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Neuendorff NR, Khan A, Ullrich F, Yates S, Devarakonda S, Lin RJ, von Tresckow B, Cordoba R, Artz A, Rosko AE. Cellular therapies in older adults with hematological malignancies: A case-based, state-of-the-art review. J Geriatr Oncol 2024; 15:101734. [PMID: 38430810 DOI: 10.1016/j.jgo.2024.101734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 11/05/2023] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
Cellular therapies, including autologous stem cell transplant (ASCT), allogeneic hematopoietic cell transplantation (alloHCT), and chimeric antigen receptor- (CAR-) T cell therapies are essential treatment modalities for many hematological malignancies. Although their use in older adults has substantially increased within the past decades, cellular therapies represent intensive treatment approaches that exclude a large percentage of older adults due to comorbidities and frailty. Under- and overtreatment in older adults with hematologic malignancy is a challenge and many treatment decisions are influenced by chronologic age. The advent of efficient and well-tolerated newer treatment approaches for multiple myeloma has challenged the role of ASCT. In the modern era, there are no randomized clinical trials of transplant versus non-transplant strategies for patients ≥65 years. Nonetheless, ASCT is feasible for selected older patients and does not result in long-term compromise in quality of life. AlloHCT is the only curative approach for acute myeloid leukemia of intermediate and unfavourable risk but carries a significant risk for non-relapse mortality depending on comorbidities, general fitness, and transplant-specific characteristics, such as intensity of conditioning and donor choice. However, alloHCT is feasible in appropriately-selected older adults. Early referral for evaluation is strongly encouraged as this is the most obvious barrier. CAR-T cell therapies have shown unprecedented clinical efficacy and durability in relapsed and refractory diffuse large B cell lymphoma. Its use is well tolerated in older adults, although evidence comes from limited case numbers. Whether patients who are deemed unfit for ASCT qualify for CAR-T cell therapy remains elusive, but the tolerability and efficacy of CAR-T cell therapy appears promising, especially for older patients. The evidence from randomized trials is strong in favor of using a comprehensive geriatric assessment (CGA) to reduce treatment-related toxicities and guide treatment intensity in the care for solid tumors; its use for evaluation of cellular therapies is less evidence-based. However, CGA can provide useful information on patients' fitness, resilient mechanisms, and reveal potential optimization strategies for compensating for vulnerabilities. In this narrative review, we will discuss key questions on cellular therapies in older adults based on illustrative patient cases.
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Affiliation(s)
- Nina Rosa Neuendorff
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany.
| | - Abdullah Khan
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
| | - Fabian Ullrich
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany
| | - Samuel Yates
- Department of Internal Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, United States of America
| | - Srinivas Devarakonda
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
| | - Richard J Lin
- Adult Bone Marrow Transplantation (BMT) Service, Cellular Therapy Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Bastian von Tresckow
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany
| | - Raul Cordoba
- Lymphoma Unit, Department of Hematology, Health Research Institute IIS-FJD, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
| | - Andrew Artz
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Ashley E Rosko
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
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Jantunen E, Partanen A, Turunen A, Varmavuo V, Silvennoinen R. Mobilization Strategies in Myeloma Patients Intended for Autologous Hematopoietic Cell Transplantation. Transfus Med Hemother 2023; 50:438-447. [PMID: 37899993 PMCID: PMC10603622 DOI: 10.1159/000531940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 06/21/2023] [Indexed: 10/31/2023] Open
Abstract
Background Multiple myeloma is currently the leading indication for autologous hematopoietic cell transplantation (AHCT). A prerequisite for AHCT is mobilization and collection of adequate blood graft to support high-dose therapy. Current mobilization strategies include granulocyte colony-stimulating factor (G-CSF) alone or in combination with chemotherapy most commonly cyclophosphamide (CY). More recently, plerixafor has become into agenda especially in patients who mobilize poorly. In the selection of a mobilization method, several factors should be considered. Summary Preplanned collection target is important as G-CSF plus plerixafor is more effective in the mobilization of CD34+ cells than G-CSF alone. On the other hand, CY plus G-CSF is superior to G-CSF only mobilization. Previous therapy and age of the patients are important considerations as G-CSF alone may not be effective enough in patients with risk factors for poor mobilization. These factors include extensive lenalidomide exposure, irradiation to bone marrow-bearing sites, higher age, or a previous mobilization failure. Also, local preferences and experiences as well as the number of apheresis needed are important issues as well as cost-effectiveness considerations. Mobilization method used may have implication for cellular composition of collected grafts, which might have an impact on posttransplant events such as hematologic and immune recovery in addition to also potential long-term outcomes. Key Message Currently, G-CSF alone and preemptive plerixafor if needed might be considered as a standard mobilization strategy in MM patients intended for AHCT.
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Affiliation(s)
- Esa Jantunen
- Institute of Clinical Medicine/Internal Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Anu Partanen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Antti Turunen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Ville Varmavuo
- Department of Medicine, Kymenlaakso Central Hospital, Kotka, Finland
| | - Raija Silvennoinen
- Department of Hematology, Comprehensive Cancer Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Hussain M, Yellapragada S, Al Hadidi S. Differential Diagnosis and Therapeutic Advances in Multiple Myeloma: A Review Article. Blood Lymphat Cancer 2023; 13:33-57. [PMID: 37731771 PMCID: PMC10508231 DOI: 10.2147/blctt.s272703] [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: 06/15/2023] [Accepted: 09/07/2023] [Indexed: 09/22/2023]
Abstract
Multiple myeloma (MM) is a hematologic malignancy characterized by the abnormal clonal proliferation of plasma cells that may result in focal bone lesions, renal failure, anemia, and/or hypercalcemia. Recently, the diagnosis and treatment of MM have evolved due to a better understanding of disease pathophysiology, improved risk stratification, and new treatments. The incorporation of new drugs, including proteasome inhibitors, immunomodulatory drugs, anti-CD38 antibodies and high-dose chemotherapy followed by hematopoietic stem cell transplantation, has resulted in a significant improvement in patient outcomes and QoL. In this review, we summarize differential diagnoses and therapeutic advances in MM.
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Affiliation(s)
- Munawwar Hussain
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sarvari Yellapragada
- Michael E. DeBakey VA Medical Center and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Samer Al Hadidi
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Lin CM, Chang LC, Shau WY, Chen CL, Yao CY, Tien FM. Treatment benefit of upfront autologous stem cell transplantation for newly diagnosed multiple myeloma: a systematic review and meta-analysis. BMC Cancer 2023; 23:446. [PMID: 37193978 DOI: 10.1186/s12885-023-10907-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/30/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Upfront high-dose therapy (HDT) followed by autologous stem cell transplantation (ASCT) remains a profitable strategy for newly diagnosed multiple myeloma (MM) patients in the context of novel agents. However, current knowledge demonstrates a discrepancy between progression-free survival (PFS) and overall survival (OS) benefit with HDT/ASCT. METHODS We conducted a systematic review and meta-analysis that included both randomized controlled trials (RCTs) and observational studies evaluating the benefit of upfront HDT/ASCT published during 2012 to 2023. Further sensitivity analysis and meta-regression were also performed. RESULTS Among the 22 enrolled studies, 7 RCTs and 9 observational studies had a low or moderate risk of bias, while the remaining 6 observational studies had a serious risk of bias. HDT/ASCT revealed advantages in complete response (CR) with an odds ratio (OR) of 1.24 and 95% confidence interval (CI) 1.02 ~ 1.51, PFS with a hazard ratio (HR) of 0.53 (95% CI 0.46 ~ 0.62), and OS with an HR of 0.58 (95% CI 0.50 ~ 0.69). Sensitivity analysis excluding the studies with serious risk of bias and trim-and-fill imputation fundamentally confirmed these findings. Older age, increased percentage of patients with International Staging System (ISS) stage III or high-risk genetic features, decreased proteasome inhibitor (PI) or combined PI/ immunomodulatory drugs (IMiD) utilization, and decreased follow-up duration or percentage of males were significantly related to a greater survival advantage with HDT/ASCT. CONCLUSIONS Upfront ASCT remains a beneficial treatment for newly diagnosed MM patients in the period of novel agents. Its advantage is especially acute in high-risk MM populations, such as elderly individuals, males, those with ISS stage III or high-risk genetic features, but is attenuated with PI or combined PI/IMiD utilization, contributing to divergent survival outcomes.
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Affiliation(s)
- Chi-Maw Lin
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Otolaryngology, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan
| | - Lih-Chyun Chang
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Division of Hospital Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Yi Shau
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chi-Ling Chen
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chi-Yuan Yao
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100225, Taiwan
| | - Feng-Ming Tien
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City, 100225, Taiwan.
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Sato S, Tsunoda S, Kawahigashi T, Kamata W, Tamai Y. Clinical significance of high-dose chemotherapy with autologous stem cell transplantation in the era of novel agents in patients older than 65 years with multiple myeloma. Ann Hematol 2023; 102:1185-1191. [PMID: 36951968 PMCID: PMC10102120 DOI: 10.1007/s00277-023-05177-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 03/11/2023] [Indexed: 03/24/2023]
Abstract
High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is the standard treatment for symptomatic multiple myeloma (MM) in patients under 65 years of age. However, the performing of ASCT in older patients > 65 years without comorbidities or complications is controversial. Introduction of novel drugs, such as daratumumab, has improved the long-term survival of patients with MM who are ineligible for ASCT. This retrospective study aimed to evaluate the clinical significance of ASCT in older patients, even in the era of novel drugs. A total of 55 patients aged 65-74 years (15 ASCT recipients and 40 ASCT-ineligible patients) newly diagnosed with MM between March 2013 and October 2021 at our institution were analyzed in this study. There were no significant differences in the 3-year overall survival (84.6% vs. 90.6%, p = 0.72) and progression-free survival (PFS) (61.2% vs. 75.1%, p = 0.40) between ASCT recipients and ASCT-ineligible patients. There was also no significant difference in complete response (CR) with minimal residual disease (MRD)-negative rate between the two groups (27% vs. 33%, p = 1.0). Multivariate analysis showed that CR was an independent predictor of PFS (hazard ratio [HR], 0.26; 95% confidence interval, 0.08-0.76; p = 0.01). In this retrospective study, despite patients who were determined to be intolerant to ASCT, the non-ASCT group was non-inferior to the ASCT group in PFS and overall response rate. The results of this study confirm that the significance of ASCT is diminishing in patients 65 years of age and older because newer agents can achieve good responses without ASCT.
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Affiliation(s)
- Shuku Sato
- Division of Hematology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-0072, Japan.
| | - Shun Tsunoda
- Division of Hematology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-0072, Japan
| | - Teiko Kawahigashi
- Division of Hematology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-0072, Japan
| | - Wataru Kamata
- Division of Hematology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-0072, Japan
| | - Yotaro Tamai
- Division of Hematology, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-0072, Japan
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Rago A, Annibali O, Tomarchio V, Coppetelli U, Fazio F, Cupelli L, Fiorini A, Piciocchi A, Tafuri A, Caravita di Toritto T. Autologous stem cell transplantation in multiple myeloma patients over 70 years: A GIMEMA Lazio Working Group experience in a retrospective case-control study. Eur J Haematol Suppl 2022; 109:250-256. [PMID: 35617025 DOI: 10.1111/ejh.13804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 11/27/2022]
Abstract
High-dose chemotherapy followed by autologous stem cell transplantation (auto-SCT) is the standard treatment for young patient ≤65 years with multiple myeloma (MM). The role of auto-SCT in elderly patients older than 70 years remains controversial in the era of novel agents and especially since the recent introduction of monoclonal antibodies (AbMo). In this study, we evaluated 12 patients with MM over 70 years old undergoing auto-SCT (elderly graft cohort) in seven centers of GIMEMA Working Group Lazio. We compared the baseline characteristics, treatment and outcome with 97 MM elderly patients who did not receive auto-SCT (nontransplant patients) from the same registry who were ≥ 70 years old, but did not undergo auto-SCT. The median progression free survival (PFS) for graft versus no-graft cohort was 56.4 versus 26.1 months, respectively. There was a trend for better PFS among graft compared to nontransplant patient (p = .1). On the other hand, the median overall survival for transplant versus nontransplant cohort was 107.6 versus 49.5 months (p = .02). Despite the small number of patients aged ≥70 years and ≤74 years, it seems that auto-SCT is well tolerated, safe and effective. Therefore, we propose that it should be considered an important treatment option in the era of new drugs in elderly fit patients with MM.
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Affiliation(s)
| | - Ombretta Annibali
- Area di Ematologia, Trapianto di Cellule Staminali, Fondazione Policlinico Campus Bio Medico, Roma, Italy
| | - Valeria Tomarchio
- Area di Ematologia, Trapianto di Cellule Staminali, Fondazione Policlinico Campus Bio Medico, Roma, Italy
| | | | - Francesca Fazio
- Dipartimento di Medicina Traslazionale e di Precisione - Ematologia, Università Sapienza di Roma, Roma, Italy
| | - Luca Cupelli
- Ospedale Sant'Eugenio, UOC Ematologia, Rome, Italy
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Pawlyn C, Cairns D, Menzies T, Jones J, Jenner M, Cook G, Boyd K, Drayson M, Kaiser M, Owen R, Gregory W, Morgan G, Jackson G, Davies F. Autologous stem cell transplantation is safe and effective for fit older myeloma patients: exploratory results from the Myeloma XI trial. Haematologica 2022; 107:231-242. [PMID: 33297668 PMCID: PMC8719065 DOI: 10.3324/haematol.2020.262360] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 11/25/2020] [Indexed: 12/03/2022] Open
Abstract
Autologous stem cell transplant (ASCT) remains standard of care for consolidation after induction therapy for eligible newly diagnosed myeloma patients. In recent clinical trials comparing ASCT to delayed ASCT, patients aged over 65 were excluded. In real-world practice stem cell transplants are not restricted to those aged under 65 and clinicians decide on transplant eligibility based on patient fitness rather than a strict age cut off. Data from the UK NCRI Myeloma XI trial, a large phase III randomised controlled trial with pathways for transplant-eligible (TE) and ineligible (TNE) patients, was used in an exploratory analysis to examine the efficacy and toxicity of ASCT in older patients including analysis using an agematched population to compare outcomes for patients receiving similar induction therapy with or without ASCT. Older patients within the TE pathway were less likely to undergo stem cell harvest at the end of induction than younger patients and of those patients undergoing ASCT there was a reduction in PFS associated with increasing age. ASCT in older patients was well tolerated with no difference in morbidity or mortality between patients aged.
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Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London.
| | - David Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - Tom Menzies
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - John Jones
- Kings Hospital NHS Foundation Trust, London
| | - Matthew Jenner
- University Hospital Southampton NHS Foundation Trust, Southampton
| | - Gordon Cook
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK; Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds
| | | | - Mark Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham
| | - Martin Kaiser
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London
| | - Roger Owen
- HMDS, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds
| | - Walter Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | | | - Graham Jackson
- Department of Haematology, Newcastle University, Newcastle
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Joseph NS, Gupta VA, Wyman S, Graiser M, Kaufman JL, Almaula D, Andrews J, Hofmeister C, Dhodapkar M, Heffner LT, Lonial S, Nooka AK. Benefits of Autologous Stem Cell Transplantation for Elderly Myeloma Patients in the Last Quarter of Life. Transplant Cell Ther 2021; 28:75.e1-75.e7. [PMID: 34626863 DOI: 10.1016/j.jtct.2021.09.024] [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: 06/28/2021] [Revised: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022]
Abstract
Although survival outcomes have improved dramatically over the last few decades in newly diagnosed myeloma patients, elderly patients have not yielded the same magnitude of benefit as evidenced by higher rates of reported myeloma-related deaths in patients over the age of 75. This is of particular importance given this cohort comprises a large proportion of myeloma patients with the median age of diagnosis being 70 years. One contributor to this discrepancy is reduced use of high-dose therapy and autologous stem cell transplantation (HDT/ASCT) in this population because of concerns for increased toxicity and safety. The objective of this retrospective analysis is to evaluate survival and safety outcomes in 53 newly diagnosed patients ≥74 years of age who underwent HDT/ASCT at our institution in comparison to 122 control patients in the same age bracket who did not undergo stem cell transplantation during this same time period. Patients treated at our institution were identified in our institutional myeloma database by age. They were all treated between November 2006 and October 2016 at the Winship Cancer Institute of Emory University. Fifty-three patients were identified who had undergone HDT/ASCT, and, to assess the relative benefit of ASCT, 122 control patients in the same age range were also identified who did not undergo HDT/ASCT during the same time period. The median age for the entire cohort was 77 years (74 years in the ASCT group versus 78 in the non-ASCT group). Median time to ASCT was 6 months (range 2-57 months). There were no gender or race differences between the 2 groups, although a higher proportion of high-risk patients underwent HDT/ASCT. Ninety-three percent of ASCT patients received triplet induction therapy with a proteasome inhibitor and immunomodulatory agent backbone in comparison to only 55% of patients the non-ASCT group. The median progression-free survival (PFS) for the ASCT group was 50 months versus 30 months in the non-ASCT group. The median overall survival (OS) was 80 months versus 40 months, respectively. In high-risk patients, the median PFS was 60.8 months, and the median OS was 77.8 months in the ASCT group compared to 26 months and 38 months in the non-ASCT group, respectively. There were no transplant-related deaths within the first 100 days in the ASCT group. This study offers real-world perspective and data on the safety and survival benefit of ASCT in the elderly population with a near doubling of OS when compared to those treated with similar regimens and modern agents without ASCT. These data provide a rationale for offering ASCT in elderly patients pending a thorough pretransplantation evaluation.
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Affiliation(s)
- Nisha S Joseph
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Vikas A Gupta
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Sarah Wyman
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Michael Graiser
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan L Kaufman
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Dhwani Almaula
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Joel Andrews
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Craig Hofmeister
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Madhav Dhodapkar
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Leonard T Heffner
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia
| | - Ajay K Nooka
- Department of Hematology and Medical Oncology, Emory University School of Medicine Emory University School of Medicine, Atlanta, Georgia.
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Devarakonda S, Efebera Y, Sharma N. Role of Stem Cell Transplantation in Multiple Myeloma. Cancers (Basel) 2021; 13:863. [PMID: 33670709 PMCID: PMC7922596 DOI: 10.3390/cancers13040863] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/09/2021] [Accepted: 02/12/2021] [Indexed: 12/11/2022] Open
Abstract
Autologous stem cell transplantation (auto-SCT) has been the standard of care in eligible newly diagnosed multiple myeloma (MM) patients. Outcomes of patients with MM have improved significantly due to the advent of several novel drugs. Upfront use of these drugs in induction therapy has significantly increased the rate and depth of responses that have translated into longer remission and survival. This has now raised a debate regarding the role and relevance of auto-SCT in the management of myeloma. However, clinical trials have confirmed the utility of auto-SCT even in the era of novel drugs. Tandem auto-SCT followed by maintenance has shown a progression-free survival (PFS) benefit in high-risk MM, and hence can be considered in young and fit patients with high-risk disease. Auto-SCT has the advantages of resetting the bone marrow microenvironment, short-lived toxicity compared to the long-term physical and financial toxicities of continued chemotherapy in the absence of SCT, very low transplant-related mortality (TRM) in high volume centers, and providing longer disease-free survival when followed by maintenance therapy. Allogeneic SCT is one potentially curative option for MM, albeit with an increased risk of death due to high TRM. Strategies to modulate the graft-versus-host disease (GVHD) while maintaining or improving the graft-versus-myeloma (GVM) effect could place allogeneic SCT back in the treatment armamentarium of MM.
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Affiliation(s)
| | - Yvonne Efebera
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center Columbus, Columbus, OH 43210, USA; (S.D.); (N.S.)
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Outcomes with autologous stem cell transplant vs. non-transplant therapy in patients 70 years and older with multiple myeloma. Bone Marrow Transplant 2020; 56:368-375. [PMID: 32782351 DOI: 10.1038/s41409-020-01026-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 11/08/2022]
Abstract
We evaluated 79 patients with multiple myeloma (MM) ≥70 years referred to our blood and marrow transplant clinic, within 1 year of diagnosis from 2010 to 2019, for consideration of autologous stem cell transplant (ASCT). Thirty-eight (48%) of 79 patients underwent ASCT. ASCT was not pursued in 41 (52%) patients due to: patient or physician preference in 80% (n = 33) or ineligibility in 20% (n = 8). Baseline characteristics of patients in the two groups were similar. Median PFS from treatment start amongst patients undergoing ASCT (n = 38) vs. not (n = 41) was 41 months vs. 33 months, p = 0.03. There was no difference in OS, with estimated 5-year OS of 73% vs. 83%, respectively (p = 0.86). Day +100 transplant-related mortality (TRM) was 0%. ASCT was an independent favorable prognostic factor for PFS in multivariate analysis, after accounting for HCT-CI score, performance status, hematologic response, and maintenance. Finally, patients ≥70 years undergoing ASCT had similar PFS compared to a contemporaneous institutional cohort of patients <70 years (n = 631) (median PFS from transplant: 36 vs. 47 months, p = 0.25). In this retrospective analysis, ASCT was associated with low TRM and better PFS in fit older adults with MM compared to non-transplant therapy, with comparable benefits as seen in younger patients.
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Cordas Dos Santos DM, Saliba RM, Patel R, Bashir Q, Saini N, Hosing C, Kebriaei P, Khouri IF, Nieto Y, Popat U, Ahmed H, Lee HC, Manasanch EE, Patel KK, Thomas SK, Weber DM, Orlowski RZ, Champlin RE, Qazilbash MH. Age Is a Prognostic Factor for the Overall Survival of Patients with Multiple Myeloma Undergoing Upfront Autologous Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 26:1077-1083. [PMID: 31786242 DOI: 10.1016/j.bbmt.2019.11.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/29/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
Abstract
In this retrospective analysis, we evaluated the impact of age on the outcome of patients with multiple myeloma who received an autologous hematopoietic stem cell transplantation (auto-HCT) at our institution. A total of 1128 patients were divided into the older (>70 years; 182 [16%]) and the younger (≤70 years; 946 [84%]) groups. Compared with the younger cohort, older patients had a higher International Staging System (ISS) stage (ISS-II, 57 [31%] versus 215 [23%]; ISS-III, 52 [28%] versus 211 [22%]; P = .01), higher use of reduced-dose melphalan as a conditioning regimen (140 mg/m², 59 [32%] versus 29 [3%]; P < .001), and a higher comorbidity index (median, 3 versus 2; P = .01). Nonrelapse mortality at 1 year after auto-HCT was significantly higher in older patients (7 [4%] versus 9 [1%]; hazard ratio [HR], 4.1; P = .005). Complete remission rates after auto-HCT for the older and the younger groups were 41% and 46%, respectively. With a median follow-up of 52 months, the 5-year progression-free survival (PFS) was 24% (95% confidence interval [CI], 17% to 32%) and 37% (95% CI, 33% to 40%) in the older and younger groups, respectively (HR, 1.3; P = .02). Five-year OS for the older and younger groups was 56% (95% CI, 47% to 64%) and 73% (95% CI, 70% to 76%; P < .001), respectively. Older age emerged as one of the predictors of shorter OS but not PFS in the multivariate classification and regression tree analysis. In conclusion, age ≥70 years was associated with shorter PFS and OS in patients with multiple myeloma who underwent an auto-HCT.
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Affiliation(s)
- David M Cordas Dos Santos
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Medicine III, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Rima M Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Romil Patel
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Neeraj Saini
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Issa F Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Haris Ahmed
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hans C Lee
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elisabet E Manasanch
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Krina K Patel
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sheeba K Thomas
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Donna M Weber
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Robert Z Orlowski
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Muzaffar H Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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12
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Jayani R, Rosko A, Olin R, Artz A. Use of geriatric assessment in hematopoietic cell transplant. J Geriatr Oncol 2019; 11:225-236. [PMID: 31761694 DOI: 10.1016/j.jgo.2019.09.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/26/2019] [Accepted: 09/30/2019] [Indexed: 12/21/2022]
Abstract
Hematopoietic cell transplant (HCT) is an important aspect of treatment for many hematologic malignancies. As cancer is a disease associated with aging, and hematologic malignancies are no exception, rates of autologous and allogeneic HCT utilization in older adults are on the rise. The most common indications for autologous HCT are multiple myeloma and lymphoma, and for allogenic HCT are acute myeloid leukemia and myelodysplastic syndrome. Older adults into their eighth decade of life can have favorable outcomes after autologous and allogeneic HCT, at least among select patients. Evaluation of older adults prior to HCT can be aided by utilizing a geriatric assessment (GA). GA can identify areas of vulnerability in older adults prior to HCT not captured by more traditional measures. In the future, GA may be utilized to guide interventions prior to HCT to improve outcomes of older adults. Further studies are needed to expand the paucity of data in utilizing GA to identify three groups of patients: those who clearly benefit from HCT, those who would clearly be harmed, and those who might benefit but would require additional support during and after HCT.
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Affiliation(s)
- Reena Jayani
- Moffitt Cancer Center, Blood and Marrow Transplant and Cellular Immunotherapy Program, 12902 USF Magnolia Dr, Tampa, FL 33612, United States of America; Vanderbilt University Medical Center, Division of Hematology and Oncology, 2220 Pierce Ave, 777 Preston Research Building, Nashville, TN 37232-6307, United States of America.
| | - Ashley Rosko
- The Ohio State University, Department of Internal Medicine, Division of Hematology, 460 W 10th Ave, Columbus, OH 43210, United States of America.
| | - Rebecca Olin
- University of California San Francisco, Department of Medicine, Division of Hematology/Oncology, 400 Parnassus Ave., Fourth Floor, San Francisco, CA 94143, United States of America.
| | - Andrew Artz
- City of Hope, Department of Hematology and Hematopoietic Cell Transplantation, 1500 E. Duarte Road, Duarte, CA 91010, United States of America.
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13
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Mian H, Mian OS, Rochwerg B, Foley R, Wildes TM. Autologous stem cell transplant in older patients (age ≥ 65) with newly diagnosed multiple myeloma: A systematic review and meta-analysis. J Geriatr Oncol 2019; 11:93-99. [PMID: 31153809 DOI: 10.1016/j.jgo.2019.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/08/2019] [Accepted: 05/15/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE While autologous stem cell transplant (ASCT) is a standard of care for newly-diagnosed younger patients with multiple myeloma, its role in older patients remains controversial. We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) assessing the efficacy and toxicity of ASCT in older patients (age ≥ 65 years) with newly-diagnosed myeloma. METHODS We searched Medline, Embase, and the Cochrane database through February 2, 2018. The primary outcome was overall survival; secondary outcomes included progression-free survival, response rates and toxicity. The Grading of Recommendations Assessment, Development and Evaluation criteria (GRADE) method was used to assess certainty in evidence. RESULTS Of 8614 abstracts screened, six observational studies and two RCTs were included in the systematic review. For overall survival, pooled observational data favored ASCT (Hazard Ratio [HR] 0.44, 95% Confidence Interval [CI] 0.34-0.58, p < .0001), while the impact of the RCT data was uncertain (HR 0.94, 95% CI 0.25-3.54, p = .93). Observational data showed higher complete response rates with ASCT (odds ratio 5.06, 95% CI 2.60-9.88, p < .0001). Progression free survival benefit from the RCTs was uncertain (HR 1.05, 95% CI 0.36-3.12, p = .93). Data were insufficient to pool for toxicity. CONCLUSION For older patients with newly diagnosed multiple myeloma, ASCT may improve the overall survival and complete response rates based upon observational data although the quality of this evidence is very low. The role of ASCT in improving overall survival based upon RCT data remains uncertain with low quality of evidence. Our study highlights the urgent need for well-conducted studies to understand the role of ASCT in older patients.
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Affiliation(s)
- Hira Mian
- Juravinski Cancer Center, Department of Oncology, McMaster University, Hamilton, Canada.
| | - Owais S Mian
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Ronan Foley
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Tanya M Wildes
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States of America
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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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Huang LW, Wong SW, Andreadis C, Olin RL. Updates on Hematologic Malignancies in the Older Adult: Focus on Acute Myeloid Leukemia, Chronic Lymphocytic Leukemia, and Multiple Myeloma. Curr Oncol Rep 2019; 21:35. [PMID: 30848394 DOI: 10.1007/s11912-019-0778-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Hematologic malignancies are common and difficult to treat in older adults. In this review, we focus on recent updates in diseases with several novel agents relevant to older adults-acute myeloid leukemia (AML), chronic lymphocytic leukemia (CLL), and multiple myeloma (MM). RECENT FINDINGS In AML, CPX-351 offers a new induction chemotherapy for secondary AML that prolongs survival, and venetoclax and IDH inhibitors are efficacious and well tolerated. In CLL, chemoimmunotherapy is being replaced by monoclonal antibodies and small molecule inhibitors that are more effective and better tolerated. In MM, new immunomodulatory drugs, proteasome inhibitors, and monoclonal antibodies have expanded treatment options for older patients. The introduction of novel agents has dramatically shifted the landscape of therapeutic options for older adults with hematologic malignancies. Clinical trials in older adults are needed to expand treatment options for these patients.
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Affiliation(s)
- Li-Wen Huang
- Department of Medicine, Division of Hematology/Oncology, University of California San Francisco, 505 Parnassus Ave, Hematology/Oncology Office, M1286, San Francisco, CA, 94143, USA.
| | - Sandy W Wong
- Department of Medicine, Division of Hematology/Oncology, University of California San Francisco, 400 Parnassus Ave, Box 1270, San Francisco, CA, 94143, USA
| | - Charalambos Andreadis
- Department of Medicine, Division of Hematology/Oncology, University of California San Francisco, 400 Parnassus Ave, Box 0324, San Francisco, CA, 94143, USA
| | - Rebecca L Olin
- Department of Medicine, Division of Hematology/Oncology, University of California San Francisco, 400 Parnassus Ave, Box 0324, San Francisco, CA, 94143, USA
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Wildes TM, Tuchman SA, Klepin HD, Mikhael J, Trinkaus K, Stockerl-Goldstein K, Vij R, Colditz G. Geriatric Assessment in Older Adults with Multiple Myeloma. J Am Geriatr Soc 2018; 67:987-991. [PMID: 30548581 DOI: 10.1111/jgs.15715] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/01/2018] [Accepted: 11/07/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES The incidence of myeloma in older adults is increasing, yet little is known about geriatric impairments in these patients. We aimed to examine the prevalence of geriatric impairments in older adults with myeloma and the association between geriatric assessment and autologous stem cell transplant eligibility. DESIGN Prospective cohort study. SETTING Two academic medical centers. PARTICIPANTS A total of 40 adults 65 years and older with newly diagnosed myeloma were enrolled. MEASUREMENT Participants completed a primarily self-administered geriatric assessment, including measures of functional status, comorbidities, polypharmacy, psychosocial status, social support, quality of life, cognition, and physical performance. Outcomes were autologous stem cell transplant eligibility and receipt. RESULTS Forty patients enrolled; their mean age was 71 years. Geriatric impairments were common: 62% reported dependence in one or more instrumental activities of daily living (IADL), 76.9% had polypharmacy (four or more medications), and 47.5% had one or more comorbidities. Median time on the Timed Up and Go was 13.3 ± 4.9 seconds. Those considered candidates for autologous stem cell transplant (N = 26) were younger, with fewer comorbidities, better performance status, and faster performance on the Timed Up and Go test. Factors independently associated with receiving autologous stem cell transplant (N = 21) included age and IADL dependence. CONCLUSION Impairments in geriatric domains are common in this population, even among those considered to have a good performance status. Geriatric assessment domains are associated with both transplant eligibility and receipt. J Am Geriatr Soc 67:987-991, 2019.
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Affiliation(s)
- Tanya M Wildes
- Division of Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Sascha A Tuchman
- Division of Hematological Malignancies, Duke Cancer Institute, Durham, North Carolina.,Division of Hematology and Oncology, Lineberger Comprehensive Cancer Center at University of North Carolina-Chapel Hill, Chapel Hill, North Carolina
| | - Heidi D Klepin
- Section on Hematology and Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Joseph Mikhael
- Department of Medicine, Mayo Clinic, Phoenix, Arizona.,Chief Medical Officer, International Myeloma Foundation, Los Angeles, California
| | - Kathryn Trinkaus
- Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri
| | | | - Ravi Vij
- Division of Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Graham Colditz
- Division of Public Health Sciences, Washington University School of Medicine, St Louis, Missouri
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18
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Wildes TM, Anderson KC. Approach to the treatment of the older, unfit patient with myeloma from diagnosis to relapse: perspectives of a US hematologist and a geriatric hematologist. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:88-96. [PMID: 30504296 PMCID: PMC6245982 DOI: 10.1182/asheducation-2018.1.88] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Mrs. A. is a 73-year-old woman who has developed increasing fatigue and lower back pain over the past year. The pain limits her exercise tolerance such that she can now walk only 1 block. She is a retired schoolteacher who does volunteer efforts in her community but has limited her activities due to fatigue. Karnofsky performance status is 70%. She has a history of chronic hypertension treated with a diuretic, adult-onset diabetes mellitus treated with metformin, and hypothyroidism treated with levothyroxine. Initial evaluation reveals anemia, renal dysfunction, an elevated total protein, and an L2 compression fracture on lumbosacral radiographs. Results of initial and subsequent evaluation are shown below, and she is referred to a hematologist for further evaluation, which revealed the following: calcium 9.0 mg/dL, creatinine 3.2 mg/dL with estimated creatinine clearance using the Modification of Diet in Renal Disease equation of 15 mL/min, hemoglobin 9.6 g/dL, total protein 11 g/dL, albumin 3.2 g/dL, immunoglobulin A (IgA) λ M protein 6.8 g/dL, total IgA 7.2 g/dL, IgG 0.4g/dL, IgM 0.03 g/dL, free κ <0.01 mg/L, free λ 1000 mg/L, serum free light chain ratio <0.01, β-2-microglobulin 4.2, viscosity 3.0, lactate dehydrogenase 200 U/L, urine protein electrophoresis: 125 mg/dL with 30% M protein, and urine immunofixation: λ light chain. Skeletal bone survey showed lytic lesions in femurs and humeri and diffusely in ribs bilaterally as well as compression fractures at T4, T6, and L2. Bone marrow biopsy revealed λ-restricted plasma cells comprising 50% of the bone marrow core. Fluorescence in situ hybridization testing on marrow showed that del 17p was present in 80% of the plasma cells. Mrs. A. is informed of the diagnosis of multiple myeloma and the need for therapy. She requests consultation with 2 of the leading world experts. However, she wants to be treated near her home and does not want treatment on a clinical trial.
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Affiliation(s)
- Tanya M. Wildes
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO; and
| | - Kenneth C. Anderson
- Jerome Lipper Multiple Myeloma Center, LeBow Institute for Myeloma Therapeutics, Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Melphalan dose in myeloma patients ≥65 years of age undergoing high-dose therapy and autologous stem cell transplantation: a multicentric observational registry study. Bone Marrow Transplant 2018; 54:1029-1037. [PMID: 30390061 DOI: 10.1038/s41409-018-0379-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/24/2018] [Accepted: 10/14/2018] [Indexed: 11/09/2022]
Abstract
The optimal melphalan dose prior to autologous stem cell transplantation (ASCT) is not known for elderly multiple myeloma (MM) patients. We analyzed data of all MM patients ≥65 years (n = 388) enrolled in the observational Swiss Blood Stem Cell Transplantation Registry. The median age was 67 years (65-77). Single ASCT was performed in 344 (88.7%) patients, with 259 patients (75.3%) receiving a melphalan dose of 200 mg/m2 (MEL200), and 85 patients (24.7%) receiving lower doses (MELlow) (median 140 mg/m2, range 70-180 mg/m2). MEL200 patients were slightly younger, and had a better renal function, but did not differ with regards to ISS stage, cytogenetic risk, remission status, and KPS. Overall mortality at day 100 was 1.5% without differences between the MEL groups (p = 0.621). Median progression-free survival (PFS) in the MEL200 and the MELlow group was 27.7 and 22.1 months, respectively (p = 0.294). Median overall survival (OS) in the MEL200 and in MELlow group was 91.2 and 61.2 months (p = 0.015). However, multivariate analysis showed no significant association of the melphalan dose and OS (HR 0.734; CI95% 0.264-2.038; p = 0.553). In conclusion, our data reveal no significant differences in safety and PFS for elderly myeloma patients treated with MEL200 or with lower MEL doses.
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20
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Marini C, Maia T, Bergantim R, Pires J, Aguiar E, Guimarães JE, Trigo F. Real-life data on safety and efficacy of autologous stem cell transplantation in elderly patients with multiple myeloma. Ann Hematol 2018; 98:369-379. [PMID: 30368589 PMCID: PMC6342895 DOI: 10.1007/s00277-018-3528-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 10/17/2018] [Indexed: 12/22/2022]
Abstract
Autologous stem cell transplantation (ASCT) is still debatable in treatment of patients over 65 years with multiple myeloma (MM). We performed a retrospective analysis of newly diagnosed MM patients who underwent ASCT between January 2010 and July 2016. A non-transplanted group with similar clinical characteristics, aged 65-70 years old, diagnosed and treated in the same timeline was used for comparison. We analyzed a total of 155 patients, 132 of which underwent ASCT (≤ 65 years, n = 103, median 56 years; > 65 years, n = 29, median 67 years) and 23 non-transplanted (median 68 years). Conditioning consisted of melphalan 200 mg/m2 (MEL200) in younger patients and melphalan 140 mg/m2 (MEL140) in half of elderly patients. Stratifying by age, there were no statistically significant differences concerning transplant-related myelotoxicity and non-hematopoietic toxicity; however, elderly patients conditioned with MEL200 had higher needs of transfusional support and more days of intravenous antibiotics. Those patients also had higher needs of transfusional support, higher grade of mucositis (p = 0.028), and more days of intravenous antibiotics (p = 0.019) than the elderly transplanted with MEL140. Global transplant-related mortality was 3.8%. Survival was not influenced by age. Non-transplanted elderly patients had comparable disease features, and induction response was similar in both groups (before ASCT in the transplanted cohort). Survival of transplanted elderly patients was superior to non-transplanted (OS, 59 months vs 30 months, p = 0.037; EFS, 45 months vs 27 months, p = 0.014). Selected elderly patients when transplanted have similar disease response and survival as younger patients. A higher dose of melphalan has more toxicity, but it is globally a well-tolerated procedure.
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Affiliation(s)
| | - Tânia Maia
- Centro Hospitalar de São João, Porto, Portugal
| | - Rui Bergantim
- Centro Hospitalar de São João, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Jorge Pires
- Centro Hospitalar de São João, Porto, Portugal
| | | | - José Eduardo Guimarães
- Centro Hospitalar de São João, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Antlanger M, Dust T, Reiter T, Böhm A, Lamm WW, Gornicec M, Willenbacher E, Nachbaur D, Weger R, Rabitsch W, Rasoul-Rockenschaub S, Worel N, Lechner D, Greinix H, Keil F, Gisslinger H, Agis H, Krauth MT. Impact of renal impairment on outcomes after autologous stem cell transplantation in multiple myeloma: a multi-center, retrospective cohort study. BMC Cancer 2018; 18:1008. [PMID: 30342509 PMCID: PMC6195957 DOI: 10.1186/s12885-018-4926-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 10/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Renal impairment (RI) is a negative prognostic factor in Multiple Myeloma (MM) and affected patients are often excluded from autologous stem cell transplantation (ASCT). However, it remains unclear whether historically inferior outcome data still hold true. Methods From a total of 475 eligible MM patients who had undergone ASCT between 1998 and 2016, 374 were included in this multi-centric retrospective cohort study. Renal function was determined both at the time of MM diagnosis and ASCT by estimated glomerular filtration rate (eGFR according to the MDRD formula, RI defined as eGFR < 60 ml/min/1.73m2). Patients were categorized into 3 groups: A) no RI diagnosis and ASCT, B) RI at diagnosis with normalization before ASCT and C) RI both at the time of diagnosis and ASCT. Log-rank testing was used for overall and progression-free survival (OS, PFS) analysis. Conclusion While severe RI at MM diagnosis confers a risk of shorter OS, MM progression after ASCT is not affected by any stage of renal failure. It can be concluded that ASCT can be safely carried out in MM patients with mild to moderate RI and should be pro-actively considered in those with severe RI. Results When comparing all groups, no difference in OS and PFS was found (p = 0.319 and p = 0.904). After further stratification according to the degree of RI at the time of diagnosis, an OS disadvantage was detected for patients with an eGFR < 45 ml/min/m2. PFS was not affected by any RI stage. Electronic supplementary material The online version of this article (10.1186/s12885-018-4926-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marlies Antlanger
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Tobias Dust
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiter
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Alexandra Böhm
- Hanusch Hospital, 3rd Medical Department, Division of Hematology and Oncology, Vienna, Austria.,Elisabethinen Hospital, Department of Internal Medicine I, Division of Hematology and Oncology, Linz, Austria
| | - Wolfgang W Lamm
- Department of Internal Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Max Gornicec
- Department of Internal Medicine, Division of Hematology, Medical University of Graz, Graz, Austria
| | - Ella Willenbacher
- Medical University of Innsbruck, Internal Medicine V, Hematology and Oncology, Innsbruck, Austria
| | - David Nachbaur
- Medical University of Innsbruck, Internal Medicine V, Hematology and Oncology, Innsbruck, Austria
| | - Roman Weger
- Medical University of Innsbruck, Internal Medicine V, Hematology and Oncology, Innsbruck, Austria
| | - Werner Rabitsch
- Department of Internal Medicine I, Bone Marrow Transplantation Unit, Medical University of Vienna, Vienna, Austria
| | - Susanne Rasoul-Rockenschaub
- Medical University of Vienna, Center for Medical Statistics, Informatics and Intelligent Systems (CeMSIIS), Vienna, Austria
| | - Nina Worel
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Lechner
- Elisabethinen Hospital, Department of Internal Medicine I, Division of Hematology and Oncology, Linz, Austria
| | - Hildegard Greinix
- Department of Internal Medicine, Division of Hematology, Medical University of Graz, Graz, Austria
| | - Felix Keil
- Hanusch Hospital, 3rd Medical Department, Division of Hematology and Oncology, Vienna, Austria
| | - Heinz Gisslinger
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Hermine Agis
- Department of Internal Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Maria-Theresa Krauth
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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Pawlyn C, Gay F, Larocca A, Roy V, Ailawadhi S. Nuances in the Management of Older People With Multiple Myeloma. Curr Hematol Malig Rep 2017; 11:241-51. [PMID: 27038805 DOI: 10.1007/s11899-016-0323-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Multiple myeloma is a disease of the elderly, with about a third of patients at diagnosis older than 75 years of age. Yet, the population of elderly patients is heterogeneous: older patients are more likely to have comorbidities and frailties complicating both their initial diagnosis and subsequent management, but these are not consistent across the group. Furthermore, patients with comorbidities and frailty are generally underrepresented in clinical trials. Despite the survival of myeloma patients increasing following the introduction of novel agents, older patients continue to have worse outcomes with increased treatment-related toxicity. Treatment tolerability is not defined by age alone, rather a combination of age, physical function, cognitive function, and comorbidities. These factors all influence patients' tolerability of treatment and therefore treatment efficacy and should also be considered when reviewing the results of clinical trials. It is the nuances of determining how these factors interact that should influence initial treatment and ongoing management decisions and these will be discussed here.
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Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, 15, Cotswold Rd, Sutton, Surrey, SM2 5NG, UK.,The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Francesca Gay
- Dipartimento di Oncologia ed Ematologia, SC Ematologia 1, A.O. Citta' della Salute e della Scienza di Torino, P.O. Molinette, C.so Bramante 88/90, 10126, Torino, Italy.,Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy
| | - Alessandra Larocca
- Dipartimento di Oncologia ed Ematologia, SC Ematologia 1, A.O. Citta' della Salute e della Scienza di Torino, P.O. Molinette, C.so Bramante 88/90, 10126, Torino, Italy.,Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy
| | - Vivek Roy
- Division of Hematology/Oncology, Department of Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Sikander Ailawadhi
- Division of Hematology/Oncology, Department of Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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23
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A phase 1 trial of 90Y-Zevalin radioimmunotherapy with autologous stem cell transplant for multiple myeloma. Bone Marrow Transplant 2017; 52:1372-1377. [PMID: 28869617 DOI: 10.1038/bmt.2017.164] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 06/01/2017] [Accepted: 06/18/2017] [Indexed: 12/20/2022]
Abstract
This phase 1 study (clinical trial NCT00477815) was conducted to determine the maximum tolerated dose (MTD) of yttrium-90 ibritumomab tiuxetan (90Y-Zevalin) with high dose melphalan (HDM) therapy in multiple myeloma (MM) patients undergoing autologous stem cell transplantation (ASCT). In a 3+3 trial design, 30 patients received rituximab 250 mg/m2 with indium-111 ibritumomab tiuxetan (111In-Zevalin) for dosimetry (day -22); rituximab 250 mg/m2 with escalating doses of 90Y-Zevalin (day -14); melphalan 100 mg/m2 (days -2,-1) followed by ASCT (day 0) and sargramostim (GM-CSF, day 0) until neutrophil engraftment. Each patient's 111In-Zevalin dosimetry data were used to calculate the dose of 90Y-Zevalin (in mCi) to deliver 10, 12, 14, 16, 18 or 20 Gy to the liver. Dose limiting toxicities were seen in 3 patients. The overall response rate was 73% (22/30) with stringent complete response in 2 patients; complete response, 5; very good partial response, 12; and partial response, 3. The median PFS was 16.5 months and the median overall survival was 63.4 months. In MM, the MTD of 90Y-Zevalin with HDM is 18 Gy to the liver. The addition of radiation with novel delivery methods such as radioimmunotherapy combined with standard transplant regimens warrants further study.
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24
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Abstract
Multiple myeloma (MM) is a plasma cell neoplasm that affects elderly individuals with two-thirds of patients over 65 years at diagnosis. However, data available are derived from clinical trials conducted in younger patients. Fewer studies investigated treatment options in the elderly. This review summarizes the clinical outcomes and toxicities associated with therapeutic regimens in older patients including doublet, triplet and high dose therapyin newly diagnosed patients and relapsed patients with MM. We highlight the importance of an approach tailored to individuals, incorporates the geriatric frailty assessment, considers comorbiditiess and commits to early recognition and management of toxicities ranging from myelosuppression to polypharmacy. To date, no trial has prospectively investigated a tailored treatment paradigm in older patients based on frailty and/or comorbidities. As the population ages, the proportion of MM patients with advanced age will grow. Studies are indicated to determine optimal treatment approaches in this increasingly heterogeneous geriatric population.
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Affiliation(s)
- Evan Diamond
- a Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Oscar B Lahoud
- a Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Heather Landau
- a Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
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25
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Sanchez L, Sylvester M, Parrondo R, Mariotti V, Eloy JA, Chang VT. In-Hospital Mortality and Post-Transplantation Complications in Elderly Multiple Myeloma Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation: A Population-Based Study. Biol Blood Marrow Transplant 2017; 23:1203-1207. [PMID: 28286198 DOI: 10.1016/j.bbmt.2017.03.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 03/07/2017] [Indexed: 10/20/2022]
Abstract
Autologous hematopoietic stem cell transplantation (auto-HSCT) has improved survival in patients with multiple myeloma (MM) and is increasingly used in elderly patients. The aim of this study was to characterize and compare in-hospital complications and mortality after auto-HSCT in younger (< age 65) versus elderly (> age 65) MM patients utilizing the Nationwide Inpatient Sample. Over a 3-year period (2008 to 2010), 2209 patients with MM were admitted to US hospitals for auto-HSCT. The median age was 59 years, with 1650 patients (74.7%) younger than age 65 and 559 patients (25.3%) 65 or older. Overall, in-hospital mortality in MM patients after auto-HSCT was rare (1.5%) and there was no significant difference in mortality between elderly and younger patients. Elderly patients did have a significantly increased mean length of stay (18.6 days + 10.8 days [SD] versus 16.8 days + 7.2 days [SD], P < .001) and mean total hospital charges ($161,117 + $105,008 [SD] versus $151,192 + $78,342 [SD] , P = .018) compared with younger patients. Elderly patients were significantly more likely than younger patients to develop major in-hospital post-transplantation complications such as severe sepsis (odds ratio [OR], 2.70; 95% confidence interval [CI], 1.40 to 5.21; P = .003), septic shock (OR, 3.10; 95% CI, 1.43 to 6.71; P = .004), pneumonia (OR, 1.62; 95% CI, 1.06 to 2.46; P = .024), acute respiratory failure (OR, 3.44; 95% CI, 1.70 to 6.96; P = .001), endotracheal intubation requiring prolonged mechanical ventilation (OR, 2.19; 95% CI, 1.06 to 4.55; P = .035), acute renal failure (OR, 2.14; 95% CI, 1.38 to 3.33; P = .001), and cardiac arrhythmias (OR, 2.06; 95% CI, 1.52 to 2.79; P <.001). These data may help guide informed consent discussions and provide a focus for future studies to reduce treatment-related morbidity in elderly MM patients undergoing auto-HSCT.
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Affiliation(s)
- Larysa Sanchez
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, New Jersey.
| | - Michael Sylvester
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ricardo Parrondo
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Veronica Mariotti
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Jean Anderson Eloy
- Department of Otolaryngology, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Victor T Chang
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, New Jersey; Section of Hematology-Oncology, VA New Jersey Health Care System, East Orange, New Jersey
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26
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Reprint of: Aging: Treating the Older Patient. Biol Blood Marrow Transplant 2017; 23:S10-S17. [PMID: 28236837 DOI: 10.1016/j.bbmt.2017.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/04/2016] [Indexed: 12/23/2022]
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27
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Rosko A, Artz A. Aging: Treating the Older Patient. Biol Blood Marrow Transplant 2017; 23:193-200. [PMID: 27864162 PMCID: PMC5967228 DOI: 10.1016/j.bbmt.2016.11.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 11/04/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Ashley Rosko
- Department of Internal Medicine, Ohio State University, Columbus, Ohio
| | - Andrew Artz
- Department of Medicine, University of Chicago, Chicago, Illinois.
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28
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McCarthy PL, Holstein SA. Role of stem cell transplant and maintenance therapy in plasma cell disorders. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:504-511. [PMID: 27913522 PMCID: PMC6142442 DOI: 10.1182/asheducation-2016.1.504] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Autologous stem cell transplant (ASCT) has been an important component of therapy for myeloma patients eligible for high-dose chemotherapy. Recent studies comparing early transplant to low-dose chemotherapy support the continued use of ASCT as consolidation following induction therapy, even in the era of immunomodulatory drugs, proteasome inhibitors, and other novel agents. Despite the marked improvements in outcomes with this approach, most patients will eventually experience disease progression. Thus, inclusion of post-ASCT consolidation/maintenance strategies is used to improve long-term disease control. Multiple randomized studies support the use of lenalidomide maintenance therapy following ASCT. The next generation of clinical trials will incorporate novel agents such as monoclonal antibodies, proteasome inhibitors, and other novel pathway modulatory agents into post-ASCT treatment strategies with the goal of achieving even deeper responses and longer durations of disease control.
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Affiliation(s)
- Philip L. McCarthy
- Department of Medicine, Blood and Marrow Transplant Program, Roswell Park Cancer Institute, Buffalo, NY; and
| | - Sarah A. Holstein
- Department of Internal Medicine, Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, NE
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29
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Abstract
AbstractAutologous stem cell transplant (ASCT) has been an important component of therapy for myeloma patients eligible for high-dose chemotherapy. Recent studies comparing early transplant to low-dose chemotherapy support the continued use of ASCT as consolidation following induction therapy, even in the era of immunomodulatory drugs, proteasome inhibitors, and other novel agents. Despite the marked improvements in outcomes with this approach, most patients will eventually experience disease progression. Thus, inclusion of post-ASCT consolidation/maintenance strategies is used to improve long-term disease control. Multiple randomized studies support the use of lenalidomide maintenance therapy following ASCT. The next generation of clinical trials will incorporate novel agents such as monoclonal antibodies, proteasome inhibitors, and other novel pathway modulatory agents into post-ASCT treatment strategies with the goal of achieving even deeper responses and longer durations of disease control.
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30
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Garderet L, Beohou E, Caillot D, Stoppa AM, Touzeau C, Chretien ML, Karlin L, Moreau P, Fontan J, Blaise D, Polge E, Gueye MS, Ikhlef S, Marjanovic Z, Labopin M, Mohty M. Upfront autologous stem cell transplantation for newly diagnosed elderly multiple myeloma patients: a prospective multicenter study. Haematologica 2016; 101:1390-1397. [PMID: 27612987 DOI: 10.3324/haematol.2016.150334] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 09/06/2016] [Indexed: 11/09/2022] Open
Abstract
The feasibility and efficacy of high-dose melphalan followed by autologous hematopoietic stem cell transplantation in newly diagnosed elderly patients with multiple myeloma was analyzed prospectively. Fifty-six multiple myeloma patients, aged 65 years or over, from 6 French centers were studied. The induction therapy was bortezomib-based in combination with dexamethasone and either thalidomide, cyclophosphamide or lenalidomide, for 4-6 cycles. Peripheral blood stem cells were collected after high-dose cyclophosphamide plus G-CSF or G-CSF alone, with plerixafor if needed. The conditioning regimen consisted of melphalan at 140 mg/m2 in 18 patients (36%) and 200 mg/m2 in 32 (64%). Three months post autologous hematopoietic stem cell transplantation, a 2-month consolidation phase with either lenalidomide plus dexamethasone or bortezomib-based combination therapy was allowed, but maintenance treatment was not given. All but 6 patients underwent autologous hematopoietic stem cell transplantation and 3 had tandem transplantations. The treatment-related mortality was 0% at 100 days post transplantation. Sixty-eight percent received consolidation therapy following transplantation. The best response achieved was 40% complete response, 36% very good partial response, and 18% partial response. After a median follow up of 21 months (range 6-31), the estimated progression-free and overall survival rates at two years were 76% [95%CI: (61.6-94.1)] and 88% [95%CI: (76.7-100)], respectively. The higher dose of melphalan (200 mg/m2) afforded superior progression-free and overall survival rates. This prospective study provides evidence for the safety and efficacy of autologous hematopoietic stem cell transplantation as a first-line treatment approach in elderly multiple myeloma patients. (clinicaltrials.gov identifier: 01671826).
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Affiliation(s)
- Laurent Garderet
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, AP-HP, Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, Université Pierre et Marie Curie-Paris 6, Paris, France
| | | | | | - Anne Marie Stoppa
- Department of Hematology, Institut Paoli Calmettes, Marseille, Paris, France
| | - Cyrille Touzeau
- Department of hematology, University Hospital Hotel Dieu, Nantes, Paris, France
| | | | - Lionel Karlin
- Department of Hematology, CHU Lyon Sud, Pierre Bénite, Paris, France
| | - Philippe Moreau
- Department of hematology, University Hospital Hotel Dieu, Nantes, Paris, France
| | - Jean Fontan
- Department of Hematology, CHU Besançon, Paris, France
| | - Didier Blaise
- Department of Hematology, Institut Paoli Calmettes, Marseille, Paris, France
| | | | - Mor Seny Gueye
- Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, France
| | - Souhila Ikhlef
- Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, France
| | - Zora Marjanovic
- Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, France
| | | | - Mohamad Mohty
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, AP-HP, Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire, F-75012, Paris, Université Pierre et Marie Curie-Paris 6, Paris, France
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31
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Autologous stem cell transplant for multiple myeloma patients 70 years or older. Bone Marrow Transplant 2016; 51:1449-1455. [PMID: 27376447 DOI: 10.1038/bmt.2016.174] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/09/2016] [Accepted: 05/17/2016] [Indexed: 12/22/2022]
Abstract
Autologous stem cell transplant (Auto-SCT) is increasingly used in older patients with multiple myeloma (MM), despite lack of phase 3 trials in this age-defined population. For 207 consecutive MM patients who underwent Auto-SCT and were 70 years or older at transplant (study cohort), data were analyzed and compared with a younger cohort (1764 Auto-SCT patients <70 years old). The proportion of Auto-SCT in the older patients increased from 7.8% of all transplants in 1998-2006 to 12.9% in 2007-2015. Sixty percent of patients required stem cell mobilization with chemotherapy or plerixafor. Full-dose melphalan conditioning was given to 55% of the older patients compared with 93% of the younger patients (P<0.001). Older patients were more likely to be hospitalized (64% vs 55%; P=0.01), but hospitalization duration was comparable. For newly diagnosed patients, median PFS was 33.5 months for the older cohort and 33.8 months for the younger cohort (P=0.91), and median overall survival was 6.1 and 7.8 years, respectively (P=0.11). Presumably, a smaller fraction of patients, age 70-76, is selected for Auto-SCT, but the benefits are comparable to those seen for younger patients. Reduced-dose melphalan was given to approximately half the patients to avoid excessive toxicity.
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