1
|
Pawlyn C, Schjesvold FH, Cairns DA, Wei LJ, Davies F, Nadeem O, Abdulhaq H, Mateos MV, Laubach J, Weisel K, Ludwig H, Rajkumar SV, Sonneveld P, Jackson G, Morgan G, Richardson PG. Progression-free survival as a surrogate endpoint in myeloma clinical trials: an evolving paradigm. Blood Cancer J 2024; 14:134. [PMID: 39134544 PMCID: PMC11319634 DOI: 10.1038/s41408-024-01109-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 07/19/2024] [Accepted: 07/23/2024] [Indexed: 08/15/2024] Open
Abstract
Measurement of overall survival (OS) remains the gold standard for interpreting the impact of new therapies for multiple myeloma in phase 3 trials. However, as outcomes have improved, it is increasingly challenging to use OS as the primary endpoint if timely approval of novel agents is to be ensured to enable maximum benefit for patients. Surrogate endpoints of OS, such as progression-free survival (PFS) and response to treatment, have contributed to approval decisions by the Food and Drug Administration (FDA) and European Medicines Agency as endpoints demonstrating clinical benefit, and the FDA has recently supported the use of minimal residual disease (MRD) as an accelerated approval endpoint in multiple myeloma. This review aims to address situations in which the use of PFS as a surrogate endpoint warrants careful interpretation especially for specific subgroups of patients and considers ways to ensure that studies can be designed to account for possible discordance between PFS and OS. The utility of subgroup analyses, including the potential for those not pre-specified, to identify target populations for new agents is also discussed.
Collapse
Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, London, UK.
- The Royal Marsden Hospital NHS Foundation Trust, London, UK.
| | - Fredrik H Schjesvold
- Oslo Myeloma Center, Department of Hematology, Oslo University Hospital, Oslo, Norway
- KG Jebsen Center for B Cell Malignancies, University of Oslo, Oslo, Norway
| | - David A Cairns
- Leeds Cancer Research UK Clinical Trials Unit of Leeds, Leeds, UK
| | - L J Wei
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Faith Davies
- Perlmutter Cancer Center, NYU Langone, New York, NY, USA
| | - Omar Nadeem
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Haifaa Abdulhaq
- University of California, San Francisco, Fresno Campus, CA, USA
| | - Maria-Victoria Mateos
- University Hospital of Salamanca; IBSAL; Institute of Cancer Molecular and Cellular Biology; and CIBERONC, Salamanca, Spain
| | | | - Katja Weisel
- University Medical Center of Hamburg-Eppendorf, Hamburg, Germany
| | - Heinz Ludwig
- Medical Department Center for Oncology, Hematology and Palliative Medicine, Wilhelminen Cancer Research Institute, Vienna, Austria
| | | | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Graham Jackson
- Northern Centre for Cancer Care, Newcastle Upon Tyne Hospitals Trust, Newcastle Upon Tyne, UK
| | - Gareth Morgan
- Perlmutter Cancer Center, NYU Langone, New York, NY, USA
| | | |
Collapse
|
2
|
Ramdany H, Lofaro T, Deplano S. The Haemato-Oncology Frailty (HOF) score to assess frailty in lymphoma. Eur J Haematol 2024; 112:611-620. [PMID: 38112247 DOI: 10.1111/ejh.14152] [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: 10/23/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
Morbidity and mortality during chemotherapy in older adults with haematological malignancy can be unpredictable. The Haemato-Oncology Frailty (HOF) score was previously found to predict outcomes in a cohort of patients with plasma cell myeloma. In this study, we assess its utility in assessing frailty in patients with lymphoma, and compare its performance to that of two other frailty scores. The HOF score was able to predict progression-free survival in this population, and was also shown to have potential in assessing the dynamism of frailty during chemotherapy. It performed well when compared to the Charlson Comorbidity Index (CCI) score and the Haematopoietic Cell Transplantation-Specific Comorbidity Index (HCTCI), although the study was not powered to assess for non-inferiority. The HOF score is a new score with the potential for application in different haematological malignancies.
Collapse
Affiliation(s)
- Hena Ramdany
- Imperial College London, Isle of Wight NHS Trust, Newport, UK
| | | | | |
Collapse
|
3
|
Teo WZY, Ong IYE, Tong JWY, Ong WL, Lin A, Song F, Tai BC, Ooi M, Seokojo CY, Chen Y, Nagarajan C, Chng WJ, de Mel S. Response-Adapted Therapy for Newly Diagnosed Multiple Myeloma. Curr Hematol Malig Rep 2023; 18:190-200. [PMID: 37400631 DOI: 10.1007/s11899-023-00704-9] [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] [Accepted: 06/13/2023] [Indexed: 07/05/2023]
Abstract
PURPOSE OF REVIEW The development of potent novel agents has improved outcomes for patients with multiple myeloma (MM). Heterogeneity of response to therapy, an expanding arsenal of treatment options, and cost are however major challenges for physicians making treatment decisions. Response-adapted therapy is hence an attractive strategy for sequencing of therapy in MM. Despite its successful application in other haematologic malignancies, response-adapted therapy is yet to become a standard of care for MM. We provide our perspective on response-adapted therapeutic strategies evaluated thus far and how they may be implemented and improved on in treatment algorithms of the future. RECENT FINDINGS While older studies suggested that early response based on International Myeloma Working Group response criteria could impact long-term outcomes, recent data have contradicted these findings. The advent of minimal residual disease (MRD) as a powerful prognostic factor in MM has raised the promise of MRD-adapted treatment strategies. The development of more sensitive techniques for paraprotein quantification as well as imaging modalities to detect extramedullary disease is likely to change response assessment in MM. These techniques combined with MRD assessment may provide sensitive and holistic response assessments which could be evaluated in clinical trials. Response-adapted treatment algorithms have the potential to allow an individualised treatment strategy, maximising efficacy, while minimising toxicities and cost. Standardisation of MRD methodology, incorporation of imaging into response assessment, and the optimal management of MRD positive patients are key questions to be addressed in future trials.
Collapse
Affiliation(s)
- Winnie Z Y Teo
- Department of Haematology-Oncology, National University Cancer Science Institute of Singapore (NCIS), National University Health System, Singapore, Singapore
- Fast and Chronic Program, Alexandra Hospital, National University Health System, Singapore, Singapore
| | - Ian Y E Ong
- Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Jason W Y Tong
- Department of General Surgery, National University Health System, Singapore, Singapore
| | - Wan Li Ong
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Adeline Lin
- Department of Haematology-Oncology, National University Cancer Science Institute of Singapore (NCIS), National University Health System, Singapore, Singapore
| | - Fangfang Song
- Department of Haematology-Oncology, National University Cancer Science Institute of Singapore (NCIS), National University Health System, Singapore, Singapore
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Melissa Ooi
- Department of Haematology-Oncology, National University Cancer Science Institute of Singapore (NCIS), National University Health System, Singapore, Singapore
| | - Cinnie Yentia Seokojo
- Department of Haematology-Oncology, National University Cancer Science Institute of Singapore (NCIS), National University Health System, Singapore, Singapore
| | - Yunxin Chen
- SingHealth Duke-NUS Blood Cancer Centre, Singapore General Hospital, Singapore, Singapore
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Chandramouli Nagarajan
- SingHealth Duke-NUS Blood Cancer Centre, Singapore General Hospital, Singapore, Singapore
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Science Institute of Singapore (NCIS), National University Health System, Singapore, Singapore
- Department of Medicine Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Cancer Science Institute, National University of Singapore, Singapore, Singapore
| | - Sanjay de Mel
- Department of Haematology-Oncology, National University Cancer Science Institute of Singapore (NCIS), National University Health System, Singapore, Singapore.
- Department of Medicine Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| |
Collapse
|
4
|
Suzuki T, Maruyama D, Machida R, Kataoka T, Fukushima N, Takayama N, Ohba R, Omachi K, Imaizumi Y, Tokunaga M, Katsuya H, Yoshida I, Sunami K, Kurosawa M, Kubota N, Morimoto H, Kobayashi M, Yamamoto K, Kameoka Y, Kagami Y, Tabayashi T, Maruta M, Kobayashi T, Iida S, Nagai H. Prognostic impact of the UK Myeloma Research Alliance Risk Profile in transplant-ineligible patients with multiple myeloma who received a melphalan, prednisolone, and bortezomib regimen: A supplementary analysis of JCOG1105. Hematol Oncol 2023; 41:590-593. [PMID: 36416678 DOI: 10.1002/hon.3103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Tomotaka Suzuki
- Department of Hematology and Oncology, Nagoya City University Hospital, Nagoya, Japan
| | - Dai Maruyama
- Department of Hematology Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryunosuke Machida
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoko Kataoka
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Noriyasu Fukushima
- Department of Hematology and Oncology, Hiroshima University Research Institute for Radiation Biology and Medicine, Hiroshima, Japan
| | - Nobuyuki Takayama
- Department of Hematology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Rie Ohba
- Department of Clinical Oncology and Hematology, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Ken Omachi
- Department of Hematology Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | | | - Masahito Tokunaga
- Department of Hematology, Imamura General Hospital, Kagoshima, Japan
| | - Hiroo Katsuya
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Isao Yoshida
- Department of Hematologic Oncology, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
| | - Kazutaka Sunami
- Department of Hematology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Mitsutoshi Kurosawa
- Department of Hematology, National Hospital Organization Hokkaido Cancer Center, Sapporo, Japan
| | - Nobuko Kubota
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Hiroaki Morimoto
- Department of Hematology, University of Occupational and Environmental Health, Kitakyusyu, Japan
| | - Miki Kobayashi
- Department of Hematology and Oncology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Kazuhito Yamamoto
- Department of Hematology and Cell Therapy, Aichi Cancer Center, Nagoya, Japan
| | - Yoshihiro Kameoka
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | | | - Takayuki Tabayashi
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Masaki Maruta
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Hospital, Ehime, Japan
| | - Tsutomu Kobayashi
- Department of Hematology and Oncology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Hospital, Nagoya, Japan
| | - Hirokazu Nagai
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| |
Collapse
|
5
|
Jenner MW, Pawlyn C, Davies FE, Menzies T, Hockaday A, Olivier C, Jones JR, Karunanithi K, Lindsay J, Kishore B, Cook G, Drayson MT, Kaiser MF, Owen RG, Gregory W, Cairns DA, Morgan G, Jackson GH. The addition of vorinostat to lenalidomide maintenance for patients with newly diagnosed multiple myeloma of all ages: results from 'Myeloma XI', a multicentre, open-label, randomised, phase III trial. Br J Haematol 2023; 201:267-279. [PMID: 36541152 PMCID: PMC10952726 DOI: 10.1111/bjh.18600] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/16/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022]
Abstract
Lenalidomide is an effective maintenance agent for patients with myeloma, prolonging first remission and, in transplant eligible patients, improving overall survival (OS) compared to observation. The 'Myeloma XI' trial, for newly diagnosed patients, aimed to evaluate whether the addition of the histone deacetylase inhibitor vorinostat to the lenalidomide maintenance backbone could improve outcomes further. Patients included in this analysis were randomised to maintenance therapy with lenalidomide alone (10 mg/day on days 1-21 of each 28-day cycle), or in combination with vorinostat (300 mg/day on day 1-7 and 15-21 of each 28-day cycle) with treatment continuing until unacceptable toxicity or progressive disease. There was no significant difference in median progression-free survival between those receiving lenalidomide-vorinostat or lenalidomide alone, 34 and 40 months respectively (hazard ratio [HR] 1.18, 95% confidence interval [CI] 0.96-1.44, p = 0.109). There was also no significant difference in median OS, not estimable and 75 months respectively (HR 0.99, 95% CI 0.76-1.29, p = 0.929). Subgroup analysis demonstrated no statistically significant heterogeneity in outcomes. Combination lenalidomide-vorinostat appeared to be poorly tolerated with more dose modifications, fewer cycles of maintenance therapy delivered and higher rates of discontinuation due to toxicity than lenalidomide alone. The trial did not meet its primary end-point, there was no benefit from the addition of vorinostat to lenalidomide maintenance.
Collapse
Affiliation(s)
| | - Charlotte Pawlyn
- The Institute of Cancer ResearchLondonUK
- The Royal Marsden NHS Foundation TrustLondonUK
| | | | - Tom Menzies
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - Anna Hockaday
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - Catherine Olivier
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - John R. Jones
- Eastbourne District General HospitalEastbourneUK
- Brighton and Sussex Medical SchoolUniversity of SussexSussexUK
- Kings College Hospital NHS Foundation TrustLondonUK
| | | | | | - Bhuvan Kishore
- University Hospitals Birmingham NHS Foundation TrustBirminghamUK
| | - Gordon Cook
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
- Leeds Cancer CentreLeeds Teaching Hospitals TrustLeedsUK
| | - Mark T. Drayson
- Institute of Immunology and ImmunotherapyUniversity of BirminghamBirminghamUK
| | - Martin F. Kaiser
- The Institute of Cancer ResearchLondonUK
- The Royal Marsden NHS Foundation TrustLondonUK
| | - Roger G. Owen
- Haematological Malignancy Diagnostic Service (HMDS), Leeds Cancer CentreLeeds Teaching Hospitals TrustLeedsUK
| | - Walter Gregory
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | - David A. Cairns
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials ResearchUniversity of LeedsLeedsUK
| | | | | | | |
Collapse
|
6
|
Bringhen S, Pour L, Benjamin R, Grosicki S, Min CK, de Farias DLC, Vorog A, Labotka RJ, Wang B, Cherepanov D, Cain LE, Manne S, Rajkumar SV, Dimopoulos MA. Ixazomib Versus Placebo as Post-Induction Maintenance Therapy in Newly Diagnosed Multiple Myeloma Patients: An Analysis by Age and Frailty Status of the TOURMALINE-MM4 Study. CLINICAL LYMPHOMA MYELOMA AND LEUKEMIA 2023:S2152-2650(23)00093-9. [PMID: 37149398 DOI: 10.1016/j.clml.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 02/28/2023] [Accepted: 03/14/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND The TOURMALINE-MM4 trial demonstrated a significant and clinically meaningful progression-free survival (PFS) benefit with ixazomib versus placebo as postinduction maintenance in nontransplant, newly-diagnosed multiple myeloma patients, with a manageable and well-tolerated toxicity profile. MATERIALS AND METHODS In this subgroup analysis, efficacy and safety were assessed by age (< 65, 65-74, and ≥ 75 years) and frailty status (fit, intermediate-fit, and frail). RESULTS In this analysis, PFS benefit with ixazomib versus placebo was seen across age subgroups, including patients aged < 65 years (hazard ratio [HR], 0.576; 95% confidence interval [CI], 0.299-1.108; P = .095), 65-74 years (HR, 0.615; 95% CI, 0.467-0.810; P < .001), and ≥ 75 years (HR, 0.740; 95% CI, 0.537-1.019; P = .064). PFS benefit was also seen across frailty subgroups, including fit (HR, 0.530; 95% CI, 0.387-0.727; P < .001), intermediate-fit (HR, 0.746; 95% CI, 0.526-1.058; P = .098), and frail (HR, 0.733; 95% CI, 0.481-1.117; P = .147) patients. With ixazomib versus placebo, rates of grade ≥ 3 treatment-emergent adverse events (TEAEs; 28-44% vs. 10-36%), serious TEAEs (15-29% vs. 3-29%), and discontinuation due to TEAEs (7-19% vs. 5-11%) were higher or similar across age and frailty subgroups, and generally somewhat higher in older age groups and intermediate-fit/frail patients in both arms. Treatment with ixazomib versus placebo did not adversely affect patient-reported quality-of-life scores across age and frailty status subgroups. CONCLUSION Ixazomib is a feasible and effective maintenance option for prolonging PFS across this heterogeneous patient population.
Collapse
|
7
|
Jolles S, Giralt S, Kerre T, Lazarus HM, Mustafa SS, Ria R, Vinh DC. Agents contributing to secondary immunodeficiency development in patients with multiple myeloma, chronic lymphocytic leukemia and non-Hodgkin lymphoma: A systematic literature review. Front Oncol 2023; 13:1098326. [PMID: 36824125 PMCID: PMC9941665 DOI: 10.3389/fonc.2023.1098326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/04/2023] [Indexed: 02/09/2023] Open
Abstract
Introduction Patients with hematological malignancies (HMs), like chronic lymphocytic leukemia (CLL), multiple myeloma (MM), and non-Hodgkin lymphoma (NHL), have a high risk of secondary immunodeficiency (SID), SID-related infections, and mortality. Here, we report the results of a systematic literature review on the potential association of various cancer regimens with infection rates, neutropenia, lymphocytopenia, or hypogammaglobulinemia, indicative of SID. Methods A systematic literature search was performed in 03/2022 using PubMed to search for clinical trials that mentioned in the title and/or abstract selected cancer (CLL, MM, or NHL) treatments covering 12 classes of drugs, including B-lineage monoclonal antibodies, CAR T therapies, proteasome inhibitors, kinase inhibitors, immunomodulators, antimetabolites, anti-tumor antibiotics, alkylating agents, Bcl-2 antagonists, histone deacetylase inhibitors, vinca alkaloids, and selective inhibitors of nuclear export. To be included, a publication had to report at least one of the following: percentages of patients with any grade and/or grade ≥3 infections, any grade and/or grade ≥3 neutropenia, or hypogammaglobulinemia. From the relevant publications, the percentages of patients with lymphocytopenia and specific types of infection (fungal, viral, bacterial, respiratory [upper or lower respiratory tract], bronchitis, pneumonia, urinary tract infection, skin, gastrointestinal, and sepsis) were collected. Results Of 89 relevant studies, 17, 38, and 34 included patients with CLL, MM, and NHL, respectively. In CLL, MM, and NHL, any grade infections were seen in 51.3%, 35.9% and 31.1% of patients, and any grade neutropenia in 36.3%, 36.4%, and 35.4% of patients, respectively. The highest proportion of patients with grade ≥3 infections across classes of drugs were: 41.0% in patients with MM treated with a B-lineage monoclonal antibody combination; and 29.9% and 38.0% of patients with CLL and NHL treated with a kinase inhibitor combination, respectively. In the limited studies, the mean percentage of patients with lymphocytopenia was 1.9%, 11.9%, and 38.6% in CLL, MM, and NHL, respectively. Two studies reported the proportion of patients with hypogammaglobulinemia: 0-15.3% in CLL and 5.9% in NHL (no studies reported hypogammaglobulinemia in MM). Conclusion This review highlights cancer treatments contributing to infections and neutropenia, potentially related to SID, and shows underreporting of hypogammaglobulinemia and lymphocytopenia before and during HM therapies.
Collapse
Affiliation(s)
- Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom,*Correspondence: Stephen Jolles,
| | - Sergio Giralt
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Tessa Kerre
- Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Hillard M. Lazarus
- Department of Medicine, Hematology-Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - S. Shahzad Mustafa
- Rochester Regional Health, Rochester, NY, United States,Department of Medicine, Allergy/Immunology and Rheumatology, University of Rochester, Rochester, NY, United States
| | - Roberto Ria
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Bari, Italy
| | - Donald C. Vinh
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Suzuki T, Maruyama D, Iida S, Nagai H. Recent advances in the management of older adults with newly diagnosed multiple myeloma in Japan. Jpn J Clin Oncol 2022; 52:966-974. [PMID: 35830865 PMCID: PMC9486880 DOI: 10.1093/jjco/hyac111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/25/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple myeloma is a cancer of plasma cells; the incidence rate of multiple myeloma is high among older adults. Although significant advances have been made in the clinical management of multiple myeloma driven by the introduction of novel drugs, such as proteasome inhibitors, immuno- modulators and antibodies, multiple myeloma remains incurable. Hence, the current therapeutic goal for multiple myeloma is to achieve long-term survival while maintaining a good quality of life. In this context, personalized treatment to balance the efficacy and safety of therapies is important, especially for older adults as they display diverse physical, cognitive or organ functioning. Furthermore, old age is also often associated with frailty. Several tools for evaluating frailty in older adults with multiple myeloma are now available, and frail patients defined by these tools have shown a poor prognosis and more treatment-related toxicities. In addition, it is important to evaluate other factors, such as the International Staging System, high-risk chromosomal abnormalities and treatment response, to predict the clinical course of patients. Further investigations are required to determine how these factors can optimize the treatment for multiple myeloma. In this review, we present a detailed account on the developments and issues related to the current treatment approaches for older adults with newly diagnosed multiple myeloma. We also discuss the ongoing phase III clinical study conducted by the lymphoma study group of the Japan Clinical Oncology Group, which targeted older adults with newly diagnosed multiple myeloma.
Collapse
Affiliation(s)
- Tomotaka Suzuki
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Dai Maruyama
- Department of Hematology Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hirokazu Nagai
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| |
Collapse
|
10
|
Coulson AB, Royle KL, Pawlyn C, Cairns DA, Hockaday A, Bird J, Bowcock S, Kaiser M, de Tute R, Rabin N, Boyd K, Jones J, Parrish C, Gardner H, Meads D, Dawkins B, Olivier C, Henderson R, Best P, Owen R, Jenner M, Kishore B, Drayson M, Jackson G, Cook G. Frailty-adjusted therapy in Transplant Non- Eligible patient s with newly diagno sed Multiple Myeloma (FiTNEss (UK-MRA Myeloma XIV Trial)): a study protocol for a randomised phase III trial. BMJ Open 2022; 12:e056147. [PMID: 35654466 PMCID: PMC9163533 DOI: 10.1136/bmjopen-2021-056147] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 03/24/2022] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Multiple myeloma is a bone marrow cancer, which predominantly affects older people. The incidence is increasing in an ageing population.Over the last 10 years, patient outcomes have improved. However, this is less apparent in older, less fit patients, who are ineligible for stem cell transplant. Research is required in this patient group, taking into account frailty and aiming to improve: treatment tolerability, clinical outcomes and quality of life. METHODS AND ANALYSIS Frailty-adjusted therapy in Transplant Non-Eligible patients with newly diagnosed Multiple Myeloma is a national, phase III, multicentre, randomised controlled trial comparing standard (reactive) and frailty-adjusted (adaptive) induction therapy delivery with ixazomib, lenalidomide and dexamethasone (IRD), and to compare maintenance lenalidomide to lenalidomide+ixazomib, in patients with newly diagnosed multiple myeloma not suitable for stem cell transplant. Overall, 740 participants will be registered into the trial to allow 720 and 478 to be randomised at induction and maintenance, respectively.All participants will receive IRD induction with the dosing strategy randomised (1:1) at trial entry. Patients randomised to the standard, reactive arm will commence at the full dose followed by toxicity dependent reactive modifications. Patients randomised to the adaptive arm will commence at a dose level determined by their International Myeloma Working Group frailty score. Following 12 cycles of induction treatment, participants alive and progression free will undergo a second (double-blind) randomisation on a 1:1 basis to maintenance treatment with lenalidomide+placebo versus lenalidomide+ixazomib until disease progression or intolerance. ETHICS AND DISSEMINATION Ethical approval has been obtained from the North East-Tyne & Wear South Research Ethics Committee (19/NE/0125) and capacity and capability confirmed by local research and development departments for each participating centre prior to opening to recruitment. Participants are required to provide written informed consent prior to trial registration. Trial results will be disseminated by conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER ISRCTN17973108, NCT03720041.
Collapse
Affiliation(s)
- Amy Beth Coulson
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Kara-Louise Royle
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | | | - David A Cairns
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Anna Hockaday
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Jennifer Bird
- Department of Haematology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Stella Bowcock
- Department of Haematology, Kings College Hospital NHS Foundation Trust, Princess Royal Hospital, Hull, UK
| | - Martin Kaiser
- Institute of Cancer Research, London, UK
- The Department of Haemato-oncology, Royal Marsden Hospital NHS Trust, London, UK
| | - Ruth de Tute
- Haematology Malignancy Diagnostic Service (HMDS), St James's University Hospital, Leeds, West Yorkshire, UK
| | - Neil Rabin
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kevin Boyd
- The Department of Haemato-oncology, Royal Marsden Hospital NHS Trust, London, UK
| | - John Jones
- King's College Hospital, London, UK
- Brighton and Sussex Medical School, Brighton, UK
| | | | - Hayley Gardner
- Department of Haematology and Stem Cell Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - David Meads
- Academic Unit of Health Economics, University of Leeds, Leeds Institute of Health Sciences, Leeds, West Yorkshire, UK
| | - Bryony Dawkins
- Academic Unit of Health Economics, University of Leeds, Leeds Institute of Health Sciences, Leeds, West Yorkshire, UK
| | - Catherine Olivier
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Rowena Henderson
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Phillip Best
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
| | - Roger Owen
- Haematology Malignancy Diagnostic Service (HMDS), St James's University Hospital, Leeds, West Yorkshire, UK
| | | | - Bhuvan Kishore
- Department of Haematology and Stem Cell Transplantation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Drayson
- Institute of Immunology and Immunotherapy, Department of Haematology, University of Birmingham, Birmingham, UK
| | - Graham Jackson
- Department of Haematology, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Gordon Cook
- Leeds Institute of Clinical Trials Research, University of Leeds Clinical Trials Research Unit, Leeds, West Yorkshire, UK
- Leeds Cancer Centre, St James's University Hospital, Leeds, West Yorkshire, UK
| |
Collapse
|
11
|
D'Agostino M, Cairns DA, Lahuerta JJ, Wester R, Bertsch U, Waage A, Zamagni E, Mateos MV, Dall'Olio D, van de Donk NWCJ, Jackson G, Rocchi S, Salwender H, Bladé Creixenti J, van der Holt B, Castellani G, Bonello F, Capra A, Mai EK, Dürig J, Gay F, Zweegman S, Cavo M, Kaiser MF, Goldschmidt H, Hernández Rivas JM, Larocca A, Cook G, San-Miguel JF, Boccadoro M, Sonneveld P. Second Revision of the International Staging System (R2-ISS) for Overall Survival in Multiple Myeloma: A European Myeloma Network (EMN) Report Within the HARMONY Project. J Clin Oncol 2022; 40:3406-3418. [PMID: 35605179 DOI: 10.1200/jco.21.02614] [Citation(s) in RCA: 131] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Patients with newly diagnosed multiple myeloma (NDMM) show heterogeneous outcomes, and approximately 60% of them are at intermediate-risk according to the Revised International Staging system (R-ISS), the standard-of-care risk stratification model. Moreover, chromosome 1q gain/amplification (1q+) recently proved to be a poor prognostic factor. In this study, we revised the R-ISS by analyzing the additive value of each single risk feature, including 1q+. PATIENTS AND METHODS The European Myeloma Network, within the HARMONY project, collected individual data from 10,843 patients with NDMM enrolled in 16 clinical trials. An additive scoring system on the basis of top features predicting progression-free survival (PFS) and overall survival (OS) was developed and validated. RESULTS In the training set (N = 7,072), at a median follow-up of 75 months, ISS, del(17p), lactate dehydrogenase, t(4;14), and 1q+ had the highest impact on PFS and OS. These variables were all simultaneously present in 2,226 patients. A value was assigned to each risk feature according to their OS impact (ISS-III 1.5, ISS-II 1, del(17p) 1, high lactate dehydrogenase 1, and 1q+ 0.5 points). Patients were stratified into four risk groups according to the total additive score: low (Second Revision of the International Staging System [R2-ISS]-I, 19.2%, 0 points), low-intermediate (II, 30.8%, 0.5-1 points), intermediate-high (III, 41.2%, 1.5-2.5 points), high (IV, 8.8%, 3-5 points). Median OS was not reached versus 109.2 versus 68.5 versus 37.9 months, and median PFS was 68 versus 45.5 versus 30.2 versus 19.9 months, respectively. The score was validated in an independent validation set (N = 3,771, of whom 1,214 were with complete data to calculate R2-ISS) maintaining its prognostic value. CONCLUSION The R2-ISS is a simple prognostic staging system allowing a better stratification of patients with intermediate-risk NDMM. The additive nature of this score fosters its future implementation with new prognostic variables.
Collapse
Affiliation(s)
- Mattia D'Agostino
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - David A Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Juan José Lahuerta
- Instituto de Investigación del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ruth Wester
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Uta Bertsch
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Anders Waage
- Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - 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
| | - María-Victoria Mateos
- Complejo Asistencial Universitario de Salamanca/IBSAL/CIC/Ciberonc, Salamanca, Spain
| | - Daniele Dall'Olio
- Dipartimento di Fisica e Astronomia, Università di Bologna, Bologna, Italy
| | - Niels W C J van de Donk
- Department of Hematology, Amsterdam UMC, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Graham Jackson
- University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom
| | - 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
| | - Hans Salwender
- Asklepios Tumorzentrum Hamburg, AK Altona and AK St Georg, Hamburg, Germany
| | | | - Bronno van der Holt
- HOVON Data Center, Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Gastone Castellani
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Francesca Bonello
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Andrea Capra
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Elias K Mai
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jan Dürig
- Department of Hematology, University Clinic Essen, Essen, Germany
| | - Francesca Gay
- SSD Clinical Trial in Oncoematologia 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, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - 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
| | - Martin F Kaiser
- The Institute of Cancer Research, London, United Kingdom and The Royal Marsden Hospital, London, United Kingdom
| | - Hartmut Goldschmidt
- University Hospital Heidelberg, Internal Medicine V and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Jesús María Hernández Rivas
- Department of Medicine, University of Salamanca, Institute of Biomedical Research of Salamanca (IBSAL), University of Salamanca-Cancer Research Center of Salamanca (IBMCC, USAL-CSIG). Hematology Department, Hospital Universitario de Salamanca (CAUSA/IBSAL), Salamanca, Spain
| | - Alessandra Larocca
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Gordon Cook
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Jesús F San-Miguel
- Clínica Universidad de Navarra, CIMA, IDISNA, CIBER-ONC (CB16/12/00369), Pamplona, Spain
| | - Mario Boccadoro
- SSD Clinical Trial in Oncoematologia e Mieloma Multiplo, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| |
Collapse
|
12
|
Möller MD, Gengenbach L, Graziani G, Greil C, Wäsch R, Engelhardt M. Geriatric assessments and frailty scores in multiple myeloma patients: a needed tool for individualized treatment? Curr Opin Oncol 2021; 33:648-657. [PMID: 34534141 PMCID: PMC8528138 DOI: 10.1097/cco.0000000000000792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Multiple myeloma is a disease of elderly adults. Improvement in survival has occurred because of biological insights and novel agents. Therapeutic options involve choices today, thus have become more complex. Demographics have led to an increased number of elderly patients and age may be associated with a poorer outcome but is not the only prognostic predictor today. RECENT FINDINGS To evaluate patients' health status rather than their chronological age alone, frailty scores and functional geriatric assessments are used to identify prognostic groups, avoid adverse events, compare clinical trials and tailor treatment. As most clinical trials exclude frail elderly patients, those enrolled therein are often younger and healthier than the typical multiple myeloma patient. This represents a challenge for frail cohorts because of their increased risk of adverse events, overtreatment and undertreatment and/or therapy discontinuation, which may lead to poorer survival and quality of life (QoL). Reassessing patients' status via geriatric assessments is also relevant during treatment to adjust interventions appropriately. SUMMARY Integrating geriatric assessments may lead to individual treatment decisions, dose adjustments, better clinical outcome and QoL. Prospective clinical trials that enroll elderly multiple myeloma patients with comorbidities, incorporate frailty scores/geriatric assessments and help with prognostication, adverse event avoidance and QoL maintenance, remain warranted.
Collapse
|
13
|
Efficacy of first-line treatment options in transplant-ineligible multiple myeloma: A network meta-analysis. Crit Rev Oncol Hematol 2021; 168:103504. [PMID: 34673218 DOI: 10.1016/j.critrevonc.2021.103504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/30/2021] [Accepted: 10/10/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite major therapeutic advances, the rational choice of the most appropriate first-line regimen in newly diagnosed transplant-ineligible multiple myeloma (TIE-MM) is currently undefined. AIM We aimed to identify the most effective first-line treatment for TIE-MM patients. METHODS A total of 37 articles, including 34 treatments and 16,681 patients, were included in this Bayesian network meta-analysis. The outcomes of interest were risk ratios (RR) for progression-free survival (PFS) and overall survival (OS). RESULTS Based on surface under cumulative ranking curve values, daratumumab-bortezomib-melphalan-prednisone (Dara-VMP) and daratumumab-lenalidomide-dexamethasone (Dara-Rd28) showed superiority compared to other combinations regarding 12-, 24-, 36-, and 48-month PFS. Dara-VMP also ranked first for 12-, 24-, 36-, and 48-month OS. CONCLUSION Our finding supports the incorporation of daratumumab into first-line regimens. Additionally, these results highlight the relative benefit of incorporating novel agents like monoclonal antibodies, immunomodulatory derivatives, and proteasome inhibitors in combination with the currently existing treatment options.
Collapse
|
14
|
Royle KL, Cairns DA. The development and validation of prognostic models for overall survival in the presence of missing data in the training dataset: a strategy with a detailed example. Diagn Progn Res 2021; 5:14. [PMID: 34344484 PMCID: PMC8335879 DOI: 10.1186/s41512-021-00103-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 06/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The United Kingdom Myeloma Research Alliance (UK-MRA) Myeloma Risk Profile is a prognostic model for overall survival. It was trained and tested on clinical trial data, aiming to improve the stratification of transplant ineligible (TNE) patients with newly diagnosed multiple myeloma. Missing data is a common problem which affects the development and validation of prognostic models, where decisions on how to address missingness have implications on the choice of methodology. METHODS Model building The training and test datasets were the TNE pathways from two large randomised multicentre, phase III clinical trials. Potential prognostic factors were identified by expert opinion. Missing data in the training dataset was imputed using multiple imputation by chained equations. Univariate analysis fitted Cox proportional hazards models in each imputed dataset with the estimates combined by Rubin's rules. Multivariable analysis applied penalised Cox regression models, with a fixed penalty term across the imputed datasets. The estimates from each imputed dataset and bootstrap standard errors were combined by Rubin's rules to define the prognostic model. Model assessment Calibration was assessed by visualising the observed and predicted probabilities across the imputed datasets. Discrimination was assessed by combining the prognostic separation D-statistic from each imputed dataset by Rubin's rules. Model validation The D-statistic was applied in a bootstrap internal validation process in the training dataset and an external validation process in the test dataset, where acceptable performance was pre-specified. Development of risk groups Risk groups were defined using the tertiles of the combined prognostic index, obtained by combining the prognostic index from each imputed dataset by Rubin's rules. RESULTS The training dataset included 1852 patients, 1268 (68.47%) with complete case data. Ten imputed datasets were generated. Five hundred twenty patients were included in the test dataset. The D-statistic for the prognostic model was 0.840 (95% CI 0.716-0.964) in the training dataset and 0.654 (95% CI 0.497-0.811) in the test dataset and the corrected D-Statistic was 0.801. CONCLUSION The decision to impute missing covariate data in the training dataset influenced the methods implemented to train and test the model. To extend current literature and aid future researchers, we have presented a detailed example of one approach. Whilst our example is not without limitations, a benefit is that all of the patient information available in the training dataset was utilised to develop the model. TRIAL REGISTRATION Both trials were registered; Myeloma IX- ISRCTN68454111 , registered 21 September 2000. Myeloma XI- ISRCTN49407852 , registered 24 June 2009.
Collapse
Affiliation(s)
- Kara-Louise Royle
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
| | - David A Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| |
Collapse
|