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Engelhardt M, Kortüm KM, Goldschmidt H, Merz M. Functional cure and long-term survival in multiple myeloma: how to challenge the previously impossible. Haematologica 2024; 109:2420-2435. [PMID: 38356448 PMCID: PMC11290544 DOI: 10.3324/haematol.2023.283058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 02/06/2024] [Indexed: 02/16/2024] Open
Abstract
Multiple myeloma (MM) is a heterogeneous disease with survival ranging from months to decades. The goal of 'cure' remains elusive for most patients, but has been shown to be possible, with durable remission and a transition to a plateau phase (analogous to monoclonal gammopathy of uncertain significance/smoldering myeloma). In this review, two representative cases set the stage to illustrate how this might be possible and what still needs to be determined to achieve functional disease control over a prolonged period. Several developments have emerged, such as improved diagnostics including the definitions and use of SLiM-CRAB criteria and measurable residual disease (MRD) with whole-genome/single-cell sequencing as well as other correlates to better understand disease biology. These advances enable earlier detection, more accurate risk stratification and improved personalized treatment strategies by facilitating analysis of genetic alterations and clonal heterogeneity. Whole-genome sequencing may also identify driver mutations and modes of resistance to immunotherapies as well as other targeted therapies. Today, induction with a CD38 antibody, proteasome inhibitor, immunomodulatory drug, and dexamethasone, potentially followed by autologous stem cell transplantation and lenalidomide maintenance, can be considered standard of care for transplant-eligible (TE) patients with newly diagnosed MM (NDMM). That prolonged disease control and functional cure can be achieved in non-transplant-eligible (NTE) patients is currently emerging as a distinct possibility: data from phase III trials that incorporate a CD38 antibody into the treatment of NTE NDMM patients demonstrate impressive MRD negativity rates that appear sustained over several years. While the long-term durability of chimeric antigen receptor T cells, bi-specific antibodies and other immunotherapies are being evaluated, several clinical trials are now investigating their role in frontline treatment for TE and NTE patients. These trials will address whether chimeric antigen receptor T-cell therapy will replace autologous stem cell transplantation and whether such immunotherapies will represent a truly curative option. We conclude that while cure remains elusive, the concept of operational or functional cure provides a new benchmark to strive for and is an emerging area of active and potentially achievable clinical research for MM.
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Affiliation(s)
- Monika Engelhardt
- Department of Medicine I Hematology and Oncology, Medical Center University of Freiburg, Faculty of Medicine, Comprehensive Cancer Center Freiburg (CCCF).
| | - K Martin Kortüm
- Department of Medicine II, University Hospital of Würzburg, Würzburg
| | - Hartmut Goldschmidt
- University Hospital Heidelberg and the National Center for Tumor Diseases, Heidelberg
| | - Maximilian Merz
- Department of Hematology, Cell therapy and Hemostaseology, University Hospital Leipzig, Leipzig.
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2
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Geng C, Yang G, Zhou H, Wang H, Li Y, Leng Y, Zhang Z, Jian Y, Chen W. Low Barthel index score is a poor prognostic factor for newly diagnosed multiple myeloma patients. Clin Exp Med 2023; 23:2593-2600. [PMID: 36703087 DOI: 10.1007/s10238-023-01002-7] [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: 10/24/2022] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Abstract
The basic activities of daily life may affect the prognosis of multiple myeloma (MM) patients and the Barthel index (BI) is currently the most widely used tool to evaluate basic activities of daily life, but few studies have evaluated its prognostic value in MM. We retrospectively enrolled patients with newly diagnosed MM and analyzed the association between the BI and the survival of newly diagnosed MM patients. We totally analyzed 538 patients and found that median overall survival (OS) and progression-free survival (PFS) were significantly shorter in the low BI (≤ 85) group compared with the high BI (> 85) group. Univariate Cox proportional hazards regression analysis showed that the low BI was associated with shorter OS and PFS. It was also confirmed that the low BI was poor prognostic factor for OS and PFS in multivariable analyses. In the propensity score matching analysis, patients with low BI also had shorter OS and PFS. Our study suggested that the low BI was a poor prognostic factor for patients with newly diagnosed MM.
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Affiliation(s)
- Chuanying Geng
- Department of Hematology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Guangzhong Yang
- Department of Hematology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Huixing Zhou
- Department of Hematology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Huijuan Wang
- Department of Hematology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Yanchen Li
- Department of Hematology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Yun Leng
- Department of Hematology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Zhiyao Zhang
- Department of Hematology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Yuan Jian
- Department of Hematology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Wenming Chen
- Department of Hematology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
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3
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Meenaghan T, Hayat A, Walpole G, Dowling M. Advances in the management of myeloma: an update. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:S4-S12. [PMID: 37737854 DOI: 10.12968/bjon.2023.32.17.s4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Myeloma is an aggressive B-cell malignancy resulting from an uncontrolled production of plasma cells in the bone marrow. A multitude of drugs and combinations of drugs are now approved for use to treat this complex disease and nurses require knowledge and skills in recognising and managing new side effects associated with these treatments. This article presents an overview of some of the newer and recently approved drugs and the important side effects that have been associated with them. Clinical nurse specialists and advanced nurse practitioners are at the forefront of patients' treatment journeys and play a central role in supporting patients and families to manage side effects. Through this support, patients can continue the treatments for as long as possible with the aim of maintaining a good quality of life.
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Affiliation(s)
- Teresa Meenaghan
- Advanced Nurse Practitioner, Haematology Department, Galway University Hospital, Ireland
| | - Amjad Hayat
- Consultant Haematologist and Director of Blood and Tissue Establishment and the Stem Cell Lab, Haematology Department, Galway University Hospital, Ireland
| | - Geraldine Walpole
- Advanced Nurse Practitioner, Haematology, Sligo University Hospital, Ireland
| | - Maura Dowling
- Associate Professor, School of Nursing and Midwifery, University of Galway, Ireland
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4
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Tyczyńska A, Krzempek MK, Cortez AJ, Jurczyszyn A, Godlewska K, Ciepłuch H, Subocz E, Hałka J, Kulikowska de Nałęcz A, Wiśniewska A, Świderska A, Waszczuk-Gajda A, Drozd-Sokołowska J, Guzicka-Kazimierczak R, Wiśniewski K, Porowska A, Knopińska-Posłuszny W, Kłoczko J, Rzepecki P, Woszczyk D, Symonowicz H, Basak GW, Zdziarska B, Jamroziak K, Zaucha JM. The Real-World Evidence on the Fragility and Its Impact on the Choice of Treatment Regimen in Newly Diagnosed Patients with Multiple Myeloma over 75 Years of Age. Cancers (Basel) 2023; 15:3469. [PMID: 37444579 DOI: 10.3390/cancers15133469] [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: 05/30/2023] [Revised: 06/24/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
Fragility scales are intended to help in therapeutic decisions. Here, we asked if the fragility assessment in MM patients ≥ 75 years old qualified for treatment by the local physician correlates with the choice of treatment: a two- or three-drug regimens. Between 7/2018 and 12/2019, we prospectively enrolled 197 MM patients at the start of treatment from the 13 Polish Myeloma Group centers. The data to assess fragility were prospectively collected, but centrally assessed fragility was not disclosed to the local center. The activity of daily living (ADL) could be assessed in 192 (97.5%) and was independent in 158 (80.2%), moderately impaired in 23 (11.7%), and 11 (5.6%) in completely dependent. Patients with more than three comorbidities made up 26.9% (53 patients). Thus, according to the Palumbo calculator, 43 patients were in the intermediate fitness group (21.8%), and the rest belonged to the frailty group (153, 77.7%). Overall, 79.7% of patients (157) received three-drug regimens and 20.3% (40) received two-drug regimens. In each ECOG group, more than three out of four patients received three-drug regimens. According to the ADL scale, 82.3% of the independent 65.2% of moderately impaired, and 81.8% of the dependent received three-drug regimens. Out of 53 patients with at least four comorbidities, 71.7% received three-drug regimens, and the rest received two-drug regimens. Thirty-four patients from the intermediate fit group (79.0%), and 123 (79.9%) from the frail group received three-drug regimens. Early mortality occurred in 25 patients (12.7%). No one discontinued treatment due to toxicity. To conclude, MM patients over 75 are mainly treated with triple-drug regimens, not only in reduced doses, regardless of their frailty scores. However, the absence of prospective fragility assessment did not negatively affect early mortality and the number of treatment discontinuations, which brings into question the clinical utility of current fragility scales in everyday practice.
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Affiliation(s)
- Agata Tyczyńska
- Department of Hematology and Transplantology, Medical University of Gdańsk, 80-214 Gdańsk, Poland
| | - Marcela Krzysława Krzempek
- Department of Biostatistics and Bioinformatics, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, 44-102 Gliwice, Poland
| | - Alexander Jorge Cortez
- Department of Biostatistics and Bioinformatics, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, 44-102 Gliwice, Poland
| | - Artur Jurczyszyn
- Plasma Cell Dyscrasia Center, Department of Hematology, Jagiellonian University Medical College, 31-008 Kraków, Poland
| | - Katarzyna Godlewska
- Department of Hematology, Medical University of Bialystok, M. Sklodowskiej-Curie 24A, 15-276 Bialystok, Poland
| | - Hanna Ciepłuch
- Copernicus Regional Oncology Center, 80-803 Gdansk, Poland
| | - Edyta Subocz
- Department of Hematology, Military Institute of Medicine, 01-755 Warsaw, Poland
| | - Janusz Hałka
- Department of Hematology, Military Institute of Medicine, 01-755 Warsaw, Poland
| | | | - Anna Wiśniewska
- Department of Oncology and Chemotherapy, Nicolas Copernicus State Hospital, 75-581 Koszalin, Poland
| | - Alina Świderska
- Department of Hematology, University Hospital of Karola Marcinkowski in Zielona Góra, 65-046 Zielona Góra, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Joanna Drozd-Sokołowska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland
| | | | - Kamil Wiśniewski
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland
| | - Agnieszka Porowska
- Department of Oncology and Hematology, Central Clinical Hospital, Ministry of the Interior, 01-150 Warsaw, Poland
| | | | - Janusz Kłoczko
- Department of Hematology, Medical University of Bialystok, M. Sklodowskiej-Curie 24A, 15-276 Bialystok, Poland
| | - Piotr Rzepecki
- Department of Hematology, Military Institute of Medicine, 01-755 Warsaw, Poland
| | | | - Hanna Symonowicz
- Department of Oncology and Chemotherapy, Nicolas Copernicus State Hospital, 75-581 Koszalin, Poland
| | - Grzegorz Władysław Basak
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Barbara Zdziarska
- Department of Hematology, Pomeranian Medical University, 70-204 Szczecin, Poland
| | - Krzysztof Jamroziak
- Department of Hematology, Institute of Hematology and Transfusion Medicine, 02-776 Warsaw, Poland
| | - Jan M Zaucha
- Department of Hematology and Transplantology, Medical University of Gdańsk, 80-214 Gdańsk, Poland
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5
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Ipek Y, Karademir N, Yilmazer O, Yilmaz G. The Effects of Second Primary Malignancies and Frailty on Overall Survival and Mortality in Geriatric Turkish Patients with Multiple Myeloma. Curr Oncol 2023; 30:5615-5630. [PMID: 37366906 DOI: 10.3390/curroncol30060423] [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: 05/03/2023] [Revised: 06/02/2023] [Accepted: 06/07/2023] [Indexed: 06/28/2023] Open
Abstract
The study aims to investigate second primary malignancy (SPM) development and frailty in Turkish geriatric patients with multiple myeloma (MM) and to assess the relationship between overall survival (OS) and various characteristics including SPM and frailty. Seventy-two patients diagnosed with and treated for MM were enrolled in the study. Frailty was determined by the IMWG Frailty Score. Fifty-three participants (73.6%) were found to have clinically-relevant frailty. Seven patients (9.7%) had SPM. Median follow-up was 36.5 (22-48.5) months, and 17 patients died during the follow-up period. Overall (OS) was 49.40 (45.01-53.80) months. Shorter OS was found in patients with SPM (35.29 (19.66-50.91) months) compared to those without (51.05 (46.7-55.4) months) (Kaplan-Meier; p = 0.018). The multivariate cox proportional hazards model revealed that patients with SPM had 4.420-fold higher risk of death than those without (HR: 4.420, 95% CI: 1.371-14.246, p = 0.013). Higher ALT levels were also independently associated with mortality (p = 0.038). The prevalence of SPM and frailty was high in elderly patients with MM in our study. The development of SPM independently reduces survival in MM; however, frailty was not found to be independently associated with survival. Our results suggest the importance of individualized approaches in the management of patients with MM, particularly with regard to SPM development.
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Affiliation(s)
- Yildiz Ipek
- Department of Hematology, Kartal Lutfi Kirdar City Hospital, 34970 Istanbul, Turkey
| | - Nevra Karademir
- Department of Internal Diseases, Kartal Lutfi Kirdar City Hospital, 34970 Istanbul, Turkey
| | - Onur Yilmazer
- Department of Internal Diseases, Kartal Lutfi Kirdar City Hospital, 34970 Istanbul, Turkey
| | - Guven Yilmaz
- Department of Hematology, Kartal Lutfi Kirdar City Hospital, 34970 Istanbul, Turkey
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6
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Monteith BE, Sandhu I, Lee AS. Management of Multiple Myeloma: A Review for General Practitioners in Oncology. Curr Oncol 2023; 30:4382-4401. [PMID: 37232792 DOI: 10.3390/curroncol30050334] [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: 03/11/2023] [Revised: 04/15/2023] [Accepted: 04/18/2023] [Indexed: 05/27/2023] Open
Abstract
Multiple myeloma (MM) is a malignant clonal plasma cell disorder in the bone marrow and is the second-most common hematologic malignancy in adults. Although patients with MM have a moderate life expectancy, it remains a heterogeneous disease that often requires multiple lines of chemotherapy for durable control and long-term survival. This review outlines current management strategies for both transplant-eligible and transplant-ineligible patients as well as for relapsed and refractory disease. Advances in drug therapies have widened management options and improved survival. In this paper, we also discuss implications for special populations and survivorship care.
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Affiliation(s)
- Bethany E Monteith
- Department of Medicine, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Irwindeep Sandhu
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton AB T6G 1Z2, Canada
| | - Ann S Lee
- Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2T4, Canada
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7
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Frail Multiple Myeloma Patients Deserve More Than Just a Score. Hematol Rep 2023; 15:151-156. [PMID: 36975728 PMCID: PMC10048422 DOI: 10.3390/hematolrep15010015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/09/2022] [Accepted: 02/16/2023] [Indexed: 02/23/2023] Open
Abstract
Frailty is a hot topic in the field of multiple myeloma (MM). Clinicians have realised that frail myeloma patients can struggle with treatment, resulting in dose reductions and treatment discontinuation, which risk shorter progression-free and overall survival. Efforts have focused on the validity of existing frailty scores and on the development of new indices to identify frail patients more accurately. This review article explores the challenges of the existing frailty scores, including the International Myeloma Working Group (IMWG) frailty score, the revised Myeloma Co-morbidity Index (R-MCI), and the Myeloma Risk Profile (MRP). We conclude that the missing link is for frailty scoring to translate into a tool useful in real-world clinical practice. The future of frailty scores lies in their ability to be woven into clinical trials, to create a robust clinical evidence base for treatment selection and dose modification, and also to identify a cohort of patients who merit additional support from the wider MM multidisciplinary team.
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8
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Mian O, Puts M, McCurdy A, Wildes TM, Fiala MA, Kang M, Salib M, Alibhai S, Mian H. Decision-making factors for an autologous stem cell transplant for older adults with newly diagnosed multiple myeloma: A qualitative analysis. Front Oncol 2023; 12:974038. [PMID: 36776355 PMCID: PMC9911655 DOI: 10.3389/fonc.2022.974038] [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: 06/20/2022] [Accepted: 12/06/2022] [Indexed: 01/28/2023] Open
Abstract
Purpose A utologous stem cell transplant (ASCT) remains a standard of care among older adults (aged ≥65) with multiple myeloma (MM). However, heterogeneity in the eligibility and utilization of ASCT remains. We identified decision-making factors that influence ASCT eligibility and utilization among older adults with MM. Methods A qualitative study across two academic and two community centres in Ontario was conducted between July 2019-July 2020. Older adults with MM (newly diagnosed MM aged 65-75 in whom a decision had been made about ASCT in <12 months) and treating oncologists completed a baseline survey and a subsequent interview, which was analyzed using thematic analysis. Results Eighteen patients completed the survey and 9 follow-up interviews were conducted. Patients were happy with their treatment decision with "trust in their oncologist" and "wanting the best treatment" as the most important to proceed with ASCT. "Afraid of side effects" was the most common reason for declining ASCT. Fifteen oncologists completed the survey and 10 follow-up interviews were conducted. Most relied on the 'eye-ball' test for ASCT eligibility over geriatric screening tools. The lack of both high-quality evidence and local guidelines impacted decision-making. Both oncologists and patients felt that chronological age alone should not affect ASCT eligibility. Conclusion While decision-making factors regarding ASCT can be variable, both oncologists and patients indicated that chronological age alone should not represent a barrier for ASCT among older adults. Future simplification and incorporation of ASCT eligibility geriatric assessment tools in studies as well as the inclusion of these tools in local guidelines may further improve ASCT decision-making.
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Affiliation(s)
- Owais Mian
- Department of Internal Medicine, University of Toronto, Toronto, ON, Canada
| | - Martine Puts
- Department of Internal Medicine, University of Toronto, Toronto, ON, Canada
| | - Arleigh McCurdy
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, ON, Canada
| | - Tanya M. Wildes
- Division of Hematology and Oncology, Department of Internal Medicine, University of Nebraska Medical Center, Nebraska Medicine, Omaha, NE, United States
| | - Mark A. Fiala
- College for Public Health and Social Justice, Saint Louis University, St Louis, MO, United States,Department of Oncology, Washington University School of Medicine, St Louis, MO, United States
| | - Matthew Kang
- Department of Oncology, Joseph Brant Hospital, Burlington, ON, Canada
| | - Mary Salib
- Department of Oncology, Walker Family Cancer Centre St. Catherine’s General Hospital, St. Catherine, ON, Canada
| | - Shabbir Alibhai
- Department of Medicine, University Health Network & University of Toronto, Toronto, ON, Canada
| | - Hira Mian
- Department of Oncology, McMaster University, Hamilton, ON, Canada,*Correspondence: Hira Mian,
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Mian H, McCurdy A, Giri S, Grant S, Rochwerg B, Winks E, Rosko AE, Engelhardt M, Pawlyn C, Cook G, Jackson G, Bringhen S, Facon T, Larocca A, Zweegman S, Wildes TM. The prevalence and outcomes of frail older adults in clinical trials in multiple myeloma: A systematic review. Blood Cancer J 2023; 13:6. [PMID: 36599867 DOI: 10.1038/s41408-022-00779-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/15/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023] Open
Abstract
Multiple myeloma (MM) is an incurable blood cancer that primarily affects older adults. Several frailty tools have been developed to address the heterogeneity of aging in this population. Uptake of these measures has been variable, leading to a gap in knowledge regarding the proportion of enrolled trial participants considered frail and uncertainty in the treatment-related effects and outcomes among this high-risk population. We performed a systematic review of therapeutic interventional MM clinical trials reporting on frailty. We included 43 clinical trials (24 randomized controlled trials and 19 non-randomized trials) which met eligibility criteria. Frailty was increasingly incorporated in studies in more recent years with 41.9% of included studies being reported in the last two years. Commonly used frailty tools included the International Myeloma Working Group (IMWG) frailty index (41.8%), and the simplified frailty score (39.5%). Frailty status was categorized with 3 levels as (frail, intermediate fit, or fit) in 51.2% of the studies and dichotomized (frail, non-frail) in 18.6% of studies. Frailty prevalence greatly varied across trials ranging from 17.2% to 73.6% of the cohort. Of the included studies, 72.0% conducted subgroup analysis (planned or post-hoc) based on frailty status. Most studies demonstrated a consistent benefit of MM interventions among the frail and non-frail populations, however in general, frail patients had worse outcomes compared to the fit. Although frailty is increasingly being incorporated in MM clinical trials, due to the variation in both the definition and categorization of frailty, there remains heterogeneity in the prevalence of frailty and its potential associated impact on outcomes.
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Affiliation(s)
- Hira Mian
- Department of Oncology, McMaster University, Hamilton, ON, Canada.
| | - Arleigh McCurdy
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Smith Giri
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Shakira Grant
- Department of Medicine, Division of Hematology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Erica Winks
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - Ashley E Rosko
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Monika Engelhardt
- Hematology and Oncology Department, Interdisciplinary Cancer Center (ITZ) and Comprehensive Cancer Center Freiburg (CCCF), Faculty of Freidburg, University of Freiburg, Hugstetterstr. 53, 79106, Freiburg, Germany
| | - Charlotte Pawlyn
- The Institute of Cancer Research and Royal Marsden Hospital NHS Foundation Trust, London, UK
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Gordon Cook
- Cancer Research UK Clinical Trials Unit, LICTR, University of Leeds, Leeds, UK
| | - Graham Jackson
- Northern Centre for Cancer Care, Newcastle Upon Tyne Hospitals Trust, Newcastle Upon Tyne, UK
| | - Sara Bringhen
- SSD Clinical Trial in Onco-hematology and Multiple Myeloma, AOU City of Health and Science of Turin, Torino, Italy
| | - Thierry Facon
- University of Lille, CHU Lille, Service des Maladies du Sang, Lille, France
- French Academy of Medicine, Paris, France
| | - Alessandra Larocca
- SSD Clinical trials in onco-ematologia e mieloma multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Tanya M Wildes
- Division of Hematology/Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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10
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Urban VS, Cegledi A, Mikala G. Multiple myeloma, a quintessential malignant disease of aging: a geroscience perspective on pathogenesis and treatment. GeroScience 2022; 45:727-746. [PMID: 36508077 PMCID: PMC9742673 DOI: 10.1007/s11357-022-00698-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
Multiple myeloma (MM) is an incurable plasma cell malignancy, which is predominantly a disease of older adults (the median age at diagnosis is 70 years). The slow progression from asymptomatic stages and the late-onset of MM suggest fundamental differences compared to many other hematopoietic system-related malignancies. The concept discussed in this review is that age-related changes at the level of terminally differentiated plasma cells act as the main risk factors for the development of MM. Epigenetic and genetic changes that characterize both MM development and normal aging are highlighted. The relationships between cellular aging processes, genetic mosaicism in plasma cells, and risk for MM and the stochastic processes contributing to clonal selection and expansion of mutated plasma cells are investigated. In line with the DNA damage accumulation theory of aging, in this review, the evolution of monoclonal gammopathy to symptomatic MM is considered. Therapeutic consequences of age-dependent comorbidities that lead to frailty and have fundamental influence on treatment outcome are described. The importance of considering geriatric states when planning the life-long treatment course of an elderly MM patient in order to achieve maximal therapeutic benefit is emphasized.
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Affiliation(s)
- Veronika S. Urban
- Department of Morphology and Physiology, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
| | - Andrea Cegledi
- Department of Hematology and Stem Cell Transplantation, South Pest Central Hospital–National Institute for Hematology and Infectious Diseases, Budapest, Hungary
| | - Gabor Mikala
- Department of Hematology and Stem Cell Transplantation, South Pest Central Hospital-National Institute for Hematology and Infectious Diseases, Budapest, Hungary.
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11
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Pawlyn C, Khan AM, Freeman CL. Fitness and frailty in myeloma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:337-348. [PMID: 36485137 PMCID: PMC9820647 DOI: 10.1182/hematology.2022000346] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
As the aging population grows, so too does the number of well-tolerated antimyeloma therapies. Physicians will see an increasing volume of patients for subsequent lines of therapy, which could now extend this relationship for over a decade. For younger patients, treatment choices are infrequently impacted by concerns of fitness, but instead about effecting the deepest, most durable response. Older adults, in contrast, are more likely to experience under- than overtreatment, and therefore more objective (and ideally straightforward) ways to evaluate their fitness and ability to tolerate therapy will increasingly assist in decision-making. Post hoc analyses categorizing the fitness of trial patients in the modern treatment era globally demonstrate that even in highly selected populations, those that are recategorized as less fit or frail are consistently at higher risk of inferior outcomes and increased toxicities. Real-world data are comparatively lacking but do demonstrate that most patients with myeloma are not representative of those enrolled on clinical trials, generally more heavily burdened by comorbidities and more likely to be categorized as "less than fit." Simultaneously, the number of therapeutic options open to patients in the relapsed setting continues to grow, now including T-cell engagers and cellular therapies, with their unique toxicity profiles. The aim of this review is to summarize the available data, highlight some of the approaches possible to easily assess fitness and how results might inform treatment selection, and illustrate ways that patients' condition can be optimized rather than lead to exclusion from the more complex therapies newly available.
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Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Abdullah M Khan
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Ciara L Freeman
- H. Lee Moffitt Cancer Centre & Research Institute, Morsani College of Medicine, University of South Florida, Tampa, FL
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Ran T, Medhekar R, Fu AZ, Patel S, Kaila S. Patient characteristics associated with dose modifications for VRd among newly diagnosed multiple myeloma patients. Future Oncol 2022; 18:3983-3991. [PMID: 36377712 DOI: 10.2217/fon-2022-0933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aim: To evaluate among multiple myeloma (MM) patients, the proportions with first-line bortezomib/lenalidomide/dexamethasone (VRd) dose modifications and the associated baseline patient characteristics. Patients & methods: Adult MM patients treated with first-line VRd were selected from the Optum claims database. VRd dose modifications were defined based on lenalidomide dose. Results: Among 1497 MM patients, 33% received VRd lite and 22% VRd reduced. Compared with VRd regular, VRd lite usage was more likely to be associated with patients aged ≥75 years and female sex; VRd reduced usage was more likely to be associated with female sex and frailty. Conclusion: A large proportion of MM patients received VRd dose modifications in the real-world, which could potentially result in reduced effectiveness of VRd.
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Affiliation(s)
- Tao Ran
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA
| | - Rohan Medhekar
- Janssen Scientific Affairs, LLC, 800 Ridgeview Drive, Horsham, PA 19044, USA
| | - Alex Z Fu
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA.,Georgetown University Medical Center, 37th & O Street NW, Washington, DC 20057, USA
| | - Sharmila Patel
- Janssen Scientific Affairs, LLC, 800 Ridgeview Drive, Horsham, PA 19044, USA
| | - Shuchita Kaila
- Janssen Scientific Affairs, LLC, 800 Ridgeview Drive, Horsham, PA 19044, USA
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Morabito F, Zamagni E, Conticello C, Pavone V, Palmieri S, Bringhen S, Galli M, Mangiacavalli S, Derudas D, Rossi E, Ria R, Catalano L, Tacchetti P, Mele G, Vincelli ID, Martino EA, Vigna E, Bruzzese A, Mendicino F, Botta C, Mele A, Pantani L, Rocchi S, Garibaldi B, Cascavilla N, Ballanti S, Tripepi G, Frigeri F, Falcone AP, Cangialosi C, Reddiconto G, Farina G, Barone M, Rizzello I, Iaccino E, Mimmi S, Curci P, Gamberi B, Musto P, De Stefano V, Musso M, Petrucci MT, Offidani M, Di Raimondo F, Boccadoro M, Cavo M, Neri A, Gentile M. Survival Risk Scores for Real-Life Relapsed/Refractory Multiple Myeloma Patients Receiving Elotuzumab or Carfilzomib In Combination With Lenalidomide and Dexamethasone as Salvage Therapy: Analysis of 919 Cases Outside Clinical Trials. Front Oncol 2022; 12:890376. [PMID: 35924160 PMCID: PMC9341470 DOI: 10.3389/fonc.2022.890376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/17/2022] [Indexed: 11/20/2022] Open
Abstract
The present study aimed to develop two survival risk scores (RS) for overall survival (OS, SRSKRd/EloRd) and progression-free survival (PFS, PRSKRd/EloRd) in 919 relapsed/refractory multiple myeloma (RRMM) patients who received carfilzomib, lenalidomide, and dexamethasone (KRd)/elotuzumab, lenalidomide, and dexamethasone (EloRd). The median OS was 35.4 months, with no significant difference between the KRd arm versus the EloRd arm. In the multivariate analysis, advanced ISS (HR = 1.31; P = 0.025), interval diagnosis–therapy (HR = 1.46; P = 0.001), number of previous lines of therapies (HR = 1.96; P < 0.0001), older age (HR = 1.72; P < 0.0001), and prior lenalidomide exposure (HR = 1.30; P = 0.026) remained independently associated with death. The median PFS was 20.3 months, with no difference between the two strategies. The multivariate model identified a significant progression/death risk increase for ISS III (HR = 1.37; P = 0.002), >3 previous lines of therapies (HR = 1.67; P < 0.0001), older age (HR = 1.64; P < 0.0001), and prior lenalidomide exposure (HR = 1.35; P = 0.003). Three risk SRSKRd/EloRd categories were generated: low-risk (134 cases, 16.5%), intermediate-risk (467 cases, 57.3%), and high-risk categories (213 cases, 26.2%). The 1- and 2-year OS probability rates were 92.3% and 83.8% for the low-risk (HR = 1, reference category), 81.1% and 60.6% (HR = 2.73; P < 0.0001) for the intermediate-risk, and 65.5% and 42.5% (HR = 4.91; P < 0.0001) for the high-risk groups, respectively. Notably, unlike the low-risk group, which did not cross the median timeline, the OS median values were 36.6 and 18.6 months for the intermediate- and high-risk cases, respectively. Similarly, three PRSKRd/EloRd risk categories were engendered. Based on such grouping, 338 (41.5%) cases were allocated in the low-, 248 (30.5%) in the intermediate-, and 228 (28.0%) in the high-risk groups. The 1- and 2-year PFS probability rates were 71.4% and 54.5% for the low-risk (HR = 1, reference category), 68.9% and 43.7% (HR = 1.95; P < 0.0001) for the intermediate-risk, and 48.0% and 27.1% (HR = 3.73; P < 0.0001) for the high-risk groups, respectively. The PFS median values were 29.0, 21.0, and 11.7 months for the low-, intermediate-, and high-risk cases. This analysis showed 2.7- and 4.9-fold increased risk of death for the intermediate- and high-risk cases treated with KRd/EloRd as salvage therapy. The combined progression/death risks of the two categories were increased 1.3- and 2.2-fold compared to the low-risk group. In conclusion, SRSKRd/EloRd and PRSKRd/EloRd may represent accessible and globally applicable models in daily clinical practice and ultimately represent a prognostic tool for RRMM patients who received KRd or EloRd.
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Affiliation(s)
- Fortunato Morabito
- Biotechnology Research Unit, AO of Cosenza, Cosenza, Italy
- Hematology and Bone Marrow Transplant Unit, Hemato-Oncology Department, Augusta Victoria Hospital, East Jerusalem, Israel
- *Correspondence: Fortunato Morabito, ; Massimo Gentile, ; Antonino Neri,
| | - Elena Zamagni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Concetta Conticello
- Division of Hematology, Azienda Policlinico-S. Marco, University of Catania, Catania, Italy
| | - Vincenzo Pavone
- Department of Hematology and Bone Marrow Transplant, Hospital Card. G. Panico, Tricase, Italy
| | | | - Sara Bringhen
- Division of Hematology, AOU Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Monica Galli
- Hematology and Bone Marrow Transplant Unit, Azienda Socio-Sanitaria Territoriale-Papa Giovanni XXIII, Bergamo, Italy
| | - Silvia Mangiacavalli
- Hematology Division, Department of Hematology-Oncology, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | | | - Elena Rossi
- Istituto di Ematologia, Università Cattolica, Fondazione Policlinico Gemelli IRCCS, Roma, Italy
| | - Roberto Ria
- Department of Biomedical Science, Internal Medicine “G. Baccelli”, Policlinico, University of Bari “Aldo Moro” Medical School, Bari, Italy
| | | | - Paola Tacchetti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Giuseppe Mele
- Department of Hematology, Hospital Perrino, Brindisi, Italy
| | - Iolanda Donatella Vincelli
- Hematology Unit, Department of Hemato-Oncology and Radiotherapy, Great Metropolitan Hospital “Bianchi-Melacrino-Morelli”, Reggio Calabria, Italy
| | | | - Ernesto Vigna
- Department of Onco-Hematology, Hematology Unit AO of Cosenza, Cosenza, Italy
| | - Antonella Bruzzese
- Department of Onco-Hematology, Hematology Unit AO of Cosenza, Cosenza, Italy
| | - Francesco Mendicino
- Department of Onco-Hematology, Hematology Unit AO of Cosenza, Cosenza, Italy
| | - Cirino Botta
- Department of Onco-Hematology, Hematology Unit AO of Cosenza, Cosenza, Italy
| | - Anna Mele
- Department of Hematology and Bone Marrow Transplant, Hospital Card. G. Panico, Tricase, Italy
| | - Lucia Pantani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Serena Rocchi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Bruno Garibaldi
- Division of Hematology, Azienda Policlinico-S. Marco, University of Catania, Catania, Italy
| | - Nicola Cascavilla
- Department of Hematology and Bone Marrow Transplant, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Stelvio Ballanti
- Institute of Haematology and Stem Cell transplantation, Ospedale Santa Maria della Misericordia, University of Perugia, Perugia, Italy
| | - Giovanni Tripepi
- Department of Internal Medicine, Nephrology Center of National Research Institute of Biomedicine and Molecular Immunology, Reggio Calabria, Italy
| | - Ferdinando Frigeri
- UOC Ematologia a Indirizzo Oncologico, AORN “Sant’Anna e San Sebastiano”, Caserta, Italy
| | - Antonetta Pia Falcone
- Department of Hematology and Bone Marrow Transplant, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Clotilde Cangialosi
- U.O.C. Ematologia A. O. Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | | | - Giuliana Farina
- UOC Ematologia a Indirizzo Oncologico, AORN “Sant’Anna e San Sebastiano”, Caserta, Italy
| | | | - Ilaria Rizzello
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Enrico Iaccino
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Selena Mimmi
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Paola Curci
- Department of Emergency and Organ Transplantation, “Aldo Moro” University School of Medicine and Unit of Hematology and Stem Cell Transplantation, AOUC Policlinico, Bari, Italy
| | - Barbara Gamberi
- Division of Hematology, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Pellegrino Musto
- Department of Emergency and Organ Transplantation, “Aldo Moro” University School of Medicine and Unit of Hematology and Stem Cell Transplantation, AOUC Policlinico, Bari, Italy
| | - Valerio De Stefano
- Istituto di Ematologia, Università Cattolica, Fondazione Policlinico Gemelli IRCCS, Roma, Italy
| | - Maurizio Musso
- U.O.C. OncoEmatologia e TMO, Dipartimento Oncologico, Palermo, Italy
| | - Maria Teresa Petrucci
- Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Roma, Italy
| | | | - Francesco Di Raimondo
- Division of Hematology, Azienda Policlinico-S. Marco, University of Catania, Catania, Italy
| | - Mario Boccadoro
- Division of Hematology, AOU Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Antonino Neri
- Scientific Directorate, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
- *Correspondence: Fortunato Morabito, ; Massimo Gentile, ; Antonino Neri,
| | - Massimo Gentile
- Department of Onco-Hematology, Hematology Unit AO of Cosenza, Cosenza, Italy
- *Correspondence: Fortunato Morabito, ; Massimo Gentile, ; Antonino Neri,
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Allogeneic Stem Cell Transplantation in Multiple Myeloma. Cancers (Basel) 2021; 14:cancers14010055. [PMID: 35008228 PMCID: PMC8750583 DOI: 10.3390/cancers14010055] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/08/2021] [Accepted: 12/15/2021] [Indexed: 12/26/2022] Open
Abstract
The development of new inhibitory and immunological agents and combination therapies significantly improved response rates and survival of patients diagnosed with multiple myeloma (MM) in the last decade, but the disease is still considered to be incurable by current standards and the prognosis is dismal especially in high-risk groups and in relapsed and/or refractory patients. Allogeneic hematopoietic stem cell transplantation (allo-SCT) may enable long-term survival and even cure for individual patients via an immune-mediated graft-versus-myeloma (GvM) effect, but remains controversial due to relevant transplant-related risks, particularly immunosuppression and graft-versus-host disease, and a substantial non-relapse mortality. The decreased risk of disease progression may outweigh this treatment-related toxicity for young, fit patients in high-risk constellations with otherwise often poor long-term prognosis. Here, allo-SCT should be considered within clinical trials in first-line as part of a tandem approach to separate myeloablation achieved by high-dose chemotherapy with autologous SCT, and following allo-SCT with a reduced-intensity conditioning to minimize treatment-related organ toxicities but allow GvM effect. Our review aims to better define the role of allo-SCT in myeloma treatment particularly in the context of new immunomodulatory approaches.
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