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Owattanapanich W, Suphadirekkul K, Kunacheewa C, Ungprasert P, Prayongratana K. Risk of febrile neutropenia among patients with multiple myeloma or lymphoma who undergo inpatient versus outpatient autologous stem cell transplantation: a systematic review and meta-analysis. BMC Cancer 2018; 18:1126. [PMID: 30445930 PMCID: PMC6240267 DOI: 10.1186/s12885-018-5054-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/06/2018] [Indexed: 02/07/2023] Open
Abstract
Background Outpatient autologous stem cell transplantations (ASCTs) in multiple myeloma and lymphoma patients have been shown to reduce the overall costs and improve the quality of life relative to inpatient ASCTs. This systematic review and meta-analysis was performed with the aim of comprehensively comparing the risk of febrile neutropenia developing in ASCT outpatients and inpatients who have multiple myeloma or lymphoma. Methods To be eligible for the meta-analysis, studies needed to be either randomized, controlled studies or cohort studies. They also need to have two groups of patients with multiple myeloma or lymphoma who underwent ASCT, with the treatment being provided to one group in an outpatient setting and to the other on an inpatient basis. The studies had to report our primary outcome of interest, the rate of febrile neutropenia after stem cell infusion, for both groups. The Mantel–Haenszel method was used to pool the effect estimates and 95% confidence intervals of each study. Results From 9 eligible studies, a total of 1940 patients were included in the meta-analysis. Contrary to conventional concerns, the patients who underwent the outpatient ASCT had a significantly lower risk of developing febrile neutropenia than those admitted for ASCT, with a pooled odds ratio (OR) of 0.44 (95% confidence interval [CI]: 0.29–0.65; p < 0.0001; I2 = 52%). The risk of septicemia was also significantly lower for the outpatients than the inpatients, with a pooled OR of 0.40 (95% CI: 0.16–0.97; p = 0.04; I2 = 23%). Additional analyses found that the odds of having grade 2–3 mucositis and transplant-related mortality were numerically lower for the outpatient group, although the pooled result was not statistically significant. The odds of surviving at 2–3 years was also numerically higher for the ASCT outpatients, but the difference did not reach statistical significance. Conclusions This study found a significantly lower odds of developing febrile neutropenia and septicemia among patients with multiple myeloma and lymphoma who received an outpatient ASCT than among those who had an inpatient ASCT. Electronic supplementary material The online version of this article (10.1186/s12885-018-5054-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Weerapat Owattanapanich
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
| | | | - Chutima Kunacheewa
- Division of Hematology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand
| | - Kannadit Prayongratana
- Division of Hematology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, 10400, Thailand
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Sivaraj D, Green MM, Li Z, Sung AD, Sarantopoulos S, Kang Y, Long GD, Horwitz ME, Lopez RD, Sullivan KM, Rizzieri DA, Chao NJ, Gasparetto C. Outcomes of Maintenance Therapy with Bortezomib after Autologous Stem Cell Transplantation for Patients with Multiple Myeloma. Biol Blood Marrow Transplant 2017; 23:262-268. [PMID: 27856369 PMCID: PMC11099879 DOI: 10.1016/j.bbmt.2016.11.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/10/2016] [Indexed: 12/21/2022]
Abstract
Comprehensive recommendations for maintenance therapy after autologous stem cell transplantation (ASCT) for patients with multiple myeloma (MM) have yet to be defined. Bortezomib has been utilized as maintenance therapy after ASCT, but data attesting to the safety and efficacy of this agent compared with lenalidomide in the post-ASCT setting are limited. Therefore, we retrospectively analyzed the outcomes of 102 patients with MM who received maintenance therapy with bortezomib after ASCT at Duke University's adult bone marrow transplant clinic between 2005 and 2015. Maintenance with bortezomib was initiated between 60 and 90 days after ASCT as a single agent 1.3 mg/m2 once every 2 weeks (n = 92) or in combination with lenalidomide (10 mg/day) (n = 10). The median age at ASCT was 64 (range, 31 to 78). Of the 99 patients with molecular data available, 42% had high-risk cytogenetics (including d17p, t(4;14), +1q, and t(14;16) by fluorescein in situ hybridization). Overall, 46% of patients experienced side effects from maintenance therapy, with 31% of all patients experiencing peripheral neuropathy. In total, 2% of patients required discontinuation of bortezomib maintenance because of adverse events. No secondary malignancies were reported from the therapy. The median progression-free survival (PFS) for patients receiving maintenance therapy with bortezomib after ASCT was 36.5 months (95% confidence interval [CI], 21.3 to not available) and median overall survival was 72.7 months (95% CI, 63.9 to not available). The PFS of patients with high-risk cytogenetics was not statistically significantly different from those with standard-risk cytogenetics, suggesting that maintenance with bortezomib may help overcome the impact of high-risk cytogenetics on early progression. These results indicate that maintenance therapy with bortezomib represents a safe, well-tolerated, and efficacious option for patients with high-risk cytogenetics, renal insufficiency, an inability to tolerate lenalidomide, or a previous history of another cancer.
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Affiliation(s)
- Dharshan Sivaraj
- Division of Cellular Therapy, Duke University, Durham, North Carolina.
| | - Michael M Green
- Division of Cellular Therapy, Duke University, Durham, North Carolina
| | - Zhiguo Li
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Anthony D Sung
- Division of Cellular Therapy, Duke University, Durham, North Carolina
| | | | - Yubin Kang
- Division of Cellular Therapy, Duke University, Durham, North Carolina
| | - Gwynn D Long
- Division of Cellular Therapy, Duke University, Durham, North Carolina
| | | | - Richard D Lopez
- Division of Cellular Therapy, Duke University, Durham, North Carolina
| | - Keith M Sullivan
- Division of Cellular Therapy, Duke University, Durham, North Carolina
| | - David A Rizzieri
- Division of Cellular Therapy, Duke University, Durham, North Carolina
| | - Nelson J Chao
- Division of Cellular Therapy, Duke University, Durham, North Carolina
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Wang Y, Yang F, Shen Y, Zhang W, Wang J, Chang VT, Andersson BS, Qazilbash MH, Champlin RE, Berenson JR, Guan X, Wang ML. Maintenance Therapy With Immunomodulatory Drugs in Multiple Myeloma: A Meta-Analysis and Systematic Review. J Natl Cancer Inst 2015; 108:djv342. [PMID: 26582244 DOI: 10.1093/jnci/djv342] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/15/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Immunomodulatory drugs (IMiDs) and proteasome inhibitors have dramatically changed management of multiple myeloma (MM). While MM remains incurable, consolidation and maintenance therapy aimed at improving duration of response can potentially improve survival outcomes. A majority of randomized controlled trials (RCTs) have demonstrated benefit of IMiD-based maintenance therapy in delaying disease progression; however, whether this therapy can lead to improved survival remains controversial. METHODS PubMed and abstract databases of major hematology and/or oncology meetings were searched for RCTs that studied maintenance therapy with IMiDs in MM. A meta-analysis was conducted to systematically evaluate the impact of IMiD-based maintenance therapy on survival outcomes and serious adverse events associated with the therapy. All statistical tests were two-sided. RESULTS Eighteen phase 3 RCTs enrolling 7730 patients were included. IMiD-based maintenance therapy statistically significantly prolonged progression-free survival (PFS; hazard ratio (HR) = 0.62, 95% confidence interval (CI) = 0.57 to 0.67, P < .001) but failed to improve overall survival (OS; HR = 0.93, 95% CI = 0.85 to 1.01, P = .082). Stratified analyses demonstrated that both thalidomide and lenalidomide provided PFS but not OS benefit in transplantation as well as nontransplantation settings. IMiD-based maintenance therapy in MM led to a higher risk of grade 3-4 thromboembolism (risk ratio = 2.52, 95% CI = 1.41 to 4.52, P = .002). Thalidomide maintenance therapy increased the risk of peripheral neuropathy; lenalidomide maintenance therapy increased the risks of myelosuppression and second primary hematological malignancies. CONCLUSIONS Thalidomide- or lenalidomide-based maintenance therapy improves PFS but not OS in MM and increases risks of grade 3-4 adverse events, including thromboembolism, peripheral neuropathy, neutropenia, and infection.
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Affiliation(s)
- Yucai Wang
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB)
| | - Fang Yang
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB)
| | - Yan Shen
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB)
| | - Wenwen Zhang
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB)
| | - Jacqueline Wang
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB)
| | - Victor T Chang
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB)
| | - Borje S Andersson
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB)
| | - Muzaffar H Qazilbash
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB)
| | - Richard E Champlin
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB)
| | - James R Berenson
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB)
| | - Xiaoxiang Guan
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB).
| | - Michael L Wang
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ (YW, VTC); Department of Medical Oncology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China (FY, YS, WZ, XG); Department of Medicine, University of Chicago, Chicago, IL (JW); Section of Hematology/Oncology, VA New Jersey Health Care System, East Orange, NJ (VTC); Department of Stem Cell Transplantation and Cellular Therapy (BSA, MHQ, REC) and Department of Lymphoma/Myeloma (MLW), The University of Texas MD Anderson Cancer Center, Houston, TX; Institute for Myeloma & Bone Cancer Research, West Hollywood, CA (JRB).
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