mohty M, Jie KS, Karlin L, Kuhnowski F, Lambert J, Leleu X, Macro M, Orsini-Piocelle F, Roussel M, Stoppa AM, van de Donk NWCJ, Wuillème S, Broijl A, Touzeau C, Tiab M, Marolleau JP, Meuleman N, Vekemans MC, Westerman M, Klein SK, Levin MD, Offner F, Escoffre-Barbe M, Eveillard JR, Garidi R, Ahmadi T, Krevvata M, Zhang K, de Boer C, Vara S, Kampfenkel T, Vanquickelberghe V, Vermeulen J, Avet-Loiseau H, Sonneveld P. Maintenance with daratumumab or observation following treatment with bortezomib, thalidomide, and dexamethasone with or without daratumumab and autologous stem-cell transplant in patients with newly diagnosed multiple myeloma (CASSIOPEIA): an open-label, randomised, phase 3 trial. Lancet Oncol 2021; 22:1378-1390. [PMID: 34529931 DOI: 10.1016/s1470-2045(21)00428-9] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND CASSIOPEIA part 1 showed superior depth of response and significantly improved progression-free survival with daratumumab, bortezomib, thalidomide, and dexamethasone (D-VTd) versus bortezomib, thalidomide, and dexamethasone (VTd) as induction and consolidation in patients with autologous stem-cell transplant (ASCT)-eligible newly diagnosed multiple myeloma. In part 2, we compared daratumumab maintenance versus observation only. METHODS CASSIOPEIA is a two-part, open-label, randomised, phase 3 trial of patients aged 18-65 years with newly diagnosed multiple myeloma and Eastern Cooperative Oncology Group performance status 0-2, done in 111 European academic and community practice centres. In part 1, patients were randomly assigned (1:1) to induction and consolidation with D-VTd or VTd. Patients still on study who had a partial response or better were randomly assigned (1:1) by an interactive web-response system to daratumumab 16 mg/kg intravenously every 8 weeks (a reduced frequency compared with standard daratumumab long-term dosing) or observation only for up to 2 years. Stratification factors were induction treatment and depth of response in part 1. The part 2 primary endpoint was progression-free survival from second randomisation. This preplanned interim analysis of progression-free survival was done after 281 events and shall be considered the primary analysis of progression-free survival. Sponsor personnel and designees who were involved in the analysis were masked to treatment group until the independent data monitoring committee recommended that the preplanned interim analysis be considered the main analysis of progression-free survival in part 2. Otherwise, treatment assignments were unmasked. The interaction between induction and consolidation and maintenance was tested at a two-sided significance level of 0·05 by a stratified Cox regression model that included the interaction term between maintenance treatment and induction and consolidation treatment. Efficacy analyses were done in the maintenance-specific intention-to-treat population, which comprised all patients who underwent second randomisation. Safety was analysed in all patients in the daratumumab group who received at least one dose and all patients randomly assigned to observation only. This trial is registered with ClinicalTrials.gov, NCT02541383. Long-term follow-up is ongoing and the trial is closed to new participants. FINDINGS Between May 30, 2016, and June 18, 2018, 886 patients (458 [84%] of 543 in the D-VTd group and 428 [79%] of 542 in the VTd group) were randomly assigned to daratumumab maintenance (n=442) or observation only (n=444). At a median follow-up of 35·4 months (IQR 30·2-39·9) from second randomisation, median progression-free survival was not reached (95% CI not evaluable [NE]-NE) with daratumumab versus 46·7 months (40·0-NE) with observation only (hazard ratio 0·53, 95% CI 0·42-0·68, p<0·0001). A prespecified analysis of progression-free survival results showed a significant interaction between maintenance and induction and consolidation therapy (p<0·0001). The most common grade 3 or 4 adverse events were lymphopenia (16 [4%] of 440 patients in the daratumumab group vs eight [2%] of 444 patients in the observation-only group), hypertension (13 [3%] vs seven [2%]), and neutropenia (nine [2%] vs ten [2%]). Serious adverse events occurred in 100 (23%) patients in the daratumumab group and 84 (19%) patients in the observation-only group. In the daratumumab group, two adverse events led to death (septic shock and natural killer-cell lymphoblastic lymphoma); both were related to treatment. INTERPRETATION Daratumumab maintenance every 8 weeks for 2 years significantly reduced the risk of disease progression or death compared with observation only. Longer follow-up and other ongoing studies will shed further light on the optimal daratumumab-containing post-ASCT maintenance treatment strategy. FUNDING Janssen Research & Development, the Intergroupe Francophone du Myélome, and the Dutch-Belgian Cooperative Trial Group for Hematology Oncology.
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Affiliation(s)
- Philippe Moreau
- Hematology Clinic, University Hospital Hôtel-Dieu, Nantes, France.
| | - Cyrille Hulin
- Bordeaux University Hospital Center, Bordeaux, France
| | - Aurore Perrot
- Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Bertrand Arnulf
- Hematology and Oncology, Hôpital Saint Louis, APHP, Paris, France
| | | | | | - Marie C Béné
- Hematology Biology, Nantes University Hospital, Nantes, France
| | - Sonja Zweegman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Hélène Caillon
- Biochemistry Laboratory, Nantes University Hospital, Nantes, France
| | - Denis Caillot
- Dijon University Hospital, Hôpital du Bocage, Dijon, France
| | - Jill Corre
- Unité de Genomique du Myélome, IUC-T Oncopole, Toulouse, France
| | - Michel Delforge
- Department of Hematology, University Hospital Leuven, Leuven, Belgium
| | - Thomas Dejoie
- Biochemistry Laboratory, Nantes University Hospital, Nantes, France
| | - Chantal Doyen
- Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Thierry Facon
- Service des Maladies du Sang, Hôpital Claude Huriez, Lille, France
| | - Cécile Sonntag
- University Hospital, Hôpital Hautepierre, Strasbourg, France
| | - Jean Fontan
- University Hospital Jean Minjoz, Besancon, France
| | - Mohamad Mohty
- Hematology and Cellular Therapy Department of Saint-Antoine Hospital, Sorbonne University, Paris, France
| | | | - Lionel Karlin
- Lyon University Hospital, Hematology Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | | | | | - Xavier Leleu
- Poitiers University Hospital, CHU la Milétrie, Poitiers, France
| | | | | | | | | | | | - Soraya Wuillème
- Hematology Biology, Nantes University Hospital, Nantes, France
| | | | - Cyrille Touzeau
- Hematology Clinic, University Hospital Hôtel-Dieu, Nantes, France
| | - Mourad Tiab
- Centre Hospitalier Départemental Vendée, La Roche sur Yon, France
| | | | - Nathalie Meuleman
- Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | | | | | | | | | | | - Réda Garidi
- Saint-Quentin Hospital Center, Saint Quentin, France
| | | | | | - Ke Zhang
- Janssen Research & Development, La Jolla, CA, USA
| | - Carla de Boer
- Janssen Research & Development, LLC, Leiden, Netherlands
| | - Sanjay Vara
- Janssen Research & Development, High Wycombe, UK
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LeBlanc MR, LeBlanc TW, Leak Bryant A, Pollak KI, Bailey DE, Smith SK. A Qualitative Study of the Experiences of Living With Multiple Myeloma. Oncol Nurs Forum 2021; 48:151-160. [PMID: 33600390 DOI: 10.1188/21.onf.151-160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To explore the ways in which multiple myeloma affects an individual's life in the modern treatment era. PARTICIPANTS & SETTING 15 individuals with multiple myeloma and 10 clinicians were recruited from two academic medical centers in the southeastern United States. METHODOLOGIC APPROACH Semistructured interviews were conducted with individuals with multiple myeloma and clinicians to explore the effect of a multiple myeloma diagnosis and treatment on individuals' lives. Transcribed interviews were analyzed using conventional content analysis. FINDINGS The following four themes emerged from the analysis. IMPLICATIONS FOR NURSING The treatment journey for those with multiple myeloma can be lifelong and may require frequent visits to an oncologist and, potentially, many successive lines of therapy. Life effects are far-reaching and long-term. Nurses should be aware of the interprofessional resources to help meet these individuals' needs. With thorough assessment, care planning, and education, nurses can play a key role in mitigating the negative effects of multiple myeloma and its treatment.
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5
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Uyl‐de Groot CA, Ramsden R, Lee D, Boersma J, Zweegman S, Dhanasiri S. Lenalidomide as maintenance treatment for patients with multiple myeloma after autologous stem cell transplantation: A pharmaco-economic assessment. Eur J Haematol 2020; 105:635-645. [PMID: 32705720 PMCID: PMC7590122 DOI: 10.1111/ejh.13497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Autologous stem cell transplantation (ASCT) has improved progression-free survival (PFS) and overall survival in eligible patients with newly diagnosed multiple myeloma (NDMM); however, relapse occurs. Maintenance therapy with lenalidomide (Len-Mt) extends survival and delays relapse and the subsequent initiation of costly second-line regimens. Here, we report the cost-effectiveness of Len-Mt following ASCT from a Dutch healthcare service perspective. METHODS A partitioned survival model was developed to assess the lifetime costs and benefits for patients with NDMM. Efficacy was taken from a pooled meta-analysis of clinical trial data. Costs and subsequent therapy data were taken from sources appropriate for the Dutch market. RESULTS Lenalidomide produced a quality-adjusted life year gain of 2.46 and a life year gain of 2.79 vs no maintenance treatment. The cost of lenalidomide was partially offset by savings of EUR 77 462 in subsequent treatment costs. The incremental cost-effectiveness ratio of Len-Mt vs no maintenance treatment was EUR 30 143. Key model drivers included subsequent therapies, dosing schedule, and time horizon. CONCLUSION Lenalidomide is cost-effective after ASCT vs no maintenance therapy in the Netherlands. By extending PFS, lenalidomide delays the cost burdens associated with relapse and subsequent treatment lines.
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Affiliation(s)
- Carin A. Uyl‐de Groot
- Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamNetherlands
| | | | - Dawn Lee
- BresMed Health SolutionsSheffieldUK
| | - Janneke Boersma
- Formerly Celgene B.V., A Bristol‐Myers Squibb CompanyUtrechtNetherlands
| | - Sonja Zweegman
- Department of HematologyCancer Center AmsterdamAmsterdam UMC, Vrije Universiteit AmsterdamAmsterdamNetherlands
| | - Sujith Dhanasiri
- Celgene International, A Bristol‐Myers Squibb CompanyBoudrySwitzerland
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Wahab A, Rafae A, Faisal MS, Mushtaq K, Ehsan H, Khakwani M, Ashraf A, Rehan T, Ahmed Z, Shah Z, Khan A, Anwer F. Advances in maintenance strategy in newly diagnosed multiple myeloma patients eligible for autologous transplantation. Expert Rev Hematol 2020; 13:1333-1347. [PMID: 33078986 DOI: 10.1080/17474086.2020.1839886] [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: 10/23/2022]
Abstract
INTRODUCTION Multiple myeloma (MM) lacks curative therapy. Therefore, researchers continue to conduct studies in an effort to improve progression-free survival (PFS) and overall survival (OS). Maintenance therapy (MT) after autologous stem cell transplant (ASCT) was extensively studied in the last decade and now considered a standard approach. AREAS COVERED This review evaluated the evidence and updates on various maintenance agents in newly diagnosed multiple myeloma (NDMM) after ASCT. Articles were searched on PubMed and Embase that were published in last 10 years. Both clinical trials and observational studies were evaluated. EXPERT OPINION Maintenance strategy after ASCT has consistent PFS benefit but lacks conclusive OS improvement. Lenalidomide is superior to thalidomide given reduced neurotoxicity. OS advantage is controversial for both due to inconsistent evidence. Lenalidomide may confer a PFS advantage even at lower doses due to toxicity with higher doses. Bortezomib-based maintenance has some evidence for OS benefit in high-risk MM (HRMM) and renal dysfunction. Ixazomib has preliminary promising results. Two or three drug combinations for MT are potentially safe and more effective, particularly in HRMM although data on this subject is still evolving. Efficacy of various MT regimens in terms of minimal residual disease status needs to be further investigated.
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Affiliation(s)
- Ahsan Wahab
- Internal Medicine/Hospital Medicine Department, University of Alabama at Birmingham , Montgomery, AL, USA
| | - Abdul Rafae
- Internal Medicine Residency Program, McLaren Regional Medical Center , Flint, MI, USA
| | | | - Kamran Mushtaq
- Internal Medicine/Hospital Medicine Department, Northeast Internal Medicine Associates , LaGrange, IN, USA
| | - Hamid Ehsan
- Biomedical Sciences/Biohazardous Threat Agents & Emerging Infectious Diseases Department, Georgetown University , Washington, DC, USA
| | - Maria Khakwani
- Internal Medicine Department, Anne Arundel Medical Center , Annapolis, MD, USA
| | - Afia Ashraf
- Internal Medicine Department, Lahore Medical and Dental College , Lahore, Pakistan
| | - Tayyab Rehan
- Internal Medicine Department, Allama Iqbal Medical College , Lahore, Pakistan
| | - Zahoor Ahmed
- Internal Medicine Department, King Edward Medical University , Lahore, Pakistan
| | - Zunairah Shah
- Internal Medicine Residency Program, Louis A. Weis Memorial Hospital , Chicago, IL, USA
| | - Aslam Khan
- Internal Medicine Department, Allama Iqbal Medical College , Lahore, Pakistan
| | - Faiz Anwer
- Hematology Oncology Department, Stem Cell Transplantation Multiple Myeloma Program, Cleveland Clinic , Cleveland, Ohio, USA
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Wang X, Vogt B, Shanahan L, Siddiqui AD, Subramonia-Iyer S, Khanani S, Bednarik JL, Mittal K, Ramanathan M, Gerber JM, Cerny J. Elotuzumab-based maintenance therapy following autologous stem cell transplant in multiple myeloma deepens post-transplant responses. Blood Cells Mol Dis 2020; 85:102482. [PMID: 32745939 DOI: 10.1016/j.bcmd.2020.102482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/24/2020] [Accepted: 07/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Post-transplant maintenance provides progression-free survival benefit in multiple myeloma (MM). Here we report our institution's experience with elotuzumab-based maintenance following autologous stem cell transplant. METHODS We retrospectively evaluated the outcomes of MM patients who were started on elotuzumab-based maintenance (elotuzumab/lenalidomide/dexamethasone, elotuzumab/bortezomib/dexamethasone, or elotuzumab/bortezomib/methylprednisolone) following transplant (N = 7). Baseline characteristics, treatment response, survival, and adverse events were reviewed. RESULTS Median age was 68 (56-81) years at the time of transplant, and median lines of induction therapy was 2 (1-6). Three patients (42.9%) had high-risk cytogenetics and five (71.4%) had stage II or greater disease at diagnosis. At a median follow-up of 24 months (12-50), five patients (71.4%) had improvement of quality of response, with a combined CR or VGPR rate increasing from 57.1% to 100% (CR = 3, VGPR = 4). All patients were alive without relapse or progression at the time of this analysis. Grade 3-4 adverse events were observed in three (42.9%) patients. None of the patients discontinued the treatment due to intolerance. CONCLUSIONS Our study demonstrates that elotuzumab-based maintenance may deepen response post-transplant in MM and can be safely administered even in older patients. Given its unique action and rare side effects, further studies of elotuzumab in the post-transplant setting are warranted.
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Affiliation(s)
- Xin Wang
- Department of Medicine, UMass Memorial Medical Center, Worcester, MA 01655, USA
| | - Bennett Vogt
- University of Massachussetts Medical School, Worcester, MA 01655, USA
| | - Lindsey Shanahan
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA 01655, USA
| | - A Daniyal Siddiqui
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA 01655, USA; Division of Hematology and Medical Oncology, Saint Vincent Hospital, Worcester, MA 01608, USA
| | | | - Saleem Khanani
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA 01655, USA
| | - Jayde L Bednarik
- Department of Pharmacy, UMass Memorial Medical Center, Worcester, MA 01655, USA
| | - Kriti Mittal
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA 01655, USA
| | - Muthalagu Ramanathan
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA 01655, USA
| | - Jonathan M Gerber
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA 01655, USA
| | - Jan Cerny
- Division of Hematology/Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, MA 01655, USA.
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Kaiser M, Beksaç M, Gulbrandsen N, Schjesvold F, Hájek R, Moreau P, de Arriba de la Fuente F, Mateos MV, West S, Spencer A, Rajkumar SV, Suryanarayan K, Czorniak M, Li C, Teng Z, Labotka R, Dimopoulos MA. Adverse event management in the TOURMALINE-MM3 study of post-transplant ixazomib maintenance in multiple myeloma. Ann Hematol 2020; 99:1793-1804. [PMID: 32613281 PMCID: PMC7340660 DOI: 10.1007/s00277-020-04149-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/14/2020] [Indexed: 12/13/2022]
Abstract
The phase 3, double-blind, placebo-controlled TOURMALINE-MM3 study (NCT02181413) demonstrated improved progression-free survival with ixazomib maintenance versus placebo post autologous stem cell transplant (ASCT) in multiple myeloma patients. We report additional safety data from TOURMALINE-MM3 to inform adverse event (AE) management recommendations. Patients were randomized 3:2 to receive ixazomib (n = 395) or placebo (n = 261) on days 1, 8, and 15 of 28-day cycles for ~ 2 years or until progressive disease/toxicity. The initial 3-mg ixazomib dose was escalated to 4 mg in cycle 5, if tolerated in cycles 1-4. Safety was a secondary endpoint assessed in all treated patients; AEs were graded using Common Terminology Criteria for AEs v4.03. The rate of grade ≥ 3 AEs was higher in the ixazomib arm (19%) than in the placebo arm (5%), but the rate of discontinuation due to AEs was similar (7% vs. 5%). For AEs of clinical interest, rates were higher with ixazomib versus placebo: nausea 39% versus 15%, vomiting 27% versus 11%, diarrhea 35% versus 24%, thrombocytopenia 13% versus 3%, and peripheral neuropathy 19% versus 15%. However, the majority of events were low-grade, manageable with supportive therapy or dose reduction, and reversible, and did not result in discontinuation. There was no evidence of cumulative, long-term, or late-onset toxicity with ixazomib maintenance. Ixazomib is an efficacious and tolerable option for post-ASCT maintenance. AEs associated with ixazomib maintenance can be managed in the context of routine post-ASCT supportive care due to the limited additional toxicity. ClinicalTrials.gov NCT02181413.
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Affiliation(s)
- Martin Kaiser
- Department of Haematology, The Royal Marsden Hospital, London, UK. .,Division of Molecular Pathology, The Institute of Cancer Research (ICR) and The Royal Marsden Hospital, 123 Old Brompton Road, London, SW7 3RP, UK.
| | - Meral Beksaç
- Department of Hematology, Ankara University, Ankara, Turkey
| | - Nina Gulbrandsen
- Oslo Myeloma Center, Oslo University Hospital, and KG Jebsen Center for B Cell Malignancies, University of Oslo, Oslo, Norway
| | - Fredrik Schjesvold
- Oslo Myeloma Center, Oslo University Hospital, and KG Jebsen Center for B Cell Malignancies, University of Oslo, Oslo, Norway
| | - Roman Hájek
- Department of Hematooncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Philippe Moreau
- Department of Hematology, University Hospital Hôtel-Dieu, Nantes, France
| | - Felipe de Arriba de la Fuente
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer y Centro Regional de Hemodonación, IMIB-Arrixaca, Universidad de Murcia, Murcia, Spain
| | - María-Victoria Mateos
- Department of Hematology, University Hospital of Salamanca, CIC, IBM CC, Salamanca, Spain
| | - Sharon West
- Department of Haematology, The Royal Marsden Hospital, London, UK
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health-Monash University, Melbourne, Australia
| | - S Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kaveri Suryanarayan
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Michael Czorniak
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Cong Li
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Zhaoyang Teng
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Richard Labotka
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Meletios A Dimopoulos
- Hematology and Medical Oncology, Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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9
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Patel DA, Gopalakrishnan R, Engelhardt BG, McArthur E, Sengsayadeth S, Culos KA, Byrne M, Goodman S, Savani BN, Chinratanalab W, Jagasia M, Mosse CA, Cornell RF, Kassim AA. Minimal residual disease negativity and lenalidomide maintenance therapy are associated with superior survival outcomes in multiple myeloma. Bone Marrow Transplant 2020; 55:1137-1146. [PMID: 31992845 DOI: 10.1038/s41409-020-0791-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 12/02/2019] [Accepted: 01/13/2020] [Indexed: 12/19/2022]
Abstract
Modern combinations of therapies for multiple myeloma have led to improvement in survival outcomes with near 100% overall response rate and 25% complete response rates, particularly with autologous hematopoietic cell transplant (AHCT). Minimal residual disease (MRD) assessment with multiparameter flow cytometry is a valid prognostic biomarker for progression-free survival (PFS) and overall survival (OS). However, few data exist regarding whether MRD positivity or negativity will meaningfully influence treatment decisions. We evaluated 433 patients who received induction therapy, followed by AHCT. Participants had MRD assessment by multiparameter flow cytometry before and at days +100 and +365 following AHCT. They also received either lenalidomide, bortezomib, or no maintenance therapy following AHCT. Maintenance treatment with lenalidomide improved MRD negativity at day +365 compared to bortezomib (92.9% vs 41.6%, p = 0.01), or no maintenance therapy (92.9% vs 24.4%, p = 0.012). The median PFS for patients who were MRD negative at day + 365 was 42 vs 17.5 months (p < 0.001) and median OS was 80.6 vs 59 months (p = 0.02). Maintenance therapy following AHCT for multiple myeloma improves the depth of response as assessed by MRD.
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Affiliation(s)
- Dilan A Patel
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ragisha Gopalakrishnan
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brian G Engelhardt
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Hematology/Oncology, Hematology and Stem Cell Transplant, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Evonne McArthur
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Salyka Sengsayadeth
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Hematology/Oncology, Hematology and Stem Cell Transplant, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katie A Culos
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Byrne
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Hematology/Oncology, Hematology and Stem Cell Transplant, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stacey Goodman
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Hematology/Oncology, Hematology and Stem Cell Transplant, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bipin N Savani
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Hematology/Oncology, Hematology and Stem Cell Transplant, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wichai Chinratanalab
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Hematology/Oncology, Hematology and Stem Cell Transplant, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Madan Jagasia
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Hematology/Oncology, Hematology and Stem Cell Transplant, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Claudio A Mosse
- Department of Pathology, Microbiology, Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
- Pathology and Laboratory Medicine, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Robert F Cornell
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Hematology/Oncology, Hematology and Stem Cell Transplant, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adetola A Kassim
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Medicine, Division of Hematology/Oncology, Hematology and Stem Cell Transplant, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
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10
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Bird SA, Jackson GH, Pawlyn C. Maintenance Strategies Post-Autologous Stem Cell Transplantation for Newly Diagnosed Multiple Myeloma. Clin Hematol Int 2020; 2:59-68. [PMID: 34595444 PMCID: PMC8432350 DOI: 10.2991/chi.d.200502.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/24/2020] [Indexed: 12/04/2022] Open
Abstract
Multiple myeloma, the second most common hematological malignancy worldwide, has demonstrated dramatic improvements in outcome in the last decade. In newly diagnosed patients, induction chemotherapy followed by autologous stem cell transplantation (ASCT) is the standard of care. After ASCT, the majority of patients experience disease remission but, despite recent therapeutic developments, most will eventually relapse. In this review we consider clinical aspects of maintenance therapies that can be used post-ASCT to prolong remission duration. We discuss the evidence for the effectiveness of each of these drugs as a maintenance therapy, alongside other benefits and drawbacks to their use, for example, route of administration and potential toxicities. We discuss questions which remain unanswered around the optimal use of currently available maintenance therapies and review newer agents being considered for use as maintenance such as emerging immunotherapies.
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Affiliation(s)
- Sarah A Bird
- The Institute of Cancer Research, London.,The Royal Marsden NHS Foundation Trust, London
| | - Graham H Jackson
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, England
| | - Charlotte Pawlyn
- The Institute of Cancer Research, London.,The Royal Marsden NHS Foundation Trust, London
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11
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Bortezomib-based consolidation or maintenance therapy for multiple myeloma: a meta-analysis. Blood Cancer J 2020; 10:33. [PMID: 32144237 PMCID: PMC7060191 DOI: 10.1038/s41408-020-0298-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/11/2020] [Accepted: 02/18/2020] [Indexed: 01/22/2023] Open
Abstract
Bortezomib-based regimens are widely used as induction therapy for multiple myeloma (MM). Unlike lenalidomide, the role of bortezomib in consolidation and maintenance therapy for MM is less clear. We performed a meta-analysis to evaluate the impact of bortezomib-based consolidation and maintenance therapy on survival outcomes and adverse events. PubMed, Web of Science, Embase databases, and major conference proceedings were searched for randomized controlled trials (RCTs) of bortezomib-based regimens as consolidation or maintenance therapy for MM. Ten RCTs enrolling 3147 patients were included in the meta-analysis. Bortezomib-based regimens were compared with regimens without bortezomib or observation. The meta-analysis suggested that bortezomib-based maintenance therapy improved progression-free survival (PFS; hazard ratio [HR] = 0.72, 95% CI 0.55-0.95, P = 0.02) and overall survival (OS; HR = 0.71, 95% CI 0.58-0.87, P = 0.001). Bortezomib-based consolidation therapy improved PFS (HR = 0.77, 95% CI 0.68-0.88, P < 0.001) but not OS (HR = 0.98, 95% CI 0.78-1.24, P = 0.87). Bortezomib-based consolidation/maintenance therapy led to a trend toward increased risk of grade ≥ 3 neurologic symptoms, gastrointestinal symptoms, and fatigue. More research is warranted to further assess the role of bortezomib-based consolidation and maintenance therapy for multiple myeloma.
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12
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Schjesvold F, Goldschmidt H, Maisnar V, Spicka I, Abildgaard N, Rowlings P, Cain L, Romanus D, Suryanarayan K, Rajkumar V, Odom D, Gnanasakthy A, Dimopoulos M. Quality of life is maintained with ixazomib maintenance in post-transplant newly diagnosed multiple myeloma: The TOURMALINE-MM3 trial. Eur J Haematol 2020; 104:443-458. [PMID: 31880006 DOI: 10.1111/ejh.13379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Health-related quality of life (HRQoL) is particularly important during maintenance therapy (MT) in newly diagnosed multiple myeloma post-transplant, when disease symptoms are limited. METHODS We assessed HRQoL in patients randomised to 26 cycles of MT (ixazomib vs placebo) in TOURMALINE-MM3 (NCT02181413). RESULTS The characteristics at study entry were well-balanced between ixazomib (n = 386) and placebo (n = 251) arms. At study entry, EORTC QLQ-C30 and MY20 scores were high for functional scales and low for symptom scales and were comparable with those of the general population. Changes in subscale scores across intervals, analysed over 30 four-week intervals using a linear mixed-effects model, were generally small and similar between arms for the EORTC QLQ-C30 Global Health Status/QoL, Physical Functioning, and Pain subscales and EORTC QLQ-MY20 Disease Symptoms subscale and Peripheral Neuropathy item. EORTC QLQ-C30 Nausea/Vomiting and Diarrhoea subscales were consistently worse for ixazomib than for placebo, in line with the ixazomib toxicity profile. Even when least-squares mean differences between arms were statistically significant, none reached the established minimal important clinical difference of 10 in multiple myeloma. CONCLUSIONS In addition to improvement in progression-free survival with ixazomib, HRQoL was maintained in both arms. Active treatment with ixazomib did not have an adverse impact on HRQoL.
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Affiliation(s)
- Fredrik Schjesvold
- Oslo Myeloma Center, Oslo University Hospital, Oslo, Norway.,KG Jebsen Center for B cell malignancies, University of Oslo, Oslo, Norway
| | - Hartmut Goldschmidt
- Department of Internal Medicine V, University Medical Hospital and National Center of Tumor Diseases, University of Heidelberg, Heidelberg, Germany
| | - Vladimir Maisnar
- Department of Medicine-Hematology, Charles University Hospital, Hradec Králové, Czech Republic
| | - Ivan Spicka
- Department of Hematology, Charles University, Prague, Czech Republic
| | - Neils Abildgaard
- Department of Hematology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Philip Rowlings
- Department of Hematology, School of Medicine & Public Health, University of Newcastle, Waratah, New South Wales, Australia
| | - Lauren Cain
- Statistical and Quantitative Sciences, Takeda Pharmaceuticals, Cambridge, MA, USA
| | - Dorothy Romanus
- Global Outcomes Research, Takeda Pharmaceuticals, Cambridge, MA, USA
| | | | - Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dawn Odom
- Biostatistics, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Ari Gnanasakthy
- Patient-Centered Outcomes Assessment, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, Hematology & Medical Oncology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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13
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Jackson G, Galinsky J, Alderson DEC, D'Souza VK, Buchanan V, Dhanasiri S, Walker S. Productivity losses in patients with newly diagnosed multiple myeloma following stem cell transplantation and the impact of maintenance therapy. Eur J Haematol 2019; 103:393-401. [PMID: 31325331 PMCID: PMC6899492 DOI: 10.1111/ejh.13298] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/05/2019] [Accepted: 07/08/2019] [Indexed: 01/25/2023]
Abstract
Objective This study examined productivity losses in European patients with newly diagnosed multiple myeloma (NDMM) undergoing autologous stem cell transplantation (ASCT), to better understand and model the impact of NDMM and lenalidomide maintenance therapy on productivity from a patient and societal perspective. Methods A cross‐sectional online patient survey was conducted across the UK, Germany, France, Spain and Italy. A partitioned survival model was used to estimate productivity loss and the impact of maintenance therapy, using human capital (HC) and friction cost approaches. Results Of the 115 eligible survey respondents, 76.5% were economically active at the time of diagnosis and highlighted return to work as an important factor affecting their quality of life; only 39.1% of respondents were economically active post‐ASCT. HC analyses estimated average total productivity losses per ASCT patient at EUR 290,601 over a 20‐year period. Modelling the impact of maintenance therapy alone for these patients reduced average productivity losses by just over 10%. Conclusion Patients with NDMM aspire to engage in productive lives post‐ASCT, but most are unable to do so. Access to treatments extending remission and supporting engagement in a productive life can have a positive impact both for patients and wider society.
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Affiliation(s)
- Graham Jackson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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14
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Dimopoulos MA, Laubach JP, Echeveste Gutierrez MA, Grzasko N, Hofmeister CC, San-Miguel JF, Kumar S, Labotka R, Lu V, Berg D, Byrne C, Teng Z, Liu G, van de Velde H, Richardson PG. Ixazomib maintenance therapy in newly diagnosed multiple myeloma: An integrated analysis of four phase I/II studies. Eur J Haematol 2019; 102:494-503. [PMID: 30943323 DOI: 10.1111/ejh.13231] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/18/2019] [Accepted: 03/20/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the safety and efficacy of maintenance therapy with the oral proteasome inhibitor ixazomib in patients with newly diagnosed multiple myeloma (NDMM) not undergoing transplantation. METHODS Data were pooled from four NDMM phase I/II studies; patients received induction therapy with once- or twice-weekly ixazomib plus lenalidomide-dexamethasone (IRd), melphalan-prednisone (IMP), or cyclophosphamide-dexamethasone (ICd), followed by single-agent ixazomib maintenance, given at the last tolerated dose during induction, until disease progression, death, or unacceptable toxicity. RESULTS A total of 121 patients achieved stable disease or better after induction (weekly IRd, n = 25; twice-weekly IRd, n = 18; weekly or twice-weekly IMP, n = 35; weekly ICd, n = 43) and received ≥ 1 dose of ixazomib maintenance. Grade ≥ 3 drug-related adverse events occurred in 24% of patients during maintenance; each event was reported in ≤2% of patients. Rates of complete response were 22% after induction and 35% after maintenance. A total of 28 patients (23%) improved their response during maintenance. CONCLUSIONS Ixazomib maintenance following ixazomib-based induction is associated with deepening of responses and a positive safety profile with no cumulative toxicity in patients with NDMM not undergoing transplantation, suggesting that ixazomib is feasible for long-term administration. Phase III investigation of ixazomib maintenance is ongoing.
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Affiliation(s)
- Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Norbert Grzasko
- Department of Hematology, St. John's Cancer Center and Medical University of Lublin, Lublin, Poland
| | - Craig C Hofmeister
- The Ohio State University, Columbus, Ohio.,Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jesus F San-Miguel
- Clinica Universidad de Navarra, Centro Investigación Medica Aplicada (CIMA), IDISNA, CIBERONC, Pamplona, Spain
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Vickie Lu
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
| | - Deborah Berg
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
| | | | - Zhaoyang Teng
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
| | - Guohui Liu
- Millennium Pharmaceuticals, Inc., Cambridge, MA, USA
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15
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Dempsey JL, Johns A, Rosko AE, Lazarus HM. The pharmacologic management of multiple myeloma in older adults. Expert Opin Pharmacother 2019; 20:887-902. [PMID: 30785310 PMCID: PMC6559717 DOI: 10.1080/14656566.2019.1577822] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 01/30/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Multiple myeloma is a disease predominately affecting older adults. Pivotal to treating older adults is understanding their physiologic differences compared to younger subjects and how the complexity of therapies has an impact upon this patient population. AREAS COVERED Herein, the authors address the efficacy of chemotherapy regimens, decision-making for older adults, chemotherapy-associated toxicity and the approach to management. This review focuses on the complex treatment of older multiple myeloma patients and management of treatment-related adverse events. EXPERT OPINION Balancing efficacy and managing toxicity is a challenge for older myeloma patients. This group is more susceptible to treatment toxicities due to a higher incidence of pre-existing comorbidities and underlying diminished physiologic reserve. Intensive therapies such as autologous hematopoietic cell transplant (AHCT), however, still should be considered for all multiple myeloma patients, including older adults. The continued development of novel therapies and increased use of multi-drug regimens has changed the treatment paradigms yet understanding the complexity of the aging adult in the context of various drugs is warranted.
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Affiliation(s)
- Jessica L. Dempsey
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Andrew Johns
- Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Ashley E. Rosko
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Hillard M. Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, USA
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16
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Kao RL, Holtan SG. Host and Graft Factors Impacting Infection Risk in Hematopoietic Cell Transplantation. Infect Dis Clin North Am 2019; 33:311-329. [PMID: 30940461 DOI: 10.1016/j.idc.2019.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Infection contributes significantly to morbidity and mortality in hematopoietic cell transplantation. A complex interplay of host, graft, and technical factors contributes to infectious risk in the recipient. Host factors such as age, underlying disease, and comorbidities; central venous access; and the preparative regimen contribute to mucosal disruption, organ dysfunction, and immunodeficiency before hematopoietic cell transplantation. Graft factors, including donor histocompatibility, cell source, and graft components, along with immunosuppression and graft-versus-host disease, contribute to the speed of immune reconstitution. Evaluation of these factors, plus previous and posttransplant exposure to pathogens, is necessary to best assess an individual recipient's infection risk.
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Affiliation(s)
- Roy L Kao
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, 420 Delaware Street Southeast, MMC 480, Minneapolis, MN 55455, USA.
| | - Shernan G Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, 420 Delaware Street Southeast, MMC 480, Minneapolis, MN 55455, USA
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17
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Gonsalves WI, Buadi FK, Ailawadhi S, Bergsagel PL, Chanan Khan AA, Dingli D, Dispenzieri A, Fonseca R, Hayman SR, Kapoor P, Kourelis TV, Lacy MQ, Larsen JT, Muchtar E, Reeder CB, Sher T, Stewart AK, Warsame R, Go RS, Kyle RA, Leung N, Lin Y, Lust JA, Russell SJ, Zeldenrust SR, Fonder AL, Hwa YL, Hobbs MA, Mayo AA, Hogan WJ, Rajkumar SV, Kumar SK, Gertz MA, Roy V. Utilization of hematopoietic stem cell transplantation for the treatment of multiple myeloma: a Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) consensus statement. Bone Marrow Transplant 2019; 54:353-367. [PMID: 29988062 PMCID: PMC6463224 DOI: 10.1038/s41409-018-0264-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/10/2018] [Accepted: 05/11/2018] [Indexed: 12/22/2022]
Abstract
Over the last two decades, the utilization of various novel therapies in the upfront or salvage settings has continued to improve survival outcomes for patients with Multiple Myeloma (MM). Thus, the conventional role for hematopoietic stem cell transplantation (HSCT) in MM either in the form of an autologous stem cell transplant (ASCT) or an allogeneic stem cell transplant (Allo-SCT) warrants re-evaluation, given the aforementioned clinical advances. Here, we present a consensus statement of our multidisciplinary group of over 30 Mayo Clinic physicians with a special interest in the care of patients with MM and provide evidence-based recommendations on the use of HSCT in MM. We specifically address topics that include the role and timing of an ASCT for MM in the era of novel agents, eligibility for an ASCT, post-ASCT consolidation, and maintenance options, and finally the utility of an upfront tandem ASCT, salvage second ASCT, and an allo-SCT in MM.
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Affiliation(s)
| | - Francis K Buadi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sikander Ailawadhi
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - P Leif Bergsagel
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Asher A Chanan Khan
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Rafael Fonseca
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Susan R Hayman
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prashant Kapoor
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Martha Q Lacy
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy T Larsen
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Craig B Reeder
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Taimur Sher
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - A Keith Stewart
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Amie L Fonder
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yi L Hwa
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Miriam A Hobbs
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Angela A Mayo
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - William J Hogan
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Shaji K Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vivek Roy
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, USA
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18
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Indatuximab Ravtansine (BT062) Monotherapy in Patients With Relapsed and/or Refractory Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:372-380. [PMID: 30930134 DOI: 10.1016/j.clml.2019.02.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/11/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Indatuximab ravtansine (BT062) is an antibody-drug conjugate that binds to CD138, which is overexpressed on multiple myeloma (MM) cells. PATIENTS AND METHODS We report from 2 clinical studies of patients with relapsed and/or refractory MM previously treated with an immunomodulatory drug and a proteasome inhibitor. Single- and multi-dosing schedules were investigated to define dose-limiting toxicities, maximum tolerated dose (MTD), recommended phase II dose, and to describe safety, efficacy, and pharmacokinetics. RESULTS In the first-in-human study, indatuximab ravtansine was administered to 32 patients on day 1 of each 21-day cycle. The MTD was 160 mg/m2. In the phase I/IIa study, indatuximab ravtansine was administered to 35 patients on days 1, 8, and 15 of each 28-day cycle, and the MTD/recommended phase II dose was 140 mg/m2. Most (88%) adverse events were grade 1 or 2, the most common being diarrhea and fatigue. There was rapid clearance of indatuximab ravtansine and no relevant accumulation. Over 75% of heavily pretreated patients achieved stable disease or better. With the multi-dose schedule, minor and partial responses occurred in 14.7% of patients, the median time to progression was 3 months, and the median overall survival was 26.7 months. CONCLUSION Our data support further investigation of indatuximab ravtansine as part of a combination regimen for relapsed and/or refractory MM.
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Dimopoulos MA, Gay F, Schjesvold F, Beksac M, Hajek R, Weisel KC, Goldschmidt H, Maisnar V, Moreau P, Min CK, Pluta A, Chng WJ, Kaiser M, Zweegman S, Mateos MV, Spencer A, Iida S, Morgan G, Suryanarayan K, Teng Z, Skacel T, Palumbo A, Dash AB, Gupta N, Labotka R, Rajkumar SV. Oral ixazomib maintenance following autologous stem cell transplantation (TOURMALINE-MM3): a double-blind, randomised, placebo-controlled phase 3 trial. Lancet 2019; 393:253-264. [PMID: 30545780 DOI: 10.1016/s0140-6736(18)33003-4] [Citation(s) in RCA: 169] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Maintenance therapy following autologous stem cell transplantation (ASCT) can delay disease progression and prolong survival in patients with multiple myeloma. Ixazomib is ideally suited for maintenance therapy given its convenient once-weekly oral dosing and low toxicity profile. In this study, we aimed to determine the safety and efficacy of ixazomib as maintenance therapy following ASCT. METHODS The phase 3, double-blind, placebo-controlled TOURMALINE-MM3 study took place in 167 clinical or hospital sites in 30 countries in Europe, the Middle East, Africa, Asia, and North and South America. Eligible participants were adults with a confirmed diagnosis of symptomatic multiple myeloma according to International Myeloma Working Group criteria who had achieved at least a partial response after undergoing standard-of-care induction therapy followed by high-dose melphalan (200 mg/m2) conditioning and single ASCT within 12 months of diagnosis. Patients were randomly assigned in a 3:2 ratio to oral ixazomib or matching placebo on days 1, 8, and 15 in 28-day cycles for 2 years following induction, high-dose therapy, and transplantation. The initial 3 mg dose was increased to 4 mg from cycle 5 if tolerated during cycles 1-4. Randomisation was stratified by induction regimen, pre-induction disease stage, and response post-transplantation. The primary endpoint was progression-free survival (PFS) by intention-to-treat analysis. Safety was assessed in all patients who received at least one dose of ixazomib or placebo, according to treatment actually received. This trial is registered with ClinicalTrials.gov, number NCT02181413, and follow-up is ongoing. FINDINGS Between July 31, 2014, and March 14, 2016, 656 patients were enrolled and randomly assigned to receive ixazomib maintenance therapy (n=395) or placebo (n=261). With a median follow-up of 31 months (IQR 27·3-35·7), we observed a 28% reduction in the risk of progression or death with ixazomib versus placebo (median PFS 26·5 months [95% CI 23·7-33·8] vs 21·3 months [18·0-24·7]; hazard ratio 0·72, 95% CI 0·58-0·89; p=0·0023). No increase in second malignancies was noted with ixazomib therapy (12 [3%] patients) compared with placebo (eight [3%] patients) at the time of this analysis. 108 (27%) of 394 patients in the ixazomib group and 51 (20%) of 259 patients in the placebo group experienced serious adverse events. During the treatment period, one patient died in the ixazomib group and none died in the placebo group. INTERPRETATION Ixazomib maintenance prolongs PFS and represents an additional option for post-transplant maintenance therapy in patients with newly diagnosed multiple myeloma. FUNDING Millennium Pharmaceuticals, a wholly owned subsidiary of Takeda Pharmaceutical Company.
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Affiliation(s)
- Meletios A Dimopoulos
- Hematology & Medical Oncology, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
| | - Francesca Gay
- Department of Oncology and Hematology, Azienda Ospedaliero-Universitaria City of Health and Science of Turin, Turin, Italy
| | - Fredrik Schjesvold
- Oslo Myeloma Center, Oslo University Hospital, Oslo, Norway; KG Jebsen Center for B cell malignancies, University of Oslo, Oslo, Norway
| | - Meral Beksac
- Department of Hematology, Ankara University, Ankara, Turkey
| | - Roman Hajek
- Department of Hematooncology, University Hospital Ostrava, Ostrava, Czech Republic
| | | | - Hartmut Goldschmidt
- Department of Internal Medicine V, University Medical Hospital and National Center of Tumor Diseases, University of Heidelberg, Heidelberg, Germany
| | - Vladimir Maisnar
- Fourth Department of Medicine-Hematology, FN and LF UK Hradec Králové, Hradec Králové, Czech Republic
| | - Philippe Moreau
- Department of Hematology, University Hospital Hôtel Dieu, University of Nantes, Nantes, France
| | - Chang Ki Min
- Department of Internal Medicine, Seoul St Mary's Hospital, Seoul, South Korea
| | - Agnieszka Pluta
- Department of Haematology, Medical University of Lodz, Multidisciplinary Provincial Centre of Traumatology and Oncology Nicolas Copernicus in Lodz, Lodz, Poland
| | - Wee-Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, Singapore and Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Martin Kaiser
- Department of Haematology, The Royal Marsden Hospital, London, UK; Division of Molecular Pathology, The Institute of Cancer Research ICR, London, UK
| | - Sonja Zweegman
- Department of Hematology, Amsterdam University Medical Center, VU University Amsterdam, Cancer Center Amsterdam, Netherlands
| | - Maria-Victoria Mateos
- Department of Hematology, University Hospital of Salamanca, CIC, IBMCC, Salamanca, Spain
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health-Monash University, Melbourne, VA, Australia
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Gareth Morgan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | | | - Antonio Palumbo
- Millennium Pharmaceuticals, Cambridge, MA, USA; Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria S Giovanni Battista, Torino, Italy; Center for Hematology and Oncology, University Hospital Zürich, Zürich, Switzerland
| | | | | | | | - S Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Amsler IG, Jeker B, Mansouri Taleghani B, Bacher U, Betticher D, Egger T, Zander T, Luethi JM, Novak U, Pabst T. Prolonged survival with increasing duration of lenalidomide maintenance after autologous transplant for multiple myeloma. Leuk Lymphoma 2019; 60:511-514. [DOI: 10.1080/10428194.2018.1473577] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Isabel G. Amsler
- Department of Medical Oncology, Bern University Hospital, Bern, Switzerland
| | - Barbara Jeker
- Department of Medical Oncology, Bern University Hospital, Bern, Switzerland
| | | | - Ulrike Bacher
- Department of Hematology, University Hospital, Bern, Switzerland
| | | | - Thomas Egger
- Department of Oncology, Kantonsspital, Solothurn, Switzerland
| | - Thilo Zander
- Department of Oncology, Kantonsspital, Lucerne, Switzerland
| | - Jean-Marc Luethi
- Department of Medical Oncology, Bern University Hospital, Regionalspital, Thun, Switzerland
| | - Urban Novak
- Department of Medical Oncology, Bern University Hospital, Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Bern University Hospital, Bern, Switzerland
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21
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Goldschmidt H, Ashcroft J, Szabo Z, Garderet L. Navigating the treatment landscape in multiple myeloma: which combinations to use and when? Ann Hematol 2019; 98:1-18. [PMID: 30470875 PMCID: PMC6334731 DOI: 10.1007/s00277-018-3546-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 11/06/2018] [Indexed: 12/31/2022]
Abstract
Multiple myeloma is one of the most common hematological malignancies, affecting mainly elderly patients. The treatment landscape for the management of this disease has evolved significantly over the past 15 years, and a vast array of therapeutics is now available, including immunomodulatory drugs, proteasome inhibitors, histone deacetylase inhibitors, and monoclonal antibodies. As a result, deciding which drugs to use and when, and whether these should be used in a particular order or combination, can be challenging. Although combination regimens are often associated with deeper responses and better long-term outcomes than monotherapy, and are becoming the standard of care, they may result in significant incremental toxicity; hence, a sequential approach may be more appropriate for some patients. In particular, treatment choices can vary depending on whether the patient has newly diagnosed multiple myeloma, is eligible for transplant, has relapsed and/or refractory multiple myeloma, or is considered to have high-risk disease. In this review, we discuss factors to be taken into account when making treatment decisions in each of these settings. We also briefly discuss possible therapeutic strategies involving agents that may become available in the future.
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Affiliation(s)
- Hartmut Goldschmidt
- Internal Medicine V and National Center for Tumor Diseases (NCT), University Clinic Heidelberg, 69120, Heidelberg, Germany.
| | - John Ashcroft
- Department of Haematology, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Zsolt Szabo
- Clinical Development, Amgen (Europe) GmbH, Zug, Switzerland
| | - Laurent Garderet
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, Paris, 75012, France
- AP-HP, Hôpital Saint Antoine, Département d'hématologie et de thérapie cellulaire, Sorbonne Université, Paris 6, Paris, France
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22
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Raab MS, Fink L, Schoen P, Gonzalez‐McQuire S, Flinois A, Cavo M, Mateos M, Yong K. Evolution of multiple myeloma treatment practices in Europe from 2014 to 2016. Br J Haematol 2018; 185:981-984. [DOI: 10.1111/bjh.15680] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Marc S. Raab
- Department of Internal Medicine V University of Heidelberg Heidelberg Germany
| | | | | | | | | | - Michele Cavo
- “Seragnoli” Institute of Haematology and Medical Oncology Bologna University School of Medicine Bologna Italy
| | | | - Kwee Yong
- Department of Haematology University College London London UK
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23
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Tay J, Vij R, Norkin M, Buadi F, Kindwall-Keller TL, Roberts JS, White DJ, Wood RP, Blanthorn-Hazell SE, Rossi AC, Dhanasiri S, Zafar F, Newhouse K, McCurdy AR. Health related quality of life for multiple myeloma patients according to treatment strategy after autologous stem cell transplant: a cross-sectional study using EORTC, EQ-5D and MY-20 scales. Leuk Lymphoma 2018; 60:1275-1282. [PMID: 30380358 DOI: 10.1080/10428194.2018.1523399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Maintenance (MT) may be prescribed after autologous stem cell transplant (ASCT) but there are often concerns about the impact on quality of life (QoL). QoL was compared between baseline patients (30-100 days post-ASCT and had not commenced MT); MT patients (>100 days post-ASCT and receiving MT), and no MT (>100 days post-ASCT and not receiving MT). Patients completed the EuroQoL five dimension (EQ-5D), the European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC QLQ-C30), and the QoL Questionnaire Myeloma 20 module (QLQ-MY20). Differences between groups were explored with ordinary least squares regressions. Across US and Canada, 303 patients participated. Regression analyses found few differences between MT and no MT. Only diarrhea (EORTC-QLQ C30) and future perspectives (MY-20) domains differentiated; patients on MT scored worse for diarrhea (+9.43; p = .0358) and future perspectives (-11.39; p = .0196). Collectively, the results suggest that MT is not associated with a notable QoL detriment.
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Affiliation(s)
- Jason Tay
- a Tom Baker Cancer Center , University of Calgary , Calgary , AB , Canada
| | - Ravi Vij
- b Division of Oncology , Washington University School of Medicine , Saint Louis , MO , USA
| | - Maxim Norkin
- c Department of Medicine/Division of Hematology Oncology , University of Florida , Gainesville , FL , USA
| | - Francis Buadi
- d Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | | | | | - Darrell J White
- g Queen Elizabeth II Health Sciences Centre , Dalhousie University , Halifax , NS , Canada
| | | | | | - Adriana C Rossi
- h Division of Hematology and Oncology , Weill Cornell Medicine/New York Presbyterian Hospital , New York , NY , USA
| | | | | | | | - Arleigh R McCurdy
- l Division of Hematology , The Ottawa Hospital and The University of Ottawa , Ottawa , ON , Canada
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24
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Popat R, Brown SR, Flanagan L, Hall A, Gregory W, Kishore B, Streetly M, Oakervee H, Yong K, Cook G, Low E, Cavenagh J. Extended follow-up and the feasibility of Panobinostat maintenance for patients with Relapsed Multiple Myeloma treated with Bortezomib, Thalidomide, Dexamethasone plus Panobinostat (MUK six open label, multi-centre phase I/II Clinical Trial). Br J Haematol 2018; 185:573-578. [PMID: 30125960 DOI: 10.1111/bjh.15551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Rakesh Popat
- NIHR/UCLH Clinical Research Facility, University College London Hospitals, London, UK
| | - Sarah R Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Louise Flanagan
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Andrew Hall
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Walter Gregory
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | | | | | - Kwee Yong
- NIHR/UCLH Clinical Research Facility, University College London Hospitals, London, UK
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25
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How I treat the young patient with multiple myeloma. Blood 2018; 132:1114-1124. [PMID: 29967130 DOI: 10.1182/blood-2017-05-693606] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/01/2018] [Indexed: 02/06/2023] Open
Abstract
The treatment landscape for multiple myeloma has been transformed by the introduction of novel agents, including immunomodulatory drugs, proteasome inhibitors, and monoclonal antibodies. These have been shown to be more effective and generally better tolerated than conventional chemotherapy, with their introduction into clinical practice leading to improved survival. Furthermore, a better understanding of disease biology, improved diagnostic criteria, and the development of sensitive and specific tools for disease prognostication have contributed to better outcome. Treatment in the younger patient can now be individualized based on host and disease features with enhanced monitoring of response and use of high-sensitivity techniques for evaluating residual disease. The current standard of care has been significantly enhanced by novel agents with a paradigm shift toward optional or delayed autologous stem cell transplant as a reasonable choice in selected patients. Conversely, extended treatment with induction of remission followed by maintenance strategies is now a standard of care, conferring prolonged disease control with more manageable toxicities in both the short and long term, as well as improved quality of life.
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26
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Byun JM, Lee J, Shin SJ, Kang M, Yoon SS, Koh Y. Busulfan plus melphalan versus high-dose melphalan as conditioning regimens in autologous stem cell transplantation for newly diagnosed multiple myeloma. Blood Res 2018; 53:105-109. [PMID: 29963515 PMCID: PMC6021568 DOI: 10.5045/br.2018.53.2.105] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/11/2017] [Accepted: 10/23/2017] [Indexed: 11/17/2022] Open
Abstract
Background High-dose melphalan (HDMEL) represents the standard conditioning regimen before autologous stem cell transplant (ASCT) in multiple myeloma (MM), but recent updates have suggested combination of melphalan with bulsulfan (BUMEL) is also associated with favorable outcomes. We performed the current study to address the lack of comparative studies between the two conditioning regimens in Asian populations. Methods Using the Korean National Health Insurance and Korean Health Insurance Review and Assessment Service databases, 1,304 patients newly diagnosed with MM undergoing ASCT between January 2010 and December 2014 were identified. Patients were divided according to conditioning regimen (HDMEL vs. BUMEL), and after case matching, 428 patients undergoing HDMEL conditioning were compared to 107 patients undergoing BUMEL conditioning with respect to clinical course and treatment outcomes. Results The 3-year progression-free survival (PFS) was 52.5% for the HDMEL conditioning group versus 70.3% for the BUMEL conditioning group (P=0.043). The 3-year overall survival (OS) was 82.0% versus 83.5% (P=0.525), respectively. Although not statistically significant, BUMEL conditioning was associated with more platelet transfusion, while HDMEL was associated with more granulocyte colony stimulating factor support. In multivariate analysis, BUMEL conditioning was not inferior to HDMEL conditioning in regard to both PFS and OS. Conclusion Our study confirmed that BUMEL is an effective and well-tolerated alternative to HDMEL conditioning, with better PFS.
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Affiliation(s)
- Ja Min Byun
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jayoun Lee
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Sang-Jin Shin
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Minjoo Kang
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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27
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Li JL, Fan GY, Liu YJ, Zeng ZH, Huang JJ, Yang ZM, Meng XY. Long-Term Efficacy of Maintenance Therapy for Multiple Myeloma: A Quantitative Synthesis of 22 Randomized Controlled Trials. Front Pharmacol 2018; 9:430. [PMID: 29760659 PMCID: PMC5936780 DOI: 10.3389/fphar.2018.00430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/12/2018] [Indexed: 12/18/2022] Open
Abstract
We aimed to quantitatively synthesize data from randomized controlled trials (RCTs) concerning maintenance for multiple myeloma (MM). We searched electronic literature databases and conference proceedings to identify relevant RCTs. We selected eligible RCTs using predefined selection criteria. We conducted meta-analysis comparing maintenance containing new agents and conventional maintenance, and subgroup analysis by transplantation status and mainstay agent as well. We performed trial sequential analysis (TSA) to determine adequacy of sample size for overall and subgroup meta-analyses. We performed network meta-analysis (NMA) to compare and rank included regimens. A total of 22 RCTs involving 9,968 MM patients and 15 regimens were included, the overall quality of which was adequate. Significant heterogeneity was detected for progression-free survival (PFS) but not overall survival (OS). Meta-analyses showed that maintenance containing new agents significantly improved PFS but not OS [PFS: Hazard Ratio (HR) = 0.59, 95% Confidence Interval (CI) = 0.54 to 0.64; OS: HR = 0.93, 95% CI = 0.87 to 1.00], compared with controls. Subgroup analyses revealed lenalidomide (Len)-based therapies better than thalidomide-based ones (HR = 0.50 and 0.66, respectively; P = 0.001). NMA revealed that most of the maintenance regimens containing new agents were significantly better than simple observation in terms of PFS but not OS. Len single agent was the most effective, considering PFS and OS both. We concluded that conventional maintenance has very limited effect. Maintenance containing new agents is highly effective in improving PFS, but has very limited effect on OS. Maintenance with Len may have the largest survival benefits. Emerging strategies may further change the landscape of maintenance of MM.
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Affiliation(s)
- Jie-Li Li
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Guang-Yu Fan
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Evidence-Based Medicine and Clinical Epidemiology, Second Clinical College of Wuhan University, Wuhan, China
| | - Yu-Jie Liu
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Evidence-Based Medicine and Clinical Epidemiology, Second Clinical College of Wuhan University, Wuhan, China
| | - Zi-Hang Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Evidence-Based Medicine and Clinical Epidemiology, Second Clinical College of Wuhan University, Wuhan, China
| | - Jing-Juan Huang
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zong-Ming Yang
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiang-Yu Meng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Evidence-Based Medicine and Clinical Epidemiology, Second Clinical College of Wuhan University, Wuhan, China
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Martins LNGF, Morita AA, Broto GE, Takakura É, da Silva SS, Tomiotto-Pellissier F, Conchon-Costa I, Pavanelli WR, Panis C, Barbosa DS. Interferon-gamma in mobilized stem cells: A possible prognostic marker in early post-transplant management in multiple myeloma. Cytokine 2018; 108:127-135. [PMID: 29602156 DOI: 10.1016/j.cyto.2018.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 03/02/2018] [Accepted: 03/08/2018] [Indexed: 01/11/2023]
Abstract
INTRODUCTION A complex network of cytokines in the bone marrow microenvironment has been implicated as an important factor in the pathogenesis of multiple myeloma (MM). Different cytokines have been studied in MM, both in peripheral blood and/or bone marrow, but there are few data correlating cytokines in leukapheresis product with post-transplant response depth to treatment. MATERIALS AND METHODS In a retrospective cross-sectional study, levels of tumor necrosis factor alpha (TNF-α), transforming growth factor beta-1 (TGF-β1) and interferon gamma (IFN-γ) in peripheral hematopoietic stem cells/leukapheresis product (PHSC) of patients with MM eligible for transplantation were evaluated. Association of these cytokines with certain factors such as mobilized CD34 + cells/kg, staging, response to treatment and outcome were analyzed. RESULTS The median baseline IFN-γ level was 826.4 pg/mL. IFN-γ levels in the leukapheresis product were significantly lower in patients who achieved complete response (CR) three months post-transplant when compared to patients with very good partial response (VGPR) (674.75 ± 80.32 pg/mL versus 939.6 ± 106.8 pg/mL, p = 0.02), respectively. Patients who lost depth of response at the third-month post-transplant had a median level of IFN-γ 1133, being considered "high-expressors" of IFN-γ, while those reaching improved response were called "low-expressors" (median level IFN-γ 485 pg/mL). Overall and progression-free survival did not have a statistically significant correlation with TNF-α, TGF-β1 or IFN-γ, as well as TNF-α and TGF-β1 levels in post-transplant response assessment. CONCLUSION IFN-γ in PHSC seems to be an important biomarker of loss of response in MM, suggesting a role in early post-transplant therapeutic management.
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Affiliation(s)
| | - Andrea Akemi Morita
- Postgraduate Program in Health Sciences, State University of Londrina (UEL), Londrina, PR, Brazil
| | - Geise Ellen Broto
- Postgraduate Program in Health Sciences, State University of Londrina (UEL), Londrina, PR, Brazil
| | - Érika Takakura
- Laboratory of Inflammatory Mediators, State University of Western Paraná (UNIOESTE), Francisco Beltrão, PR, Brazil
| | - Suelen Santos da Silva
- Department of Pathological Sciences, State University of Londrina (UEL), Londrina, PR, Brazil
| | | | - Ivete Conchon-Costa
- Department of Pathological Sciences, State University of Londrina (UEL), Londrina, PR, Brazil
| | | | - Carolina Panis
- Laboratory of Inflammatory Mediators, State University of Western Paraná (UNIOESTE), Francisco Beltrão, PR, Brazil.
| | - Décio Sabbatini Barbosa
- Postgraduate Program in Health Sciences, State University of Londrina (UEL), Londrina, PR, Brazil
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29
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Richardson PG, Holstein SA, Schlossman RL, Anderson KC, Attal M, McCarthy PL. Lenalidomide in combination or alone as maintenance therapy following autologous stem cell transplant in patients with multiple myeloma: a review of options for and against. Expert Opin Pharmacother 2017; 18:1975-1985. [DOI: 10.1080/14656566.2017.1409207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
| | - Sarah A. Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Michel Attal
- Department of Hematology, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Philip L. McCarthy
- Blood and Marrow Transplant Program, Roswell Park Cancer Institute, Buffalo, NY, USA
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30
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Jimenez-Zepeda VH, Duggan P, Neri P, Chaudhry A, Tay J, Bahlis N. Immunoparesis and polyclonal immunoglobulin recovery after auto-SCT for patients with multiple myeloma treated at a single institution. Leuk Lymphoma 2017; 59:1920-1926. [PMID: 29160734 DOI: 10.1080/10428194.2017.1403026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Immunoparesis and polyclonal immunoglobulin recovery have been recently described as common indicators of immune dysfunction in patients with multiple myeloma. In the present study, we aimed to assess the impact of immunoparesis and polyclonal immunoglobulin recovery at day-100 post autologous stem cell transplant (auto-SCT) on clinical outcomes. A total of 302 patients were included for the analysis of immunoparesis, and 197 were evaluable for polyclonal immunoglobulin recovery evaluation. Immunoparesis was observed in 93.5% of cases, with 47% of cases having polyclonal immunoglobulin recovery at 12 months post auto-SCT. Median overall and progression-free survival were longer in the group of patients with complete or partial normalization of polyclonal immunoglobulins. Patients receiving consolidation had a lower level of polyclonal reconstitution. In conclusion, polyclonal immunoglobulin recovery by 12 months post-auto-SCT is associated with superior overall and progression free survival in patients with MM. Efforts to better enhance polyclonal recovery deserve further investigation.
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Affiliation(s)
- Victor H Jimenez-Zepeda
- a Department of Medical Oncology and Hematology , Tom Baker Cancer Center , Calgary , Canada
| | - Peter Duggan
- a Department of Medical Oncology and Hematology , Tom Baker Cancer Center , Calgary , Canada
| | - Paola Neri
- a Department of Medical Oncology and Hematology , Tom Baker Cancer Center , Calgary , Canada
| | - Ahsan Chaudhry
- a Department of Medical Oncology and Hematology , Tom Baker Cancer Center , Calgary , Canada
| | - Jason Tay
- a Department of Medical Oncology and Hematology , Tom Baker Cancer Center , Calgary , Canada
| | - Nizar Bahlis
- a Department of Medical Oncology and Hematology , Tom Baker Cancer Center , Calgary , Canada
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