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Manier S, Dimopoulos M, Hulin C, Leleu X, Delforge M, Weisel K, Mouro J, Costa B, Sturniolo M, Facon T. Predictors of Lenalidomide Refractory Relapse Timing With Newly Diagnosed Multiple Myeloma: A FIRST Trial Subanalysis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e297-e306.e1. [PMID: 37393121 DOI: 10.1016/j.clml.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/16/2023] [Accepted: 06/01/2023] [Indexed: 07/03/2023]
Abstract
INTRODUCTION/BACKGROUND Multiple myeloma (MM) is considered an incurable cancer. Patients with newly diagnosed MM (NDMM) are at risk for relapse within 1 year of frontline therapy. The immunomodulatory agent lenalidomide combined with dexamethasone (Rd) may be used as treatment for NDMM or relapsed MM, including in patients ineligible for autologous stem cell transplant. PATIENTS This subanalysis of the phase III FIRST trial characterized patients with transplant-ineligible NDMM who experienced relapse while receiving Rd therapy by relapse timing (early [<12 months] versus late [≥12 months]) and type (CRAB vs. non-CRAB). METHODS The Kaplan-Meier product limit method was used to estimate time-to-event endpoints, including progression-free survival (PFS) and overall survival (OS). Factors associated with the odds of late relapse were identified by logistic regression with univariate and multivariate analyses using a binary outcome (relapse at <12 vs. ≥12 months) in patient-, disease-, and treatment-specific baseline variables. RESULTS Patients with early refractory relapse had functionally high-risk disease and inferior outcomes. In patients with early relapse versus those with late relapse, median OS (95% CI) was 26.8 months (21.9-32.8) versus 63.9 months (57.0-78.0), median OS from disease progression to death was 19.9 months (16.0-25.5) versus 36.4 months (27.9-47.0), and median PFS from randomization to second progression was 19.1 months (17.3-22.5) versus 42.1 months (37.4-44.9). Lactate dehydrogenase, baseline β2 microglobulin, and myeloma subtype were shown to predict time to relapse. CONCLUSIONS Clinicians could use these factors to consider more aggressive treatment regimens for those at highest risk of early relapse.
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Affiliation(s)
- Salomon Manier
- Department of Hematology, Université de Lille, CHU Lille, Lille, France.
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece
| | - Cyrille Hulin
- Department of Hematology, Hôpital Haut Lévêque, University Hospital, Pessac, France
| | - Xavier Leleu
- Department of Hematology and Cellular Therapy, CIC U1402 CHU de Poitiers, Poitiers, France
| | | | - Katja Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation with Department of Pneumonology, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jorge Mouro
- Worldwide Medical Affairs, Celgene International Sàrl, a Bristol-Myers Squibb Company, Boudry, Switzerland
| | - Bruno Costa
- Worldwide Medical Affairs, Celgene International Sàrl, a Bristol-Myers Squibb Company, Boudry, Switzerland
| | - Michael Sturniolo
- Worldwide Medical Affairs, Celgene, a Bristol-Myers Squibb Company, Princeton, NJ
| | - Thierry Facon
- Department of Hematology, Université de Lille, CHU Lille, Lille, France
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de Arriba de la Fuente F, Montes Gaisán C, de la Rubia Comos J. How to Manage Patients with Lenalidomide-Refractory Multiple Myeloma. Cancers (Basel) 2022; 15:cancers15010155. [PMID: 36612152 PMCID: PMC9818178 DOI: 10.3390/cancers15010155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/20/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Although lenalidomide-based combinations, such as lenalidomide plus a proteasome inhibitor or an anti-CD38 monoclonal antibody, improve the overall response rate, progression-free survival, and overall survival of patients with relapsed/refractory multiple myeloma (RRMM), there is a tendency to use these regimens as a frontline treatment. This strategy has led to the development of refractoriness early in the disease course, usually after the patient's first treatment. Since lenalidomide-free regimens have so far shown limited efficacy in lenalidomide-refractory patients, there is an unmet need for other treatment options. In this review, we discuss the therapeutic options available to treat the general population of lenalidomide-refractory patients (mono, double and triple refractory) and the subpopulation of patients with other high-risk features such as renal failure, extramedullary disease, and high-risk cytogenetics. Moreover, new promising individual therapies and the possible impact of immunotherapy in RRMM patients are debated.
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Affiliation(s)
- Felipe de Arriba de la Fuente
- Haematology and Medical Oncology Department, Hospital General Universitario Morales Meseguer, Instituto Murciano de Investigación Biomédica (IMIB)-Arrixaca, Universidad de Murcia, 30008 Murcia, Spain
| | - Carmen Montes Gaisán
- Haematology Department, Hospital Universitario Marqués de Valdecilla, 39008 Cantabria, Spain
| | - Javier de la Rubia Comos
- Haematology Department, Hospital Universitario y Politécnico La Fe and Universidad Católica “San Vicente Mártir”, CIBERONC CB16/12/00284, 46001 Valencia, Spain
- Correspondence:
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Bao L, Liu A, Chu B, Wang Q, Dong Y, Lu M, Shi L, Gao S, Wang Y, Wang L, Chen W, Zhuang J. Front-line treatment efficacy and clinical outcomes of elderly patients with multiple myeloma in a real-world setting: A multicenter retrospective study in China. Cancer Med 2022; 12:3101-3111. [PMID: 36271592 PMCID: PMC9939119 DOI: 10.1002/cam4.5234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/12/2022] [Accepted: 08/23/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The use of proteasome inhibitors (PIs), new immune modulators (IMiDs), and other new drugs, as well as high-dose chemotherapy combined with autologous stem cell transplantation has considerably improved the survival of young patients with multiple myeloma (MM). However, the improvement in survival among elderly patients remains insufficient. Optimal treatment recommendation models for elderly patients with MM have not been developed especially there are quite few study in the real world. METHODS We retrospectively analyzed the treatment patterns and outcomes of 328 Chinese patients (≥65 years) with MM in a real-world setting. Patients were divided into three groups according to induction regimens. RESULTS The median age of the cohort was 70 (65-86) years. The patients were divided into group 1 (PIs based regimens, n = 218), group 2 (IMiDs based regimens, n = 48) and group 3 (PIs + IMiDs, n = 62). Induction regimens in group 3 produced higher overall response rate than group 1 and 2 (85.42% vs. 71.08% vs. 66.67%, p = 0.016). The median follow-up of the cohort was 30 (interquartile range [IQR] 18-36) months. For the entire cohort median progression-free survival (PFS) was 26 (IQR 12.00-42.89) months and overall survival (OS) was 60 (IQR 40.00-67.20) months. The PFS were not significantly different among the three groups (28 months vs. 18 months vs. 26 months, p = 0.182). So were the OS (60 months vs. 59 months vs. not reached, p = 0.067). Multivariate analysis revealed that age >70 year, frailty status (Geriatric vulnerability score), induction efficacy < partial remission, and no maintenance treatment were independent poor prognostic factors for OS. CONCLUSION Front-line induction regimens combining PIs and IMiDs developed more deep response than single PI or IMiD based regimens. Maintenance treatment can further improve the clinical outcome in elderly MM patients in real-world setting.
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Affiliation(s)
- Li Bao
- Department of HematologyBeijing Jishuitan HospitalBeijingChina
| | - Ai‐Jun Liu
- Department of HematologyBeijing Chaoyang HospitalBeijingChina
| | - Bin Chu
- Department of HematologyBeijing Jishuitan HospitalBeijingChina
| | - Qian Wang
- Department of HematologyPeking University First HospitalBeijingChina
| | - Yu‐Jun Dong
- Department of HematologyPeking University First HospitalBeijingChina
| | - Min‐Qiu Lu
- Department of HematologyBeijing Jishuitan HospitalBeijingChina
| | - Lei Shi
- Department of HematologyBeijing Jishuitan HospitalBeijingChina
| | - Shan Gao
- Department of HematologyBeijing Jishuitan HospitalBeijingChina
| | - Yu‐Tong Wang
- Department of HematologyBeijing Jishuitan HospitalBeijingChina
| | - Li‐Fang Wang
- Department of Epidemiology and StatisticsBeijing Jishuitan HospitalBeijingChina
| | - Wen‐Ming Chen
- Department of HematologyBeijing Chaoyang HospitalBeijingChina
| | - Jun‐Ling Zhuang
- Department of HematologyPeking Union Medical College HospitalBeijingChina
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Kocaata Z, Wilke T, Fischer F, Welte R, Einsele H. Healthcare Resource Utilization and Cost of Patients with Multiple Myeloma in Germany: A Retrospective Claims Data Analysis. PHARMACOECONOMICS - OPEN 2022; 6:619-628. [PMID: 35750956 PMCID: PMC9283612 DOI: 10.1007/s41669-022-00344-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This study aimed to analyze the healthcare resource use (HCRU) and associated costs of multiple myeloma (MM) using German claims data. METHODS Anonymized claims data from one of the largest sickness funds in Germany were analyzed. Costs and HCRU were calculated from the perspective of the statutory health insurance. To analyze MM-associated incremental costs in a most recent calendar period for an overall MM population (31 March 2018-31 March 2019), a prevalent cohort of MM patients (continuously insured during 01 January 2010 until 31 March 2019 or death; two or more outpatient and/or one inpatient MM diagnoses [ICD-10: C90.0-] and alive on 31 March 2018) was compared with a control group (not diagnosed with MM) employing propensity-score matching. Additionally, to describe MM-associated HCRU and costs for treated patients per line of treatment (lot), a cohort of newly treated patients was considered (≥ 12 months' pre-index period without MM treatment). Therapy lines were determined based on observed days of medication supply, treatment switches, and treatment discontinuations. RESULTS Overall, 2523 prevalent MM patients (52.0% female, mean age: 71.3 years) and 1673 newly treated MM patients (50.2% female, mean age: 73.0 years) met the selection criteria and were included in the analyses. After matching, a non-MM counterpart could be identified for 2474 prevalent out of 2523 MM patients. MM-associated incremental HCRU was characterized by an increased number of hospitalizations and a higher number of outpatient specialist visits (per patient-year [ppy] 0.48 additional hospitalizations and 3.80 additional specialist visits; p < 0.001), being also drivers of the associated total incremental add-on costs (15,381.09 € ppy, p < 0.001). Among newly treated patients, total direct costs ppy increased as patients received subsequent treatments (1st lot: 67,681,55 €; 4th lot+: 114,934.01 €), driven by outpatient MM prescriptions (1st lot: 28,692.32 €; 4th lot+: 62,980.72 €). CONCLUSION The economic burden of MM is driven by outpatient prescriptions, inpatient hospitalizations, and outpatient specialist visits. Treatment and overall costs increase substantially when patients move to later lines of treatment.
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Affiliation(s)
- Zeki Kocaata
- Ingress-Health HWM GmbH, Wismar, Germany
- GlaxoSmithKline GmbH & Co. KG, Munich, Germany
| | | | | | | | - Hermann Einsele
- Medizinische Klinik und Poliklinik II des Universitätsklinikums, Zentrum Innere Medizin, Würzburg, Germany
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Improving outcomes for patients with relapsed multiple myeloma: Challenges and considerations of current and emerging treatment options. Blood Rev 2021; 49:100808. [PMID: 33863601 DOI: 10.1016/j.blre.2021.100808] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/22/2020] [Accepted: 01/29/2021] [Indexed: 01/23/2023]
Abstract
Despite the recent introduction of new therapies for multiple myeloma (MM), it remains an incurable disease. As MM progresses, patients experience cycles of relapse and remission, with remission periods becoming increasingly shorter as the disease becomes less treatment-sensitive. The treatment of relapsed refractory MM (RRMM) remains a significant clinical challenge. Patients with RRMM are a highly heterogeneous group and choosing the most appropriate treatment requires careful consideration. Furthermore, the number of treatment options for MM is continually growing with no definitive consensus to guide treating clinicians. The emergence of second-generation proteasome inhibitors (e.g., carfilzomib and ixazomib), immunomodulatory drugs (e.g., pomalidomide) and monoclonal antibodies (e.g., isatuximab) has expanded an already complex treatment landscape. This review provides a clear summary of the available treatments for MM and discusses how to tailor treatments to individual patients' needs. Novel treatments currently under clinical development, including venetoclax, melflufen and CAR T-cell therapies, are also discussed.
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Maouche N, Kishore B, Jenner MW, Boyd K, Bhatti Z, Bird SA, Chander G, Robinson R, Vallance GD, Offer M, Kothari J, Peniket A, Aitchison R, Dungarwalla M, Collings F, Bygrave C, Ramasamy K. Ixazomib, lenalidomide, and dexamethasone is effective and well tolerated in multiply relapsed (≥2nd relapse) refractory myeloma: a multicenter real world UK experience. Leuk Lymphoma 2020; 62:1396-1404. [PMID: 33356703 DOI: 10.1080/10428194.2020.1864355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
There are limited real world data on ixazomib, lenalidomide, and dexamethasone (IRd) in multiply relapsed myeloma. We analyzed outcomes of 116 patients who received IRd predominantly at second and subsequent relapse including those refractory to proteasome inhibitors (PIs). With a median follow up 16.3 months, the overall response rate was 66.9%; median progression-free survival (PFS) was 17.7 months with median overall survival (OS) not reached (NR). PFS and OS were significantly shorter in advanced disease (PFS; 12.6 vs. 21.2 months (p = .01), OS; 15.9 months vs. NR (p = .01) for ISS3 vs. ISS 1&2, respectively). PFS and OS were significantly shorter in clinical high risk (CHR) compared to standard risk (SR) patients (PFS; 9.3 months vs. NR (p = .001), OS; 11.5 months vs. NR (p < .001), respectively). There was a trend toward shorter PFS in PI-refractory patients 13.7 vs. 19.6 months for non-PI refractory (p = .2). The triplet combination was generally well tolerated.
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Affiliation(s)
- Nadjoua Maouche
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bhuvan Kishore
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Matthew W Jenner
- Department of Haematology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kevin Boyd
- Department of Haemato-Oncology, The Royal Marsden Hospital, Sutton, UK
| | - Zara Bhatti
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sarah Anne Bird
- Department of Haemato-Oncology, The Royal Marsden Hospital, Sutton, UK
| | - Gurvin Chander
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Rebecca Robinson
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Grant D Vallance
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mark Offer
- Department of Haematology, Frimley Health NHS Foundation Trust, Frimley, UK
| | - Jaimal Kothari
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andy Peniket
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robin Aitchison
- Department of Haematology, Buckinghamshire Healthcare NHS Trust, Bucks, UK
| | - Moez Dungarwalla
- Department of Haematology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Freya Collings
- Department of Haematology, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Ceri Bygrave
- Department of Haematology, University Hospital of Wales, Cardiff, UK
| | - Karthik Ramasamy
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Belch A, Bahlis N, White D, Cheung M, Chen C, Shustik C, Song K, Tosikyan A, Dispenzieri A, Anderson K, Brown D, Robinson S, Srinivasan S, Facon T. Continuous lenalidomide and low-dose dexamethasone in patients with transplant-ineligible newly diagnosed MM: FIRST trial subanalysis of Canadian/US patients. Cancer Med 2020; 9:8923-8930. [PMID: 33049118 PMCID: PMC7724300 DOI: 10.1002/cam4.3511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/16/2020] [Accepted: 09/05/2020] [Indexed: 12/14/2022] Open
Abstract
The phase 3 FIRST trial demonstrated significant improvement in progression-free survival (PFS) and overall survival (OS) with an immune-stimulatory agent, lenalidomide, in combination with low-dose dexamethasone until disease progression (Rd continuous) vs melphalan +prednisone + thalidomide (MPT) in transplant-ineligible patients with newly diagnosed multiple myeloma (NDMM). Rd continuous similarly extended PFS vs fixed-duration Rd for 18 cycles (Rd18). Outcomes in the Canadian/US subgroup (104 patients per arm) are reported in this analysis. Rd continuous demonstrated a significant improvement in PFS vs MPT (median, 29.3 vs 20.2 months; HR, 0.69 [95% CI, 0.49-0.97]; p = 0.03326) and an improvement vs Rd18 (median, 21.9 months). Median OS was 56.9 vs 46.8 months with Rd continuous vs MPT (p = 0.15346) and 59.5 months with Rd18. The overall response rate was higher with Rd continuous and Rd18 (78.8% and 79.8%) vs MPT (65.4%). In the 49.0%, 52.9%, and 29.8% of patients with at least very good partial response in the Rd continuous, Rd18, and MPT arms, respectively, the median PFS was 56.0, 30.9, and 40.2 months, respectively. The most common grade 3/4 treatment-emergent adverse events were neutropenia (28.4%, 30.1%, and 52.0%), anemia (23.5%, 21.4%, and 23.5%), and infections (37.3%, 30.1%, and 24.5%) with Rd continuous, Rd18, and MPT, respectively. These results were consistent with those in the intent-to-treat population, confirming the benefit of Rd continuous vs MPT in the Canadian/US subgroup and supporting the role of Rd continuous as a standard of care for transplant-ineligible patients with NDMM.
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Affiliation(s)
| | | | - Darrell White
- Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | | | - Chaim Shustik
- McGill University Health Centre, Montréal, QC, Canada
| | - Kevin Song
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Axel Tosikyan
- Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada
| | | | | | - Diane Brown
- Celgene, a Bristol-Myers Squibb Company, Mississauga, ON, Canada
| | | | | | - Thierry Facon
- Service des Maladies du Sang, Hôpital Claude Huriez, Lille, France
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Abstract
INTRODUCTION The survival of multiple myeloma patients is increasing due to new medications, the widespread implementation of autologous stem cell transplantation and better supportive treatments. The controversy surrounding post-transplant treatment is debated due to a lack of large randomized trials comparing the different treatment modalities. The questions for each proposed treatment are whether it improves outcomes, has low cumulative toxicities and is easy to administer. Areas covered: In this review, we have summarized the current data on maintenance therapy in newly diagnosed MM patients undergoing ASCT, focusing on bortezomib, thalidomide and lenalidomide as well as newer agents Expert opinion: Maintenance treatment has been shown to deepen and prolong responses and increase PFS and OS. Lenalidomide is approved for maintenance and guidelines recommend its use post ASCT. Ixazomib has recently been reported to improve PFS.
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Affiliation(s)
- Iuliana Vaxman
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA.,b Institute of Hematology, Davidoff Cancer Center , Rabin Medical Center Petah , Tikva , Israel.,c Israel Sackler Faculty of Medicine , Tel-Aviv University , Tel-Aviv , Israel
| | - Morie Gertz
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
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Dimopoulos MA, Jakubowiak AJ, McCarthy PL, Orlowski RZ, Attal M, Bladé J, Goldschmidt H, Weisel KC, Ramasamy K, Zweegman S, Spencer A, Huang JSY, Lu J, Sunami K, Iida S, Chng WJ, Holstein SA, Rocci A, Skacel T, Labotka R, Palumbo A, Anderson KC. Developments in continuous therapy and maintenance treatment approaches for patients with newly diagnosed multiple myeloma. Blood Cancer J 2020; 10:17. [PMID: 32054831 PMCID: PMC7018731 DOI: 10.1038/s41408-020-0273-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/13/2019] [Accepted: 09/18/2019] [Indexed: 12/30/2022] Open
Abstract
The evolving paradigm of continuous therapy and maintenance treatment approaches in multiple myeloma (MM) offers prolonged disease control and improved outcomes compared to traditional fixed-duration approaches. Potential benefits of long-term strategies include sustained control of disease symptoms, as well as continued cytoreduction and clonal control, leading to unmeasurable residual disease and the possibility of transforming MM into a chronic or functionally curable condition. "Continuous therapy" commonly refers to administering a doublet or triplet regimen until disease progression, whereas maintenance approaches typically involve single-agent or doublet treatment following more intensive prior therapy with autologous stem cell transplant (ASCT) or doublet, triplet, or even quadruplet induction therapy. However, the requirements for agents and regimens within these contexts are similar: treatments must be tolerable for a prolonged period of time, should not be associated with cumulative or chronic toxicity, should not adversely affect patients' quality of life, should ideally be convenient with a minimal treatment burden for patients, and should not impact the feasibility or efficacy of subsequent treatment at relapse. Multiple agents have been and are being investigated as long-term options in the treatment of newly diagnosed MM (NDMM), including the immunomodulatory drugs lenalidomide and thalidomide, the proteasome inhibitors bortezomib, carfilzomib, and ixazomib, and the monoclonal antibodies daratumumab, elotuzumab, and isatuximab. Here we review the latest results with long-term therapy approaches in three different settings in NDMM: (1) maintenance treatment post ASCT; (2) continuous frontline therapy in nontransplant patients; (3) maintenance treatment post-frontline therapy in the nontransplant setting. We also discuss evidence from key phase 3 trials. Our review demonstrates how the paradigm of long-term treatment is increasingly well-established across NDMM treatment settings, potentially resulting in further improvements in patient outcomes, and highlights key clinical issues that will need to be addressed in order to provide optimal benefit.
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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.
| | | | | | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michel Attal
- Hematology Department, University Hospital Purpan, Toulouse, France
| | - Joan Bladé
- Hematology Department, Hospital Clinic, Institut de Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Hartmut Goldschmidt
- Department of Internal Medicine V, University Medical Hospital and National Center of Tumor Diseases, University of Heidelberg, Heidelberg, Germany
| | - Katja C Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Sonja Zweegman
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health-Monash University, Melbourne, Australia
| | | | - Jin Lu
- Department of Hematology, Peking University People's Hospital and Peking University Institute of Hematology, Beijing, China
| | - Kazutaka Sunami
- Department of Hematology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Wee-Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, and Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Sarah A Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Alberto Rocci
- Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, School of Medical Science, Division of Cancer Science, University of Manchester, Manchester, UK
| | - Tomas Skacel
- 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
| | - Antonio Palumbo
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
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Piechotta V, Jakob T, Langer P, Monsef I, Scheid C, Estcourt LJ, Ocheni S, Theurich S, Kuhr K, Scheckel B, Adams A, Skoetz N. Multiple drug combinations of bortezomib, lenalidomide, and thalidomide for first-line treatment in adults with transplant-ineligible multiple myeloma: a network meta-analysis. Cochrane Database Syst Rev 2019; 2019:CD013487. [PMID: 31765002 PMCID: PMC6876545 DOI: 10.1002/14651858.cd013487] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Multiple myeloma is a bone marrow-based hematological malignancy accounting for approximately two per cent of cancers. First-line treatment for transplant-ineligible individuals consists of multiple drug combinations of bortezomib (V), lenalidomide (R), or thalidomide (T). However, access to these medicines is restricted in many countries worldwide. OBJECTIVES To assess and compare the effectiveness and safety of multiple drug combinations of V, R, and T for adults with newly diagnosed transplant-ineligible multiple myeloma and to inform an application for the inclusion of these medicines into the World Health Organization's (WHO) list of essential medicines. SEARCH METHODS We searched CENTRAL and MEDLINE, conference proceedings and study registries on 14 February 2019 for randomised controlled trials (RCTs) comparing multiple drug combinations of V, R and T for adults with newly diagnosed transplant-ineligible multiple myeloma. SELECTION CRITERIA We included RCTs comparing combination therapies of V, R, and T, plus melphalan and prednisone (MP) or dexamethasone (D) for first-line treatment of adults with transplant-ineligible multiple myeloma. We excluded trials including adults with relapsed or refractory disease, trials comparing drug therapies to other types of therapy and trials including second-generation novel agents. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias of included trials. As effect measures we used hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS) and risk ratios (RRs) for adverse events. An HR or RR < 1 indicates an advantage for the intervention compared to the main comparator MP. Where available, we extracted quality of life (QoL) data (scores of standardised questionnaires). Results quoted are from network meta-analysis (NMA) unless stated. MAIN RESULTS We included 25 studies (148 references) comprising 11,403 participants and 21 treatment regimens. Treatments were differentiated between restricted treatment duration (treatment with a pre-specified amount of cycles) and continuous therapy (treatment administered until disease progression, the person becomes intolerant to the drug, or treatment given for a prolonged period). Continuous therapies are indicated with a "c". Risk of bias was generally high across studies due to the open-label study design. Overall survival (OS) Evidence suggests that treatment with RD (HR 0.63 (95% confidence interval (CI) 0.40 to 0.99), median OS 55.2 months (35.2 to 87.0)); TMP (HR 0.75 (95% CI 0.58 to 0.97), median OS: 46.4 months (35.9 to 60.0)); and VRDc (HR 0.49 (95% CI 0.26 to 0.92), median OS 71.0 months (37.8 to 133.8)) probably increases survival compared to median reported OS of 34.8 months with MP (moderate certainty). Treatment with VMP may result in a large increase in OS, compared to MP (HR 0.70 (95% CI 0.45 to 1.07), median OS 49.7 months (32.5 to 77.3)), low certainty). Progression-free survival (PFS) Treatment withRD (HR 0.65 (95% CI0.44 to 0.96), median PFS: 24.9 months (16.9 to 36.8)); TMP (HR 0.63 (95% CI 0.50 to 0.78), median PFS:25.7 months (20.8 to 32.4)); VMP (HR 0.56 (95% CI 0.35 to 0.90), median PFS: 28.9 months (18.0 to 46.3)); and VRDc (HR 0.34 (95% CI 0.20 to 0.58), median PFS: 47.6 months (27.9 to 81.0)) may result in a large increase in PFS (low certainty) compared to MP (median reported PFS: 16.2 months). Adverse events The risk of polyneuropathies may be lower with RD compared to treatment with MP (RR 0.57 (95% CI 0.16 to 1.99), risk for RD: 0.5% (0.1 to 1.8), mean reported risk for MP: 0.9% (10 of 1074 patients affected), low certainty). However, the CIs are also compatible with no difference or an increase in neuropathies. Treatment with TMP (RR 4.44 (95% CI1.77 to 11.11), risk: 4.0% (1.6 to 10.0)) and VMP (RR 88.22 (95% CI 5.36 to 1451.11), risk: 79.4% (4.8 to 1306.0)) probably results in a large increase in polyneuropathies compared to MP (moderate certainty). No study reported the amount of participants with grade ≥ 3 polyneuropathies for treatment with VRDc. VMP probably increases the proportion of participants with serious adverse events (SAEs) compared to MP (RR 1.28 (95% CI 1.06 to 1.54), risk for VMP: 46.2% (38.3 to 55.6), mean risk for MP: 36.1% (177 of 490 patients affected), moderate certainty). RD, TMP, and VRDc were not connected to MP in the network and the risk of SAEs could not be compared. Treatment with RD (RR 4.18 (95% CI 2.13 to 8.20), NMA-risk: 38.5% (19.6 to 75.4)); and TMP (RR 4.10 (95% CI 2.40 to 7.01), risk: 37.7% (22.1 to 64.5)) results in a large increase of withdrawals from the trial due to adverse events (high certainty) compared to MP (mean reported risk: 9.2% (77 of 837 patients withdrew)). The risk is probably slightly increased with VMP (RR 1.06 (95% CI 0.63 to 1.81), risk: 9.75% (5.8 to 16.7), moderate certainty), while it is much increased with VRDc (RR 8.92 (95% CI 3.82 to 20.84), risk: 82.1% (35.1 to 191.7), high certainty) compared to MP. Quality of life QoL was reported in four studies for seven different treatment regimens (MP, MPc, RD, RMP, RMPc, TMP, TMPc) and was measured with four different tools. Assessment and reporting differed between studies and could not be meta-analysed. However, all studies reported an improvement of QoL after initiation of anti-myeloma treatment for all assessed treatment regimens. AUTHORS' CONCLUSIONS Based on our four pre-selected comparisons of interest, continuous treatment with VRD had the largest survival benefit compared with MP, while RD and TMP also probably considerably increase survival. However, treatment combinations of V, R, and T also substantially increase the incidence of AEs, and lead to a higher risk of treatment discontinuation. Their effectiveness and safety profiles may best be analysed in further randomised head-to-head trials. Further trials should focus on consistent reporting of safety outcomes and should use a standardised instrument to evaluate QoL to ensure comparability of treatment-combinations.
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Affiliation(s)
- Vanessa Piechotta
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Tina Jakob
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Peter Langer
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Ina Monsef
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Christof Scheid
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Stem Cell Transplantation Program, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Lise J Estcourt
- NHS Blood and Transplant, Haematology/Transfusion Medicine, Level 2, John Radcliffe Hospital, Headington, Oxford, UK, OX3 9BQ
| | - Sunday Ocheni
- University of Nigeria, Department of Haematology & Immunology, Ituku-Ozalla Campus, Enugu, Enugu State, Nigeria
| | - Sebastian Theurich
- University Hospital LMU, Ludwig-Maximilians-Universität München, Department of Medicine III, Marchioninistrasse 15, Munich, Bavaria, Germany, 81377
| | - Kathrin Kuhr
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Medical Statistics and Computational Biology, Kerpener Str. 62, Cologne, Germany, 50937
| | - Benjamin Scheckel
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute of Health Economics and Clinical Epidemiology, Gleueler Str. 176-178, Cologne, NRW, Germany, 50935
| | - Anne Adams
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Medical Statistics and Computational Biology, Kerpener Str. 62, Cologne, Germany, 50937
| | - Nicole Skoetz
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, Germany, 50937
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11
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Mikhael J, Ismaila N, Cheung MC, Costello C, Dhodapkar MV, Kumar S, Lacy M, Lipe B, Little RF, Nikonova A, Omel J, Peswani N, Prica A, Raje N, Seth R, Vesole DH, Walker I, Whitley A, Wildes TM, Wong SW, Martin T. Treatment of Multiple Myeloma: ASCO and CCO Joint Clinical Practice Guideline. J Clin Oncol 2019; 37:1228-1263. [PMID: 30932732 DOI: 10.1200/jco.18.02096] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To provide evidence-based recommendations on the treatment of multiple myeloma to practicing physicians and others. METHODS ASCO and Cancer Care Ontario convened an Expert Panel of medical oncology, surgery, radiation oncology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and some phase II studies published from 2005 through 2018. Outcomes of interest included survival, progression-free survival, response rate, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 124 relevant studies to inform the evidence base for this guideline. RECOMMENDATIONS Evidence-based recommendations were developed for patients with multiple myeloma who are transplantation eligible and those who are ineligible and for patients with relapsed or refractory disease.
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Affiliation(s)
- Joseph Mikhael
- 1 City of Hope Cancer Center, Phoenix, AZ.,2 International Myeloma Foundation, North Hollywood, CA
| | | | | | | | | | | | | | - Brea Lipe
- 8 University of Rochester Medical Center, Rochester, NY
| | | | - Anna Nikonova
- 10 Juravinski Cancer Center, Hamilton, Ontario, Canada
| | - James Omel
- 11 Education and Advocacy, Grand Island, NE
| | | | - Anca Prica
- 13 Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Noopur Raje
- 14 Massachusetts General Hospital, Boston, MA
| | - Rahul Seth
- 15 Upstate Medical University, Syracuse, NY
| | - David H Vesole
- 16 Hackensack University Medical Center, Hackensack, NJ.,17 Georgetown University, Washington, DC
| | - Irwin Walker
- 18 McMaster University, Hamilton, Ontario, Canada
| | | | | | - Sandy W Wong
- 21 University of California San Francisco, San Francisco, CA
| | - Tom Martin
- 21 University of California San Francisco, San Francisco, CA
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12
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Richardson PG, San Miguel JF, Moreau P, Hajek R, Dimopoulos MA, Laubach JP, Palumbo A, Luptakova K, Romanus D, Skacel T, Kumar SK, Anderson KC. Interpreting clinical trial data in multiple myeloma: translating findings to the real-world setting. Blood Cancer J 2018; 8:109. [PMID: 30413684 PMCID: PMC6226527 DOI: 10.1038/s41408-018-0141-0] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/26/2018] [Accepted: 10/09/2018] [Indexed: 01/04/2023] Open
Abstract
Substantial improvements in survival have been seen in multiple myeloma (MM) over recent years, associated with the introduction and widespread use of multiple novel agents and regimens, as well as the emerging treatment paradigm of continuous or long-term therapy. However, these therapies and approaches may have limitations in the community setting, associated with toxicity burden, patient burden, and other factors including cost. Consequently, despite improvements in efficacy in the rigorously controlled clinical trials setting, the same results are not always achieved in real-world practice. Furthermore, the large number of different treatment options and regimens under investigation in various MM settings precludes the feasibility of obtaining head-to-head clinical trial data, and there is a temptation to use cross-trial comparisons to evaluate data across regimens. However, multiple aspects, including patient-related, disease-related, and treatment-related factors, can influence clinical trial outcomes and lead to differences between studies that may confound direct comparisons between data. In this review, we explore the various factors requiring attention when evaluating clinical trial data across available agents/regimens, as well as other considerations that may impact the translation of these findings into everyday MM management. We also investigate discrepancies between clinical trial efficacy and real-world effectiveness through a literature review of non-clinical trial data in relapsed/refractory MM on novel agent-based regimens and evaluate these data in the context of phase 3 trial results for recently approved and commonly used regimens. We thereby demonstrate the complexity of interpreting data across clinical studies in MM, as well as between clinical studies and routine-care analyses, with the aim to help clinicians consider all the necessary issues when tailoring individual patients' treatment approaches.
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Affiliation(s)
| | - Jesus F San Miguel
- Centro Investigación Medica Aplicada (CIMA), IDISNA; CIBERONC, Clinica Universidad de Navarra, Pamplona, Spain
| | - Philippe Moreau
- Department of Hematology, University Hospital Hôtel Dieu, Nantes, France
| | - Roman Hajek
- Department of Hematooncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jacob P Laubach
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Antonio Palumbo
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Katarina Luptakova
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Dorothy Romanus
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Tomas Skacel
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Shaji K Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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13
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Ziogas DC, Dimopoulos MA, Kastritis E. Prognostic factors for multiple myeloma in the era of novel therapies. Expert Rev Hematol 2018; 11:863-879. [DOI: 10.1080/17474086.2018.1537776] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Dimitrios C. Ziogas
- Department of Clinical Therapeutics, School of Medicine, “Alexandra” General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, “Alexandra” General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, “Alexandra” General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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14
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Klausen TW, Gregersen H, Abildgaard N, Andersen NF, Frølund UC, Gimsing P, Helleberg C, Vangsted AJ. The majority of newly diagnosed myeloma patients do not fulfill the inclusion criteria in clinical phase III trials. Leukemia 2018; 33:546-549. [DOI: 10.1038/s41375-018-0272-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/18/2018] [Accepted: 09/03/2018] [Indexed: 01/10/2023]
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15
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Mina R, Petrucci MT, Corradini P, Spada S, Patriarca F, Cerrato C, De Paoli L, Pescosta N, Ria R, Malfitano A, Musto P, Baldini L, Guglielmelli T, Gamberi B, Mannina D, Benevolo G, Zambello R, Falcone AP, Palumbo A, Nagler A, Calafiore V, Hájek R, Spencer A, Boccadoro M, Bringhen S. Treatment Intensification With Autologous Stem Cell Transplantation and Lenalidomide Maintenance Improves Survival Outcomes of Patients With Newly Diagnosed Multiple Myeloma in Complete Response. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:533-540. [DOI: 10.1016/j.clml.2018.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/08/2018] [Accepted: 05/21/2018] [Indexed: 11/28/2022]
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16
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Richardson PG, Laubach J, Gandolfi S, Facon T, Weisel K, O’Gorman P. Maintenance and continuous therapy for multiple myeloma. Expert Rev Anticancer Ther 2018; 18:751-764. [DOI: 10.1080/14737140.2018.1490181] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Paul G. Richardson
- Department of Hematology and Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jacob Laubach
- Department of Hematology and Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Sara Gandolfi
- Department of Hematology and Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Thierry Facon
- Department of Haematology, Service des Maladies du Sang, Hôpital Claude Huriez, Lille, France
| | - Katja Weisel
- Department of Hematology and Oncology, University Hospital of Tuebingen, Tuebingen, Germany
| | - Peter O’Gorman
- Department of Haematology, Mater Misericordiae University Hospital, University College Dublin, Dublin, Ireland
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