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Esteghamat NS, Brunson A, Rosenberg AS, Schonfeld SJ, Valcarcel B, Abrahão R, Cooley JJP, Meyer CL, Auletta JJ, Morton LM, Muffly L, Wun T, Keegan THM. Utilization of Autologous Hematopoietic Cell Transplantation Over Time in Multiple Myeloma: A Population-Based Study. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:e119-e129. [PMID: 38195324 DOI: 10.1016/j.clml.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE Autologous hematopoietic cell transplantation (autoHCT) is associated with survival benefits in multiple myeloma (MM), but utilization remains low and differs by sociodemographic factors. Prior population-based studies have not fully captured autoHCT utilization or examined relationships between sociodemographic factors and autoHCT trends over time. PATIENTS AND METHODS We used a novel data linkage between the California Cancer Registry, Center for International Blood and Marrow Transplant Research, and hospitalizations to capture autoHCT in a population-based MM cohort (n = 29, 109; 1991-2016). Due to interactions by treatment era, stratified multivariable Cox proportional hazards regression models determined factors associated with autoHCT. RESULTS The frequency of MM patients who received autoHCT increased from 5.7% (1991-1995) to 27.4% (2011-2016). In models by treatment era, patients with public/no (vs. private) health insurance were less likely to receive autoHCT (2011-2016 Medicare hazard ratio (HR) 0.70, 95% confidence interval (CI): 0.63-0.78; Medicaid HR 0.81, CI: 0.72-0.91; no insurance HR 0.56, CI: 0.32-0.99). In each treatment era, Black/African American (vs. non-Hispanic White) patients were less likely to receive autoHCT (2011-2016 HR 0.83, CI: 0.72-0.95). Hispanic patients were less likely to undergo autoHCT, most prominently in the earliest treatment era (1991-1995 HR 0.58, 95% CI: 0.37-0.90; 2011-2016 HR 1.07, CI: 0.96-1.19). Patients in lower socioeconomic status neighborhoods were less likely to utilize autoHCT, but differences decreased over time. CONCLUSIONS Despite increases in autoHCT utilization, sociodemographic disparities remain. Identifying and mitigating barriers to autoHCT is essential to ensuring more equitable access to this highly effective therapy.
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Affiliation(s)
- Naseem S Esteghamat
- Division of Malignant Hematology, Cellular Therapy and Transplantation, University of California Davis Comprehensive Cancer Center, Sacramento, CA.
| | - Ann Brunson
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | - Aaron S Rosenberg
- Division of Malignant Hematology, Cellular Therapy and Transplantation, University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | - Sara J Schonfeld
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Bryan Valcarcel
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Renata Abrahão
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | - Julianne J P Cooley
- California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | - Christa L Meyer
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, MN
| | - Jeffery J Auletta
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, MN; Divisions of Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH
| | - Lindsay M Morton
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Lori Muffly
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University, Stanford, CA
| | - Ted Wun
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA; California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA
| | - Theresa H M Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, University of California Davis Comprehensive Cancer Center, Sacramento, CA; California Cancer Reporting and Epidemiologic Surveillance Program, University of California Davis Comprehensive Cancer Center, Sacramento, CA
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2
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Bashir Q, Braunstein M, Buck T, Chmielewski C, Hartmann B, Janakiram M, McMahon MA, Romundstad L, Steele L, Usmani SZ, Zwibel K, Kharfan-Dabaja MA. Overcoming Barriers to Autologous Stem Cell Transplantation in Multiple Myeloma: Recommendations from a Multidisciplinary Roundtable Discussion. Transplant Cell Ther 2023; 29:666-673. [PMID: 37661071 DOI: 10.1016/j.jtct.2023.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/05/2023]
Abstract
Autologous stem cell transplantation (ASCT) is a standard of care treatment for patients with multiple myeloma (MM). However, only 20% to 30% of patients with MM for whom the procedure is indicated undergo ASCT. Barriers to ASCT may be informational, financial, logistic, or cultural and may affect patients and treating oncologists. Available and accessible accurate ASCT-related information is essential to overcome these barriers. Such resources can be created by blood and marrow transplantation societies and patient advocacy groups, ideally in collaboration with MM specialists at transplant centers. An umbrella office at the society level is also recommended to connect oncologists, advocacy groups, and transplantation specialists; provide informational resources to patients; and conduct research into region- and population-specific barriers to ASCT.
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Affiliation(s)
- Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Marc Braunstein
- NYU Long Island School of Medicine, NYU Perlmutter Cancer Center, Mineola, New York
| | - Tondre Buck
- Gibbs Cancer Center & Research Institute, Medical Group of the Carolinas, Spartanburg, South Carolina
| | | | | | | | - Marisa A McMahon
- Perlmutter Cancer Center, NYU Langone Health, New York, New York
| | | | - Lynn Steele
- The Leukemia & Lymphoma Society, Rye Brook, New York
| | | | | | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation and Cellular Therapies Program, Mayo Clinic, Jacksonville, Florida
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3
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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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4
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Swan D, Hayden PJ, Eikema DJ, Koster L, Sauer S, Blaise D, Nicholson E, Rabin N, Touzeau C, Byrne J, Huynh A, Cornelissen JJ, Potter V, Forcade E, Parrish C, Gribben J, Chretien ML, Mielke S, Gedde-Dahl T, Reményi P, Tsirigotis P, Garcia Guiñón A, Beksac M, Schönland S, Yakoub-Agha I. Trends in autologous stem cell transplantation for newly diagnosed multiple myeloma: Changing demographics and outcomes in European Society for Blood and Marrow Transplantation centres from 1995 to 2019. Br J Haematol 2022; 197:82-96. [PMID: 35166376 DOI: 10.1111/bjh.18025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/26/2021] [Accepted: 12/15/2021] [Indexed: 11/29/2022]
Abstract
Multiple myeloma (MM) accounts for 10% of haematological malignancies. Overall survival (OS) has improved in recent years due to increased use of autologous stem cell transplantation (ASCT) in the treatment of newly diagnosed MM and the advent of novel agents, including proteasome inhibitors, immunomodulatory drugs and monoclonal antibodies. To assess trends in ASCT including patient selection, choice of induction regimen, depth of response and survival, we performed a retrospective analysis of all patients undergoing first ASCT for MM in European Society for Blood and Marrow Transplantation centres between 1995 and 2019. A total of 117 711 patients across 575 centres were included. The number of transplants performed increased sevenfold across the study period. The median age increased from 55 to 61 years, and the percentage of patients aged >65 years rose from 7% to 30%. Use of chemotherapy-based induction fell significantly, being largely replaced by bortezomib-based regimens. The two-year complete response rate increased from 22% to 42%. The five-year progression-free survival and OS rates increased from 28% to 31% and from 52% to 69%, respectively. Transplant mortality fell from 5.9% to 1.5%. Ongoing advances in MM treatment may challenge the future role of ASCT. However, at the current time, ASCT remains central to the MM treatment paradigm.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, St James's Hospital, Dublin, Ireland
| | | | - Dirk-Jan Eikema
- European Society for Blood and Marrow Transplantation (EBMT) Statistical Unit, Leiden, the Netherlands
| | | | | | - Didier Blaise
- Programme de Transplantation and Therapie Cellulaire, Marseille, France
| | | | - Neil Rabin
- University College London Hospital, London, UK
| | | | | | - Anne Huynh
- CHU - Institut Universitaire du Cancer Toulouse, Toulouse, France
| | | | | | | | | | - John Gribben
- St Bartholomew's and The Royal London NHS Trust, London, UK
| | | | | | | | | | | | | | - Meral Beksac
- Ankara University Faculty of Medicine, Ankara, Turkey
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5
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Bergin K, Wellard C, Augustson B, Cooke R, Blacklock H, Harrison SJ, Ho J, King T, Quach H, Mollee P, Walker P, Moore E, McQuilten Z, Wood E, Spencer A. Real-world utilisation of ASCT in multiple myeloma (MM): a report from the Australian and New Zealand myeloma and related diseases registry (MRDR). Bone Marrow Transplant 2021; 56:2533-2543. [PMID: 34011965 DOI: 10.1038/s41409-021-01308-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 12/22/2022]
Abstract
Supported by clinical trial proven survival benefit, clinical guidelines recommend upfront autologous stem cell transplantation (ASCT) for eligible MM patients. However, reported real-world utilisation is lower than expected (40-60%). We reviewed ASCT utilisation, demographics and outcomes for MM patients (≤70 years, ≥12-month follow-up) enroled onto the Australian/New Zealand MRDR from June 2012 to May 2020. In 982 patients (<65 years: 684, 65-70 years: 298), ASCT utilisation was 76% overall (<65 years: 83%, 65-70 years: 61%, front-line therapy: 67%). Non-ASCT recipients were older (median age: 65 years vs 60 years, p < 0.001), had more comorbidities (cardiac disease: 16.9% vs 5.4%, p < 0.001; diabetes: 19.1% vs 7.0%, p < 0.001; renal dysfunction: median eGFR(ml/min): 68 vs 80, p < 0.001), inferior performance status (ECOG ≥ 2: 26% vs 13%, p < 0.001) and higher-risk MM (ISS-3: 37% vs 26%, p = 0.009, R-ISS-3 18.6% vs 11.8%, p = 0.051) than ASCT recipients. ASCT survival benefit (median progression-free survival (PFS): 45.3 months vs 35.2 months, p < 0.001; overall survival (OS): NR vs 64.0 months, p < 0.001) was maintained irrespective of age (<65 years: median PFS: 45.3 months vs 37.7 months, p = 0.04, OS: NR vs 68.2 months, p = 0.002; 65-70 years: median PFS: 46.7 months vs 29.2 months, p < 0.001, OS: 76.9 months vs 55.6 months, p = 0.005). This large, real-world cohort reaffirms ASCT survival benefit, including in 'older' patients necessitating well-designed studies evaluating ASCT in 'older' MM to inform evidence-based patient selection.
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Affiliation(s)
- Krystal Bergin
- Alfred Health-Monash University, Melbourne, VIC, Australia
| | - Cameron Wellard
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | | | | | - Simon J Harrison
- Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Melbourne, VIC, Australia
- Sir Peter MacCallum Dept of Oncology, Melbourne University, Melbourne, VIC, Australia
| | - Joy Ho
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Tracy King
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Hang Quach
- St.Vincent's Hospital, Melbourne, VIC, Australia
| | - Peter Mollee
- Princess Alexandra Hospital and University of Queensland, Brisbane, QLD, Australia
| | | | - Elizabeth Moore
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Zoe McQuilten
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Erica Wood
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrew Spencer
- Alfred Health-Monash University, Melbourne, VIC, Australia.
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6
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Ravi G, Gonsalves WI. Current diagnosis, risk stratification and treatment paradigms in newly diagnosed multiple myeloma. Cancer Treat Res Commun 2021; 29:100444. [PMID: 34555665 DOI: 10.1016/j.ctarc.2021.100444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 07/03/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Gayathri Ravi
- Division of Hematology, Mayo Clinic, Rochester MN, USA
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7
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Effect of autologous hematopoietic stem cell transplant on the development of second primary malignancies in multiple myeloma patients. Blood Cancer J 2021; 11:5. [PMID: 33414400 PMCID: PMC7791054 DOI: 10.1038/s41408-020-00400-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/16/2020] [Accepted: 12/07/2020] [Indexed: 02/06/2023] Open
Abstract
Autologous stem cell transplant (aHSCT) is associated with improved survival for multiple myeloma (MM) patients but may be associated with second primary malignancy (SPM) development. Using the California Cancer Registry linked to statewide hospitalization data, we determined the cumulative incidence (CMI) of SPMs more than 1 year after MM diagnosis, accounting for the competing risk of death. AHSCT recipients were matched 1:2 to non-aHSCT patients. Adjusted hazard ratios (aHR) were estimated using the Fine and Gray method. Among 16,331 patients, 933 (5.7%) developed a SPM more than 1 year after diagnosis. The 10-year CMI of developing any SPM was 6.6%, 5.7% for solid tumor SPM and 0.9% for hematologic malignancies. The 10-year CMI of developing any SPM was similar among aHSCT [9.1% (7.7-10.7%)] and non-aHSCT [7.5% (6.5-8.6%)] (P = 0.26) recipients and there was no difference in solid-tumor SPMs (P = 0.98). The 10-year CMI of hematologic SPMs was higher among aHSCT recipients [2.1% (1.4-2.9%) vs. 0.8% (0.5-1.2%); P = 0.005], corresponding to a 1.3% absolute increase and an aHR of 1.51 (1.01-2.27). Ten-year myeloma-specific and non-cancer mortality rates were 59% (58.2-60.0%) and 18.1% (17.4-18.8%), respectively. Although aHSCT was associated with a small increase in hematologic SPMs, mortality was driven by MM and non-cancer causes.
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8
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Jansen L, Merz M, Engelhardt M, Weisel K, Scheid C, Straka C, Langer C, Salwender H, Einsele H, Kröger N, Beelen DW, Dreger P, Goldschmidt H, Brenner H. Autologous stem cell transplantation in multiple myeloma patients: utilization patterns and hospital effects. Leuk Lymphoma 2020; 61:2365-2374. [PMID: 32476543 DOI: 10.1080/10428194.2020.1768383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Evidence on volume outcome associations for autologous stem cell transplantation (ASCT) in multiple myeloma (MM) is limited. We investigated ASCT utilization patterns and volume outcome associations in the German National Registry for Stem Cell Transplants (DRST). MM patients with an upfront ASCT between 1998 and 2014 registered in the DRST were included. ASCT utilization increased strongly from 6% to 17% between 1999 and 2013 with the largest increase for patients aged 60-64 years (8-34%). The mean number of ASCTs conducted in the hospitals per year varied (quintiles, Q1:0.0-8.2 to Q5:31.0-102.7). Center volume was not associated with survival after upfront ASCT (lowest vs. highest center volume, hazard ratios and 95% confidence intervals: 0.95 (0.76-1.18), p = 0.92). Our findings may reflect a high standard of care and degree of specialization of centers performing ASCT for MM in Germany.
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Affiliation(s)
- Lina Jansen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Maximilian Merz
- Medizinische Klinik V, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Katja Weisel
- II. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | - Hans Salwender
- Asklepios Kliniken Altona und St. Georg, Hamburg, Germany
| | | | - Nikolaus Kröger
- Interdisziplinäre Klinik für Stammzelltransplantation, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Dietrich W Beelen
- Klinik für Knochenmarktransplantation des Universitätsklinikums Essen, Essen, Germany
| | - Peter Dreger
- Medizinische Klinik V, University Hospital Heidelberg, Heidelberg, Germany
| | - Hartmut Goldschmidt
- Medizinische Klinik V, University Hospital Heidelberg, Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Hermann Brenner
- Medizinische Klinik V, University Hospital Heidelberg, Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
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9
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Rosenberg AS, Brunson A, Jonas BA, Keegan THM, Wun T. Association Between Autologous Stem Cell Transplant and Survival Among Californians With Multiple Myeloma. J Natl Cancer Inst 2020; 111:78-85. [PMID: 29897481 DOI: 10.1093/jnci/djy073] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 03/16/2018] [Indexed: 12/22/2022] Open
Abstract
Background Autologous hematopoietic stem cell transplant (aHSCT) is an efficacious treatment for newly diagnosed multiple myeloma patients. However, as rapid advances have resulted in other highly efficacious and less intensive therapies, the role of aHSCT has been questioned. Methods We utilized population-based data to identify 13 494 newly diagnosed patients younger than age 80 years between 1998 and 2012. Patient characteristics of aHSCT and non-aHSCT groups were balanced using inverse probability weighting of a propensity score predicting aHSCT use. Multivariable models adjusted for baseline comorbidities, demographics, and socioeconomic status estimated the adjusted hazard ratio (aHR) and 95% confidence intervals (CIs) of death. Results Twenty point eight percent (2807) of patients underwent aHSCT, and this rate increased over time from 15.4% in 1998-2002 to 23.9% in 2008-2012. aHSCT was utilized among 37.6% and 11.5% of patients younger than age 60 years and 60 to 79 years, respectively. The median time to aHSCT was 9.4 months, and 89% of all aHSCTs occurred within two years of diagnosis. The median overall survival from time of aHSCT was 72.9 months (95% confidence interval [CI] = 68 to 78). Autologous HSCT at any time was associated with improved survival (aHR = 0.83, 95% CI = 0.75 to 0.92). Among aHSCT recipients, transplant more than 12 months after diagnosis (vs ≤12 months) was associated with worse survival (aHR = 1.33, 95% CI = 1.16 to 1.51). The positive effect of aHSCT on overall survival was similar across study time periods and age groups. Conclusion In the era of highly efficacious induction therapies, aHSCT remained infrequently used but continued to be associated with improved survival for multiple myeloma patients and should be considered for newly diagnosed patients.
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Affiliation(s)
- Aaron S Rosenberg
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, CA.,University of California, Davis Comprehensive Cancer Center, Sacramento, CA
| | - Ann Brunson
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, CA
| | - Brian A Jonas
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, CA.,University of California, Davis Comprehensive Cancer Center, Sacramento, CA.,VA Northern California Health Care System, Sacramento, CA
| | - Theresa H M Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, CA.,University of California, Davis Comprehensive Cancer Center, Sacramento, CA
| | - Ted Wun
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology Oncology, University of California, Davis School of Medicine, Sacramento, CA.,University of California, Davis Comprehensive Cancer Center, Sacramento, CA.,VA Northern California Health Care System, Sacramento, CA
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10
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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: 0] [Impact Index Per Article: 0] [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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11
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Pros and cons of frontline autologous transplant in multiple myeloma: the debate over timing. Blood 2019; 133:652-659. [DOI: 10.1182/blood-2018-08-825349] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/15/2018] [Indexed: 02/06/2023] Open
Abstract
Abstract
The treatment landscape for multiple myeloma has dramatically changed over the past decade with the introduction of several new classes of drugs, which are very effective at controlling the disease for prolonged periods of time, especially when used in multidrug combinations. Prior to the advent of these new agents, peripheral blood autologous stem cell transplantation (ASCT) was the mainstay of therapy for patients who were eligible to undergo the procedure, with deep and durable responses in the majority of patients. Despite the introduction of more effective therapies, ASCT continues to play an important role in overall management of younger patients, where it has been integrated with the other therapeutic approaches to provide maximum benefit. Recent phase 3 trials have once again confirmed the survival benefit associated with ASCT in myeloma. Retrospective studies have also demonstrated the feasibility of using ASCT at the time of first relapse rather than as a component of the initial treatment. Significant geographical variations exist in the use of ASCT, especially between the United States and Europe in terms of its use as part of upfront therapy. Much of these differences are driven by the availability of drugs and drug combinations for initial therapy of myeloma as well as maintenance approaches post-ASCT. It is amply clear from these trials that ASCT will continue to play an important role in management of myeloma and is likely to be used as a platform for enhancing the efficacy of other treatment modalities that are currently in development.
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12
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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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13
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Radivoyevitch T, Dean RM, Shaw BE, Brazauskas R, Tecca HR, Molenaar RJ, Battiwalla M, Savani BN, Flowers MED, Cooke KR, Hamilton BK, Kalaycio M, Maciejewski JP, Ahmed I, Akpek G, Bajel A, Buchbinder D, Cahn JY, D’Souza A, Daly A, DeFilipp Z, Ganguly S, Hamadani M, Hayashi RJ, Hematti P, Inamoto Y, Khera N, Kindwall-Keller T, Landau H, Lazarus H, Majhail NS, Marks DI, Olsson RF, Seo S, Steinberg A, William BM, Wirk B, Yared JA, Aljurf M, Abidi MH, Allewelt H, Beitinjaneh A, Cook R, Cornell RF, Fay JW, Hale G, Chakrabarty JH, Jodele S, Kasow KA, Mahindra A, Malone AK, Popat U, Rizzo JD, Schouten HC, Warwick AB, Wood WA, Sekeres MA, Litzow MR, Gale RP, Hashmi SK. Risk of acute myeloid leukemia and myelodysplastic syndrome after autotransplants for lymphomas and plasma cell myeloma. Leuk Res 2018; 74:130-136. [PMID: 30055822 PMCID: PMC6219911 DOI: 10.1016/j.leukres.2018.07.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/26/2018] [Accepted: 07/17/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Exposures to DNA-damaging drugs and ionizing radiations increase risks of acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). METHODS 9028 recipients of hematopoietic cell autotransplants (1995-2010) for Hodgkin lymphoma (HL; n = 916), non-Hodgkin lymphoma (NHL; n = 3546) and plasma cell myeloma (PCM; n = 4566), reported to the CIBMTR, were analyzed for risk of subsequent AML or MDS. RESULTS 335 MDS/AML cases were diagnosed posttransplant (3.7%). Variables associated with an increased risk for AML or MDS in multivariate analyses were: (1) conditioning with total body radiation versus chemotherapy alone for HL (HR = 4.0; 95% confidence interval [1.4, 11.6]) and NHL (HR = 2.5 [1.1, 2.5]); (2) ≥3 versus 1 line of chemotherapy for NHL (HR = 1.9 [1.3, 2.8]); and (3) subjects with NHL transplanted in 2005-2010 versus 1995-1999 (HR = 2.1 [1.5, 3.1]). Using Surveillance, Epidemiology and End Results (SEER) data, we found risks for AML/MDS in HL, NHL and PCM to be 5-10 times the background rate. In contrast, relative risks were 10-50 for AML and approximately 100 for MDS in the autotransplant cohort. CONCLUSIONS There are substantial risks of AML and MDS after autotransplants for HL, NHL and PCM.
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Affiliation(s)
- Tomas Radivoyevitch
- Dept. of Translational Hematology & Oncology Research, Cleveland Clinic Foundation, Cleveland, OH
| | - Robert M. Dean
- Dept. of Translational Hematology & Oncology Research, Cleveland Clinic Foundation, Cleveland, OH
| | - Bronwen E. Shaw
- CIBMTR (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI
| | - Ruta Brazauskas
- CIBMTR (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Heather R. Tecca
- CIBMTR (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI
| | - Remco J. Molenaar
- Dept. of Translational Hematology & Oncology Research, Cleveland Clinic Foundation, Cleveland, OH
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Minoo Battiwalla
- Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD
| | - Bipin N. Savani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Mary E. D. Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Kenneth R. Cooke
- Pediatric Blood and Marrow Transplantation Program, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Betty K. Hamilton
- Blood & Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio
| | - Matt Kalaycio
- Blood & Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio
| | | | - Ibrahim Ahmed
- Department of Hematology Oncology and Bone Marrow Transplantation, The Children’s Mercy Hospitals and Clinics, Kansas City, MO
| | - Görgün Akpek
- Stem Cell Transplantation and Cell Therapy, Rush University Medical Center, Chicago, IL
| | - Ashish Bajel
- Royal Melbourne Hospital City Campus, Melbourne, Australia
| | - David Buchbinder
- Division of Pediatrics Hematology, Children’s Hospital of Orange County, Orange, CA
| | - Jean-Yves Cahn
- Department of Hematology, CHU Grenoble Alpes, Grenoble, France
| | - Anita D’Souza
- CIBMTR (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI
| | - Andrew Daly
- Tom Baker Cancer Center, Calgary, AB, Canada
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, MA
| | - Siddhartha Ganguly
- Blood and Marrow Transplantation, University of Kansas Medical Center, Kansas City, KS
| | - Mehdi Hamadani
- CIBMTR (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI
| | - Robert J. Hayashi
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Peiman Hematti
- Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Nandita Khera
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, AZ
| | - Tamila Kindwall-Keller
- Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, VA
| | - Heather Landau
- Bone Marrow Transplant Service, Division of Hematology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hillard Lazarus
- Seidman Cancer Center, Case Western Reserve University, Cleveland, OH
| | | | - David I. Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Richard F. Olsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Sachiko Seo
- Department of Hematology & Oncology; National Cancer Research Center East, Chiba, Japan
| | - Amir Steinberg
- Department of Hematology-Oncology, Mount Sinai Hospital, New York, NY
| | | | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA
| | - Jean A. Yared
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital,, Riyadh, Saudi Arabia
| | - Muneer H. Abidi
- Department of Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, MI
| | | | | | - Rachel Cook
- Oregon Health and Science University, Portland, OR
| | - Robert F. Cornell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Gregory Hale
- Department of Hematology/Oncology, Johns Hopkins All Children’s Hospital, St. Petersburg, FL
| | | | - Sonata Jodele
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Anuj Mahindra
- Scripps Blood & Marrow Transplant Program, La Jolla, CA
| | - Adriana K. Malone
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - J. Douglas Rizzo
- CIBMTR (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI
| | - Harry C. Schouten
- Department of Hematology, Academische Ziekenhuis, Maastricht, Netherlands
| | - Anne B. Warwick
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - William A. Wood
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mikkael A. Sekeres
- Dept. of Translational Hematology & Oncology Research, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Robert P. Gale
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Shahrukh K. Hashmi
- Department of Oncology, King Faisal Specialist Hospital,, Riyadh, Saudi Arabia
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14
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Liu Y, Han H, Shah G, Giralt S, Ola Landgren C, He J, Lesokhin AM. Significant Nationwide Variability in the Costs and Hospital Mortality Rates of Autologous Stem Cell Transplantation for Multiple Myeloma: An Analysis of the Nationwide Inpatient Sample Database. Biol Blood Marrow Transplant 2018; 25:41-46. [PMID: 30195073 DOI: 10.1016/j.bbmt.2018.08.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/29/2018] [Indexed: 12/22/2022]
Abstract
Autologous hematopoietic stem cell transplantation (AHCT) is the standard of care for eligible patients with multiple myeloma (MM). In this study, we explored disparities in hospital cost and in-hospital mortality among patients with MM who underwent AHCT. Data were obtained from the Nationwide Inpatient Sample database for 2005 to 2014. International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis and procedure codes were used to identify patients. Hospitals were divided into quintiles according to the weighted volume of AHCTs performed in patients with MM. Multiple imputation with chained equation was used for missing data. Linear trend analysis of age- and sex-adjusted mortality, as well as inflation-adjusted hospital cost, was performed. Univariate regression screening followed by stepwise multivariate regression was performed for dependent variables, including mortality and inflation-adjusted hospital cost. Identified significant predictors underwent sensitivity analyses. Overall age- and sex-adjusted mortality rates and inflation-adjusted hospital costs decreased between 2005 and 2014; however, tremendous nationwide variability exists. Patients who underwent AHCT at very-low-volume hospitals (Q1) had significantly higher in-hospital mortality. Both geographic location and hospital type had impacted age- and sex-adjusted mortality rates and inflation-adjusted hospital costs. Despite an overall improvement in mortality and decreased cost of AHCT for patients with MM, nationwide variability in care exists. Further study is needed to identify correctable factors that contribute to the identified correlation.
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Affiliation(s)
- Yuzhou Liu
- Department of Medicine, Icahn School of Medicine at Mount Sinai St. Luke's and Mount Sinai West, New York, New York
| | - Hedong Han
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Gunjan Shah
- Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio Giralt
- Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - C Ola Landgren
- Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jia He
- Department of Health Statistics, Second Military Medical University, Shanghai, China.
| | - Alexander M Lesokhin
- Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
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15
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Dumontet C, Couray-Targe S, Teisseire M, Karlin L, Maucort-Boulch D. Real life management of patients hospitalized with multiple myeloma in France. PLoS One 2018; 13:e0196596. [PMID: 29715281 PMCID: PMC5929551 DOI: 10.1371/journal.pone.0196596] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 04/16/2018] [Indexed: 12/15/2022] Open
Abstract
Background Patients with multiple myeloma included in prospective clinical trials are highly selected and therefore are expected not to be representative of the entire patient population. Additionally recommendations based on literature data and randomized trials are not systematically implemented in all patients. We sought to determine how patients hospitalized with a diagnosis of multiple myeloma are currently treated in France. Methods and findings We performed a nation-wide search using the Programme de Médicalisation des Systèmes d’Information (PMSI) database which includes anonymous data for all patients hospitalized in France. We identified newly diagnosed cases in 2012 and analyzed the number and duration of hospital stays, coexisting conditions and treatment modalities with data available until the end of 2015. A diagnosis of multiple myeloma was determined for the first time during a hospitalization in France in 2012 in 6,282 patients (3,234 males and 3,048 females). The median age at diagnosis was 74 years (72 in males and 76 in females). A majority (55.3%) of patients were diagnosed and treated in a single heath center, including 37% in a university hospital and 52% in a non-university public hospital. Comorbidities potentially impacting on myeloma treatment were present in 57.5% of patients at diagnosis, and 15% had an associated diagnosis of another neoplasia. Intensive therapies with stem cell transplants were performed in 1033 patients (16% of total), the majority of which were aged less than 65 (881 patients, 85.3%). Stem cell transplants were performed more frequently in males while the distance between the site of residence and the transplant center had no impact on likelihood of receiving a transplant. Only 60% of patients less than 65 years old who were treated for their disease underwent intensification with stem cell transplant within the 4-year follow-up period. Conclusions A large majority of patients hospitalized with a diagnosis of multiple myeloma are elderly, in particular females, and not eligible for transplants. Among the patients aged less than 65 and receiving therapy for their disease, 40% do not undergo transplants. These data emphasize the need for alternative therapies.
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Affiliation(s)
- Charles Dumontet
- Hematology Department, Hospices Civils de Lyon, Pierre-Bénite, France.,Université Lyon I, Villeurbanne, France
| | | | | | - Lionel Karlin
- Hematology Department, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Delphine Maucort-Boulch
- Université Lyon I, Villeurbanne, France.,Hospices Civils de Lyon, Service de Biostatistiques, Lyon, France.,CNRS UMR 5558, Equipe Biostatistique Santé, Pierre-Bénite, France
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16
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Gupta S, Abouzaid S, Liebert R, Parikh K, Ung B, Rosenberg AS. Assessing the Effect of Adherence on Patient-reported Outcomes and Out of Pocket Costs Among Patients With Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:210-218. [PMID: 29429817 DOI: 10.1016/j.clml.2018.01.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 01/04/2018] [Accepted: 01/24/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND The present study characterized the effect of multiple myeloma (MM) on work productivity, health care resource usage, and out of pocket costs (OOPCs) and examined the association of adherence with quality of life (QoL) and productivity loss. MATERIALS AND METHODS The present cross-sectional study included 162 patients categorized by their 4-item Morisky Medication Adherence Scale (MMAS-4) score (4 vs. ≤ 3). Online surveys included the Work Productivity and Activity Impairment questionnaire, Functional Assessment of Cancer Therapy-Multiple Myeloma (FACT-MM), and MM-specific questions. RESULTS On average, patients reported FACT-MM scores of 98.5 ± 29.3, absenteeism of 18.3% ± 17.8%, presenteeism of 51.8% ± 30.2%, overall work productivity impairment of 57.3% ± 31.7%, and activity impairment of 49.9% ± 29.5% in the previous 7 days. During the previous 3 months, the mean OOPCs were $709 ± $1307; prescription medications accounted for 55% of these costs. Patients attended 4.1 ± 4.6 visits to oncologists or hematologists during that time, which accounted for 45% of the OOPCs. Patients spent an average of 6.8 ± 8.3 hours at MM-related monthly appointments, and 35.2% reported frustration while at the doctor's office. Patients with an MMAS-4 score of 4 reported higher FACT-MM scores (106.9 vs. 89.2; P < .001). Patients with an MMAS-4 score of ≤ 3 reported greater activity impairment (56.5% vs. 39.8%; P = .015) and feeling overwhelmed or frustrated with rescheduling MM appointments (64.0% vs. 26.0%; P = .002). CONCLUSION MM was associated with significant workplace and functional impairment, high OOPCs, and frequent office visits. High medication adherence was associated with better outcomes across these domains. As survival for patients with MM improves, patient QoL should be considered to enhance these outcomes.
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Affiliation(s)
- Shaloo Gupta
- Health Outcomes Practice, Kantar Health, New York, NY.
| | - Safiya Abouzaid
- US Health Economics and Outcomes Research, Celgene Corporation, Summit, NJ
| | - Ryan Liebert
- Health Outcomes Practice, Kantar Health, New York, NY
| | - Kejal Parikh
- US Health Economics and Outcomes Research, Celgene Corporation, Summit, NJ
| | - Brian Ung
- US Health Economics and Outcomes Research, Celgene Corporation, Summit, NJ
| | - Aaron S Rosenberg
- Division of Hematology and Oncology, Davis Comprehensive Cancer Center, University of California, Sacramento, CA
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17
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Fiala MA, Dukeman J, Tuchman SA, Keller M, Vij R, Wildes TM. Development of an Algorithm to Distinguish Smoldering Versus Symptomatic Multiple Myeloma in Claims-Based Data Sets. JCO Clin Cancer Inform 2017; 1:CCI.17.00089. [PMID: 30547156 PMCID: PMC6289182 DOI: 10.1200/cci.17.00089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Purpose The distinction of patients with symptomatic multiple myeloma (MM) from those with smoldering MM poses a challenge for researchers who use administrative databases. Historically, researchers either have included all patients or used treatment receipt as the distinguishing factor; both methods have drawbacks. We present an algorithm for distinguishing between symptomatic and smoldering MM using ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes for the classic defining events of symptomatic MM commonly referred to as the CRAB criteria (hypercalcemia, renal impairment, anemia, and bone lesions). Patients and Methods SEER-Medicare-linked data from 4,187 patients with MM diagnosed between 2007 and 2011 were used for this analysis. Results Eighty-four percent had ICD-9-CM codes consistent with CRAB criteria, whereas only 57% received treatment. Overall survival of patients with symptomatic MM defined as receipt of treatment was 32.3 months versus 26.6 months for the overall population and 22.9 months for patients with symptomatic MM defined by CRAB criteria. Conceptually, removal of patients with smoldering MM should result in a reduction in overall survival; however, the cohort of patients who received treatment tended to be younger and healthier than the overall population, which could have skewed the results. Conclusion The algorithm we present resulted in a larger and more representative sample than classification by treatment status and reduced potential bias that could result from including all patients with smoldering MM in the analysis. Although this study was performed using the SEER-Medicare database, the methodology was broad enough that the algorithm could be extended to additional claims-based data sets with relative ease.
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Affiliation(s)
- Mark A. Fiala
- Mark A. Fiala, James Dukeman, Matt Keller, Ravi Vij, and Tanya M. Wildes, Washington University School of Medicine, St Louis, MO; and Sascha A. Tuchman, University of North Carolina, Chapel Hill, NC
| | - James Dukeman
- Mark A. Fiala, James Dukeman, Matt Keller, Ravi Vij, and Tanya M. Wildes, Washington University School of Medicine, St Louis, MO; and Sascha A. Tuchman, University of North Carolina, Chapel Hill, NC
| | - Sascha A. Tuchman
- Mark A. Fiala, James Dukeman, Matt Keller, Ravi Vij, and Tanya M. Wildes, Washington University School of Medicine, St Louis, MO; and Sascha A. Tuchman, University of North Carolina, Chapel Hill, NC
| | - Matt Keller
- Mark A. Fiala, James Dukeman, Matt Keller, Ravi Vij, and Tanya M. Wildes, Washington University School of Medicine, St Louis, MO; and Sascha A. Tuchman, University of North Carolina, Chapel Hill, NC
| | - Ravi Vij
- Mark A. Fiala, James Dukeman, Matt Keller, Ravi Vij, and Tanya M. Wildes, Washington University School of Medicine, St Louis, MO; and Sascha A. Tuchman, University of North Carolina, Chapel Hill, NC
| | - Tanya M. Wildes
- Mark A. Fiala, James Dukeman, Matt Keller, Ravi Vij, and Tanya M. Wildes, Washington University School of Medicine, St Louis, MO; and Sascha A. Tuchman, University of North Carolina, Chapel Hill, NC
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18
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Westin GF, Dias AL, Go RS. Exploring Big Data in Hematological Malignancies: Challenges and Opportunities. Curr Hematol Malig Rep 2017; 11:271-9. [PMID: 27177742 DOI: 10.1007/s11899-016-0331-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Secondary analysis of large datasets has become a useful alternative to address research questions outside the reach of clinical trials. It is increasingly utilized in hematology and oncology. In this review, we provided an overview of some examples of commonly used large datasets in the USA and described common research themes that can be pursued using such a methodology. We selected a sample of 14 articles on adult hematologic malignancies published in 2015 and highlighted their contributions as well as limitations.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Databases, Factual
- Hematologic Neoplasms/diagnosis
- Hematologic Neoplasms/economics
- Hematologic Neoplasms/pathology
- Hematologic Neoplasms/therapy
- Hematopoietic Stem Cell Transplantation
- Hodgkin Disease/diagnosis
- Hodgkin Disease/economics
- Hodgkin Disease/pathology
- Hodgkin Disease/therapy
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/economics
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/economics
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/therapy
- Multiple Myeloma/diagnosis
- Multiple Myeloma/economics
- Multiple Myeloma/pathology
- Multiple Myeloma/therapy
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Affiliation(s)
- Gustavo F Westin
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ajoy L Dias
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Burden A, Roche N, Miglio C, Hillyer EV, Postma DS, Herings RM, Overbeek JA, Khalid JM, van Eickels D, Price DB. An evaluation of exact matching and propensity score methods as applied in a comparative effectiveness study of inhaled corticosteroids in asthma. Pragmat Obs Res 2017; 8:15-30. [PMID: 28356782 PMCID: PMC5367458 DOI: 10.2147/por.s122563] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Cohort matching and regression modeling are used in observational studies to control for confounding factors when estimating treatment effects. Our objective was to evaluate exact matching and propensity score methods by applying them in a 1-year pre–post historical database study to investigate asthma-related outcomes by treatment. Methods We drew on longitudinal medical record data in the PHARMO database for asthma patients prescribed the treatments to be compared (ciclesonide and fine-particle inhaled corticosteroid [ICS]). Propensity score methods that we evaluated were propensity score matching (PSM) using two different algorithms, the inverse probability of treatment weighting (IPTW), covariate adjustment using the propensity score, and propensity score stratification. We defined balance, using standardized differences, as differences of <10% between cohorts. Results Of 4064 eligible patients, 1382 (34%) were prescribed ciclesonide and 2682 (66%) fine-particle ICS. The IPTW and propensity score-based methods retained more patients (96%–100%) than exact matching (90%); exact matching selected less severe patients. Standardized differences were >10% for four variables in the exact-matched dataset and <10% for both PSM algorithms and the weighted pseudo-dataset used in the IPTW method. With all methods, ciclesonide was associated with better 1-year asthma-related outcomes, at one-third the prescribed dose, than fine-particle ICS; results varied slightly by method, but direction and statistical significance remained the same. Conclusion We found that each method has its particular strengths, and we recommend at least two methods be applied for each matched cohort study to evaluate the robustness of the findings. Balance diagnostics should be applied with all methods to check the balance of confounders between treatment cohorts. If exact matching is used, the calculation of a propensity score could be useful to identify variables that require balancing, thereby informing the choice of matching criteria together with clinical considerations.
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Affiliation(s)
- Anne Burden
- Observational and Pragmatic Research Institute Pte Ltd, Singapore
| | - Nicolas Roche
- University Paris Descartes (EA2511), Cochin Hospital Group (AP-HP), Paris, France
| | - Cristiana Miglio
- Observational and Pragmatic Research Institute Pte Ltd, Singapore
| | | | - Dirkje S Postma
- Department of Pulmonology, University Medical Center Groningen, University of Groningen, Groningen
| | - Ron Mc Herings
- PHARMO Institute for Drug Outcomes Research, Utrech, the Netherlands
| | - Jetty A Overbeek
- PHARMO Institute for Drug Outcomes Research, Utrech, the Netherlands
| | | | | | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore; Academic Primary Care, University of Aberdeen, Aberdeen, UK
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Nadiminti K, Singh Abbi KK, Mott SL, Dozeman L, Tricot A, Schultz A, Behrends S, Zhan F, Tricot G. VTD-melphalan is well tolerated and results in very high rates of stringent CR and MRD-negative status in multiple myeloma. Onco Targets Ther 2017; 10:217-226. [PMID: 28123303 PMCID: PMC5229169 DOI: 10.2147/ott.s112423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The addition of cytotoxic drugs to high-dose melphalan as a preparative regimen for autologous stem cell transplantation in multiple myeloma has not resulted in superior activity. Although novel agents have significantly improved outcome in multiple myeloma, their role in preparative regimens remains largely unknown. We have evaluated the toxicity and efficacy of combining bortezomib, thalidomide, and dexamethasone with high-dose melphalan. An institutional review board-approved retrospective analysis was performed on 100 consecutive patients receiving 153 transplants; 53 had tandem transplants; 64 patients received early transplants; and 36 had salvage transplantation. Endpoints were treatment-related toxicity and mortality, and quality of response post-transplantation with assessment of stringent complete remission (sCR) and minimal residual disease (MRD) status. Median age was 61 years, and median follow-up was 16.2 months. At 6 months, sCR was attained in 56% of patients and CR in 20%. An MRD status, assessed by sensitive (10−4) multiparameter flow cytometry, was achieved in 85%. The 100-day mortality rate was 2.6% (4/153); 1.8% for early transplants and 4.5% for salvage transplants. Grade 3–5 non-hematologic toxicities were mainly related to metabolism/nutrition; gastrointestinal and infectious problems. Median time to absolute neutrophil count of >500/µL was 12 days for both early and salvage transplantations. No significant differences in quality of response were observed between early and salvage transplantation or between single and tandem autologous stem cell transplantation. Since both sCR and MRD are excellent early surrogate markers for progression-free and overall survival, this regimen will likely be superior to melphalan alone, but it needs to be formally assessed in a randomized study.
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Affiliation(s)
- Kalyan Nadiminti
- Division of Hematology/Oncology; Holden Comprehensive Cancer Center
| | - Kamal Kant Singh Abbi
- Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | | | | | | | - Sonya Behrends
- Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Fenghuang Zhan
- Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Guido Tricot
- Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Fiala MA, Wildes TM. Racial disparities in treatment use for multiple myeloma. Cancer 2017; 123:1590-1596. [PMID: 28085188 DOI: 10.1002/cncr.30526] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/23/2016] [Accepted: 12/05/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Recent treatment advances have greatly improved the prognosis of patients with multiple myeloma. However, some of these newer, more effective treatments are intensive and expensive and their use remains low, particularly among black patients. METHODS In the current study, the authors reviewed the use patterns of stem cell transplantation and bortezomib using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. RESULTS After controlling for overall health and potential access barriers, black patients were found to be 37% (P<.0001) less likely to undergo stem cell transplantation, and 21% (P<.0001) less likely to be treated with bortezomib. Moreover, the authors found that the underuse of these treatments was associated with a 12% increase in the hazard ratio for death among black patients (P = 0.0007). CONCLUSIONS Eliminating health disparities, a current focus of US public policy, is highly complex, as illustrated by the results of the current study. In patients with multiple myeloma, treatment disparities are not completely explained by potential access barriers. Additional factors, such as structural barriers in the health care system and individual decision making among black and white patients, must be explored to fully explain the disparity. Cancer 2017;123:1590-1596. © 2017 American Cancer Society.
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Affiliation(s)
- Mark A Fiala
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.,George Warren Brown School of Social Work, Washington University, St. Louis, Missouri
| | - Tanya M Wildes
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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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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Merz M, Jansen L, Castro FA, Hillengass J, Salwender H, Weisel K, Scheid C, Luttmann S, Emrich K, Holleczek B, Katalinic A, Nennecke A, Straka C, Langer C, Engelhardt M, Einsele H, Kröger N, Beelen D, Dreger P, Brenner H, Goldschmidt H. Survival of elderly patients with multiple myeloma—Effect of upfront autologous stem cell transplantation. Eur J Cancer 2016; 62:1-8. [DOI: 10.1016/j.ejca.2016.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/23/2016] [Accepted: 04/04/2016] [Indexed: 12/01/2022]
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Shah GL, Winn AN, Lin PJ, Klein A, Sprague KA, Smith HP, Buchsbaum R, Cohen JT, Miller KB, Comenzo R, Parsons SK. Cost-Effectiveness of Autologous Hematopoietic Stem Cell Transplantation for Elderly Patients with Multiple Myeloma using the Surveillance, Epidemiology, and End Results-Medicare Database. Biol Blood Marrow Transplant 2015; 21:1823-9. [PMID: 26033281 PMCID: PMC4933291 DOI: 10.1016/j.bbmt.2015.05.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 05/14/2015] [Indexed: 12/22/2022]
Abstract
In the past decade, the number of autologous hematopoietic stem cell transplants (Auto HSCT) for older patients with multiple myeloma (MM) has increased dramatically, as has the cost of transplantation. The cost-effectiveness of this modality in patients over age 65 is unclear. Using the Surveillance, Epidemiology, and End Results-Medicare database to create a propensity-score matched sample of patients over age 65 between 2000 and 2007, we compared the survival and cost for those who received Auto HSCT to those who did not undergo transplantation but survived at least 6 months after diagnosis, and we calculated an incremental cost-effectiveness ratio (ICER). Two hundred seventy patients underwent transplantation. Median overall survival from diagnosis in those who underwent transplantation was significantly longer than in patients who did not (58 months versus 37 months, P < .001). For patients living longer than 2 years, the median monthly cost during the first year was significantly different, but the middle and last year of life costs were similar. The median cost of the first 100 days after transplantation was $60,000 (range, $37,000 to $85,000). The resultant ICER was $72,852 per life-year gained. Survival after transplantation was comparable to that in those who underwent transplantation patients under 65 years and significantly longer than older patients who did not undergo transplantation. With an ICER less than $100,000/life-year gained, Auto HSCT is cost-effective when compared with nontransplantation care in the era of novel agents and should be considered, where clinically indicated, for patients over the age of 65.
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Affiliation(s)
- Gunjan L Shah
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York.
| | - Aaron N Winn
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts; Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Pei-Jung Lin
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Andreas Klein
- Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Kellie A Sprague
- Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Hedy P Smith
- Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Rachel Buchsbaum
- Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Kenneth B Miller
- Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Raymond Comenzo
- Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Susan K Parsons
- Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts; Center for Health Solutions, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
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