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Gu X, Tang W, Zhang L, Zheng Y, Pan L, Niu T. Maintenance therapy for cytogenetically high-risk multiple myeloma: landscape in the era of novel drugs. Clin Exp Med 2024; 24:179. [PMID: 39105954 PMCID: PMC11303491 DOI: 10.1007/s10238-024-01445-6] [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: 06/03/2024] [Accepted: 07/19/2024] [Indexed: 08/07/2024]
Abstract
Although the significant strides in novel therapeutic approaches have prolonged the survival of multiple myeloma (MM) patients, the unfavorable prognosis of cytogenetically high-risk newly diagnosed MM (NDMM) remains intractable with the lack of consensus regarding the choice of maintenance regimens. Therefore, this study was initiated with the aim of examining the effectiveness of various maintenance treatments for this group of patients in jeopardy. Overall, 17 studies with 1937 high-risk NDMM patients were included in the network meta-analysis. Combination therapies involving novel drugs presented encouraging prospects in the maintenance phase, while the patients and circumstances for the application of different regimens still needed to be further distinguished and clarified. To investigate the current status of maintenance therapy of high-risk NDMM patients in clinical practice, a real-world cohort of high-risk NDMM was retrospectively incorporated 80 patients with lenalidomide maintenance and 53 patients with bortezomib maintenance, presenting the median PFS of 31.7 months and 30.4 months, respectively (p = 0.874, HR = 0.966, 95% CI: 0.628-1.486). Collectively, this study illuminated the present constraints of conventional approaches during the maintenance phase for high-risk NDMM patients while highlighting the future potential associated with enhanced regimens integrating novel medications.
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Affiliation(s)
- Xinyuan Gu
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 Guo Xue Xiang Street, Chengdu, 610041, China
- Sichuan University, Chengdu, China
| | - Wenjiao Tang
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 Guo Xue Xiang Street, Chengdu, 610041, China
| | - Li Zhang
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 Guo Xue Xiang Street, Chengdu, 610041, China.
| | - Yuhuan Zheng
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 Guo Xue Xiang Street, Chengdu, 610041, China
| | - Ling Pan
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 Guo Xue Xiang Street, Chengdu, 610041, China
| | - Ting Niu
- Department of Hematology, Institute of Hematology, West China Hospital, Sichuan University, #37 Guo Xue Xiang Street, Chengdu, 610041, China
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2
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Went M, Duran-Lozano L, Halldorsson GH, Gunnell A, Ugidos-Damboriena N, Law P, Ekdahl L, Sud A, Thorleifsson G, Thodberg M, Olafsdottir T, Lamarca-Arrizabalaga A, Cafaro C, Niroula A, Ajore R, Lopez de Lapuente Portilla A, Ali Z, Pertesi M, Goldschmidt H, Stefansdottir L, Kristinsson SY, Stacey SN, Love TJ, Rognvaldsson S, Hajek R, Vodicka P, Pettersson-Kymmer U, Späth F, Schinke C, Van Rhee F, Sulem P, Ferkingstad E, Hjorleifsson Eldjarn G, Mellqvist UH, Jonsdottir I, Morgan G, Sonneveld P, Waage A, Weinhold N, Thomsen H, Försti A, Hansson M, Juul-Vangsted A, Thorsteinsdottir U, Hemminki K, Kaiser M, Rafnar T, Stefansson K, Houlston R, Nilsson B. Deciphering the genetics and mechanisms of predisposition to multiple myeloma. Nat Commun 2024; 15:6644. [PMID: 39103364 DOI: 10.1038/s41467-024-50932-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 07/24/2024] [Indexed: 08/07/2024] Open
Abstract
Multiple myeloma (MM) is an incurable malignancy of plasma cells. Epidemiological studies indicate a substantial heritable component, but the underlying mechanisms remain unclear. Here, in a genome-wide association study totaling 10,906 cases and 366,221 controls, we identify 35 MM risk loci, 12 of which are novel. Through functional fine-mapping and Mendelian randomization, we uncover two causal mechanisms for inherited MM risk: longer telomeres; and elevated levels of B-cell maturation antigen (BCMA) and interleukin-5 receptor alpha (IL5RA) in plasma. The largest increase in BCMA and IL5RA levels is mediated by the risk variant rs34562254-A at TNFRSF13B. While individuals with loss-of-function variants in TNFRSF13B develop B-cell immunodeficiency, rs34562254-A exerts a gain-of-function effect, increasing MM risk through amplified B-cell responses. Our results represent an analysis of genetic MM predisposition, highlighting causal mechanisms contributing to MM development.
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Affiliation(s)
- Molly Went
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Laura Duran-Lozano
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | | | - Andrea Gunnell
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Nerea Ugidos-Damboriena
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | - Philip Law
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Ludvig Ekdahl
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | - Amit Sud
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, SW7 3RP, UK
| | | | - Malte Thodberg
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | | | - Antton Lamarca-Arrizabalaga
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | - Caterina Cafaro
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | - Abhishek Niroula
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | - Ram Ajore
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | - Aitzkoa Lopez de Lapuente Portilla
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | - Zain Ali
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | - Maroulio Pertesi
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden
| | - Hartmut Goldschmidt
- Department of Internal Medicine V, University of Heidelberg, 69120, Heidelberg, Germany
| | | | - Sigurdur Y Kristinsson
- Landspitali, National University Hospital of Iceland, IS-101, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, IS-101, Reykjavik, Iceland
| | - Simon N Stacey
- deCODE Genetics/Amgen, Sturlugata 8, IS-101, Reykjavik, Iceland
| | - Thorvardur J Love
- Landspitali, National University Hospital of Iceland, IS-101, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, IS-101, Reykjavik, Iceland
| | - Saemundur Rognvaldsson
- Landspitali, National University Hospital of Iceland, IS-101, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, IS-101, Reykjavik, Iceland
| | - Roman Hajek
- University Hospital Ostrava and University of Ostrava, Ostrava, Czech Republic
| | - Pavel Vodicka
- Institute of Experimental Medicine, Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | | | - Florentin Späth
- Department of Radiation Sciences, Umeå University, SE-901 87, Umeå, Sweden
| | - Carolina Schinke
- Myeloma Center, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Frits Van Rhee
- Myeloma Center, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Patrick Sulem
- deCODE Genetics/Amgen, Sturlugata 8, IS-101, Reykjavik, Iceland
| | | | | | | | | | - Gareth Morgan
- Perlmutter Cancer Center, Langone Health, New York University, New York, NY, USA
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, 3075 EA, Rotterdam, The Netherlands
| | - Anders Waage
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Box 8905, N-7491, Trondheim, Norway
| | - Niels Weinhold
- Department of Internal Medicine V, University of Heidelberg, 69120, Heidelberg, Germany
- German Cancer Research Center (DKFZ), D-69120, Heidelberg, Germany
| | | | - Asta Försti
- German Cancer Research Center (DKFZ), D-69120, Heidelberg, Germany
- Hopp Children's Cancer Center, Heidelberg, Germany
| | - Markus Hansson
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden
- Section of Hematology, Sahlgrenska University Hospital, Gothenburg, SE-413 45, Sweden
- Skåne University Hospital, SE-221 85, Lund, Sweden
| | - Annette Juul-Vangsted
- Department of Haematology, University Hospital of Copenhagen at Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Unnur Thorsteinsdottir
- deCODE Genetics/Amgen, Sturlugata 8, IS-101, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, IS-101, Reykjavik, Iceland
| | - Kari Hemminki
- German Cancer Research Center (DKFZ), D-69120, Heidelberg, Germany
- Faculty of Medicine in Pilsen, Charles University, 30605, Pilsen, Czech Republic
| | - Martin Kaiser
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, SW7 3RP, UK
| | - Thorunn Rafnar
- deCODE Genetics/Amgen, Sturlugata 8, IS-101, Reykjavik, Iceland
| | - Kari Stefansson
- deCODE Genetics/Amgen, Sturlugata 8, IS-101, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, IS-101, Reykjavik, Iceland
| | - Richard Houlston
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, SW7 3RP, UK.
| | - Björn Nilsson
- Department of Laboratory Medicine, Lund University, SE-221 84, Lund, Sweden.
- Lund Stem Cell Center, Lund University, SE-221 84, Lund, Sweden.
- Broad Institute, 415 Main Street, Cambridge, MA, 02142, USA.
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3
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Kaiser MF, Hall A, Walker K, Sherborne A, De Tute RM, Newnham N, Roberts S, Ingleson E, Bowles K, Garg M, Lokare A, Messiou C, Houlston RS, Jackson G, Cook G, Pratt G, Owen RG, Drayson MT, Brown SR, Jenner MW. Daratumumab, Cyclophosphamide, Bortezomib, Lenalidomide, and Dexamethasone as Induction and Extended Consolidation Improves Outcome in Ultra-High-Risk Multiple Myeloma. J Clin Oncol 2023; 41:3945-3955. [PMID: 37315268 DOI: 10.1200/jco.22.02567] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/05/2023] [Accepted: 05/02/2023] [Indexed: 06/16/2023] Open
Abstract
PURPOSE The multicenter OPTIMUM (MUKnine) phase II trial investigated daratumumab, low-dose cyclophosphamide, lenalidomide, bortezomib, and dexamethasone (Dara-CVRd) before and after autologous stem-cell transplant (ASCT) in newly diagnosed patients with molecularly defined ultra-high-risk (UHiR) multiple myeloma (NDMM) or plasma cell leukemia (PCL). To provide clinical context, progression-free survival (PFS) and overall survival (OS) were referenced to contemporaneous outcomes seen in patients with UHiR NDMM treated in the recent Myeloma XI (MyeXI) trial. METHODS Transplant-eligible all-comers NDMM patients were profiled for UHiR disease, defined by presence of ≥2 genetic risk markers t(4;14)/t(14;16)/t(14;20), del(1p), gain(1q), and del(17p), and/or SKY92 gene expression risk signature. Patients with UHiR MM/PCL were offered treatment with Dara-CVRd induction, V-augmented ASCT, extended Dara-VR(d) consolidation, and Dara-R maintenance. UHiR patients treated in MyeXI with carfilzomib, lenalidomide, dexamethasone, and cyclophosphamide, or lenalidomide, dexamethasone, and cyclophosphamide, ASCT, and R maintenance or observation were identified by mirrored molecular screening. OPTIMUM PFS at 18 months (PFS18m) was compared against MyeXI using a Bayesian framework, and patients were followed up to the end of consolidation for PFS and OS. RESULTS Of 412 screened NDMM OPTIMUM patients, 103 were identified as UHiR or PCL and subsequently treated on trial with Dara-CVRd; 117 MyeXI patients identified as UHiR formed the external comparator arm, with comparable clinical and molecular characteristics to OPTIMUM. Comparison of PFS18m per Bayesian framework resulted in a 99.5% chance of OPTIMUM being superior to MyeXI. At 30 months' follow-up, PFS was 77% for OPTIMUM versus 39.8% for MyeXI, and OS 83.5% versus 73.5%, respectively. Extended post-ASCT Dara-VRd consolidation therapy was highly deliverable, with limited toxicity. CONCLUSION Our results suggest that Dara-CVRd induction and extended post-ASCT Dara-VRd consolidation markedly improve PFS for UHiR NDMM patients over conventional management, supporting further evaluation of this strategy.
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Affiliation(s)
- Martin F Kaiser
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, United Kingdom
- Department of Haematology, The Royal Marsden Hospital, London, United Kingdom
| | - Andrew Hall
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Katrina Walker
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Amy Sherborne
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, United Kingdom
| | - Ruth M De Tute
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Nicola Newnham
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Sadie Roberts
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Emma Ingleson
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Kristian Bowles
- Department of Haematology, Norfolk and Norwich University Hospitals NHS Trust, Norwich, United Kingdom
| | - Mamta Garg
- Department of Haematology, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Anand Lokare
- Department of Haematology, Birmingham Heartlands, Birmingham, United Kingdom
| | - Christina Messiou
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, United Kingdom
- Department of Haematology, The Royal Marsden Hospital, London, United Kingdom
| | - Richard S Houlston
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, United Kingdom
| | - Graham Jackson
- Department of Haematology, Newcastle University, Newcastle, United Kingdom
| | - Gordon Cook
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
- Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Guy Pratt
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Roger G Owen
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Mark T Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Sarah R Brown
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Matthew W Jenner
- Department of Haematology, University Hospital Southampton, Southampton, United Kingdom
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4
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Costa BA, Mouhieddine TH, Ortiz RJ, Richter J. Revisiting the Role of Alkylating Agents in Multiple Myeloma: Up-to-Date Evidence and Future Perspectives. Crit Rev Oncol Hematol 2023; 187:104040. [PMID: 37244325 DOI: 10.1016/j.critrevonc.2023.104040] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023] Open
Abstract
From the 1960s to the early 2000s, alkylating agents (e.g., melphalan, cyclophosphamide, and bendamustine) remained a key component of standard therapy for newly-diagnosed or relapsed/refractory multiple myeloma (MM). Later on, their associated toxicities (including second primary malignancies) and the unprecedented efficacy of novel therapies have led clinicians to increasingly consider alkylator-free approaches. Meanwhile, new alkylating agents (e.g., melflufen) and new applications of old alkylators (e.g., lymphodepletion before chimeric antigen receptor T-cell [CAR-T] therapy) have emerged in recent years. Given the expanding use of antigen-directed modalities (e.g., monoclonal antibodies, bispecific antibodies, and CAR-T therapy), this review explores the current and future role of alkylating agents in different treatment settings (e.g., induction, consolidation, stem cell mobilization, pre-transplant conditioning, salvage, bridging, and lymphodepleting chemotherapy) to ellucidate the role of alkylator-based regimens in modern-day MM management.
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Affiliation(s)
- Bruno Almeida Costa
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tarek H Mouhieddine
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ricardo J Ortiz
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua Richter
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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5
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Xu T, Yang Y, Li J, Xu J, Wang W, Wang Y, Maihemaiti A, Ren L, Lan T, Zhou C, Li P, Wang P, Liu P. Real world outcomes of lenalidomide or bortezomib maintenance in patients with multiple myeloma not undergoing stem cell transplantation. Ann Hematol 2023; 102:1171-1184. [PMID: 36882560 DOI: 10.1007/s00277-023-05148-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 12/19/2022] [Indexed: 03/09/2023]
Abstract
Maintenance is one form of long-term therapies in multiple myeloma (MM). Lenalidomide and bortezomib are two commonly used options. The role of maintenance in patients not undergoing transplant remains unclear. A total of 248 newly diagnosed MM patients who received over 180 days of any standard-of-care induction therapy and did not receive autologous stem cell transplantation were included. Patients either receive lenalidomide, bortezomib or no maintenance. Patterns of usage, survival benefit, discontinuation status were analyzed. 93, 99 and 56 patients received no, lenalidomide (Len) and bortezomib (Bor) maintenance respectively. Patients receiving Bor had a higher incidence of traditional high-risk cytogenetics (14.0% (No) vs 14.1% (Len) vs 41.1% (Bor), P < 0.001). Len maintenance conferred a superior progression-free survival (PFS) and overall survival (OS) compared to no maintenance (median PFS, 60.1 vs 26.9 months, P = 0.003; median OS, NR vs 56.7 months, P = 0.046), with a near independent impact on PFS (adjusted HR 0.580, P = 0.058). The PFS and OS benefit of Len maintenance was seen in subgroups of ISS stage I/II, traditional standard-risk cytogenetics, and pre-maintenance < CR. Bor maintenance did not confer PFS or OS benefit for the entire cohort, but improved OS in patients with pre-maintenance < CR. Discontinuation due to toxicity was recorded in 11.1% and 8.9% of patients receiving Len or Bor maintenance respectively. Our study supports lenalidomide maintenance as the standard-of-care in MM patients not undergoing transplant. Further studies are warranted for bortezomib maintenance in the non-transplant setting, and better maintenance strategy is needed for patients with adverse prognostic factors.
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Affiliation(s)
- Tianhong Xu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Hematology, Shanghai Geriatric Medical Center, Shanghai, China
| | - Yang Yang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiadai Xu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenjing Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yawen Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Aziguli Maihemaiti
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liang Ren
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianwei Lan
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chi Zhou
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Panpan Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pu Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Peng Liu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China. .,Department of Hematology, Shanghai Geriatric Medical Center, Shanghai, China.
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6
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Etekal T, Koehn K, Sborov DW, McClune B, Prasad V, Haslam A, Berger K, Booth C, Al Hadidi S, Abdallah AO, Goodman A, Mohyuddin GR. Time-to-event surrogate end-points in multiple myeloma randomised trials from 2005 to 2019: A surrogacy analysis. Br J Haematol 2023; 200:587-594. [PMID: 36495317 DOI: 10.1111/bjh.18568] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/25/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
Use of surrogate end-points such as progression-free survival (PFS) and other time-to-event (TTE) end-points is common in multiple myeloma (MM) clinical trials. This systematic review characterises all published randomised controlled trials (RCTs) in MM using PFS or other TTE end-points between 2005 and 2019 and assesses strength of surrogacy of PFS for overall survival (OS). The association between OS hazard ratios (HRs) and PFS HRs was evaluated with linear regression, and the coefficient of determination with Pearson's correlation. We identified 88 RCTs of which 67 (76%) used PFS as the primary/co-primary end-point. One trial indicated whether progression was biochemical or clinical. Of the variance in OS, 39% was due to variance in PFS. Correlation between PFS and OS was weak (0.62, 95% confidence interval [CI] 0.38-0.78). In newly diagnosed MM, 43% of the variance in OS was due to changes in PFS. The correlation between PFS and OS was weak (0.65, 95% CI 0.30-0.84). In relapsed/refractory MM, 58% of the variance in OS was due to changes in PFS. Correlation between PFS and OS was medium (0.76, 95% CI 0.42-0.91). We demonstrate that PFS and progression characteristics are characterised poorly in MM trials and that PFS is a poor surrogate for OS in MM.
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Affiliation(s)
- Tommy Etekal
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Kelly Koehn
- Division of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Lawrence, Kansas, USA
| | - Douglas W Sborov
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Brian McClune
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Vinay Prasad
- Division of Hematology/Oncology, University of California San Francisco, San Francisco, California, USA
| | - Alyson Haslam
- Department of Epidemiology/Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Katherine Berger
- Patient Advocate, University of Hartford, West Hartford, Connecticut, USA
| | - Christopher Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, Kingston, Ontario, Canada
| | - Samer Al Hadidi
- Myeloma Institute, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Al-Ola Abdallah
- Division of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Lawrence, Kansas, USA
| | - Aaron Goodman
- Division of Blood and Marrow Transplantation, University of California San Diego, La Jolla, California, USA
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, Utah, USA
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7
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AAOS Clinical Practice Guideline Summary: Treatment of Metastatic Carcinoma and Myeloma of the Femur. J Am Acad Orthop Surg 2023; 31:e118-e129. [PMID: 36656274 DOI: 10.5435/jaaos-d-21-00888] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/28/2022] [Indexed: 01/20/2023] Open
Abstract
The Musculoskeletal Tumor Society, in partnership with American Society of Clinical Oncology and American Society for Radiation Oncology, has developed a clinical practice guideline to assist providers with the care of patients with metastatic carcinoma and myeloma of the femur. The guideline was developed by an Expert Panel consisting of representatives of all three organizations by American Academy of Orthopaedic Surgeons (AAOS) methodologists using the AAOS standardized guideline development process. A systematic review of the available evidence was conducted, and the identified evidence was rated was rated for quality and potential for bias. Recommendations were developed based on this evidence in a standardized fashion. The guideline was approved by the guideline approval bodies of all three organizations. Thirteen recommendations were synthesized covering relevant subtopics such as imaging, use of bone-modifying agents, radiation therapy, and surgical reconstruction. The consensus of the expert panel was that bone-modifying agents may assist in reducing the incidence of femur fracture, regardless of tumor histology. The panel recommended the use of radiation therapy to decrease the rate of femur fractures for patients considered at increased risk. The panel recommended arthroplasty be considered to improve patient function and decrease the need of postoperative radiation therapy in patients with pathologic fractures in the femur.
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8
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Zhuang Z, Tian Y, Shi L, Zou D, Feng R, Tian WW, Yu H, Dong F, Liao A, Ma Y, Liu Q, Liu S, Jing H, Fu R, Ma LM, Liu H, Sun W, Bao L, Wu Y, Chen W, Zhuang J. Lenalidomide or bortezomib as maintenance treatment remedy the inferior impact of high-risk cytogenetic abnormalities in non-transplant patients with newly diagnosed multiple myeloma: a real-world multi-centered study in China. Front Oncol 2023; 13:1028571. [PMID: 37152063 PMCID: PMC10157094 DOI: 10.3389/fonc.2023.1028571] [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: 08/26/2022] [Accepted: 03/29/2023] [Indexed: 05/09/2023] Open
Abstract
Maintenance treatment is a pivotal part in the whole process management of multiple myeloma (MM), which further deepens response and improves survival. However, evidence of maintenance in non-transplant MM patients is inadequate in real-world practice. Here, we retrospectively analyzed the efficacy and survival of 375 non-transplant MM patients from 11 centers between 2010 and 2021 in north China. After a median of seven cycles of front-line regimens, there were 141, 79, and 155 patients receiving lenalidomide maintenance (L-MT), bortezomib maintenance (B-MT), or thalidomide maintenance (T-MT), respectively. Patients on L-MT and B-MT had significantly greater proportions of high-risk cytogenetic abnormalities (HRCAs) detected by fluorescence in situ hybridization (FISH), which was defined as 1q21 gain, 17p deletion, adverse immunoglobulin heavy chain (IgH) translocations. Although the progression-free survival (PFS) and overall survival (OS) were comparable among the three groups, L-MT and B-MT remedied the negative impact of HRCAs on survival (PFS of patients with HRCAs vs. patients without HRCAs: L-MT, 26.9 vs. 39.2 months, p=0.19; B-MT, 20.0 vs. 29.7 months, p=0.36; OS not reached in all groups). Patients with HRCAs in the T-MT group presented inferior clinical outcomes compared to standard-risk patients (PFS, 12.1 vs. 22.8 months, p=0.02, HR=1.8, 95% CI 1.0-3.4; OS, 54.9 months vs. NR, p<0.001, HR=3.2, 95% CI 1.5-7.0). Achieving complete response (CR) after induction therapy led to superior PFS compared to other degrees of response, regardless of maintenance medication. Furthermore, maintenance duration over 24 months correlated with favorable survival. Due to the large gap of transplant eligibility in China, optimizing maintenance therapy is important for non-transplant MM patients. In this real-world multi-centered study, our findings suggest that clinicians prefer to prescribe lenalidomide or bortezomib as maintenance therapy in high-risk settings, which are superior to thalidomide in non-transplant MM patients. Achievement of CR and maintenance duration over 2 years are positive factors that influence survival.
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Affiliation(s)
- Zhe Zhuang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Tian
- Department of Hematology, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
| | - Lei Shi
- Department of Hematology, Beijing University, Beijing Jishuitan Hospital, Beijing, China
| | - Dongmei Zou
- Department of Hematology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ru Feng
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Wei-wei Tian
- Department of Hematology, Shanxi Bethune Hospital of Shanxi Medical University, Taiyuan, China
| | - Hong Yu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Fei Dong
- Department of Hematology, Peking University Third Hospital, Beijing, China
| | - Aijun Liao
- Department of Hematology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yanping Ma
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Qinhua Liu
- Department of Hematology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Shuangjiao Liu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongmei Jing
- Department of Hematology, Peking University Third Hospital, Beijing, China
| | - Rong Fu
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Liang-ming Ma
- Department of Hematology, Shanxi Bethune Hospital of Shanxi Medical University, Taiyuan, China
| | - Hui Liu
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Science, Beijing, China
| | - Wanling Sun
- Department of Hematology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Li Bao
- Department of Hematology, Beijing University, Beijing Jishuitan Hospital, Beijing, China
- *Correspondence: Li Bao, ; Yin Wu, ; Wenming Chen, ; Junling Zhuang,
| | - Yin Wu
- Department of Hematology, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
- *Correspondence: Li Bao, ; Yin Wu, ; Wenming Chen, ; Junling Zhuang,
| | - Wenming Chen
- Department of Hematology, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
- *Correspondence: Li Bao, ; Yin Wu, ; Wenming Chen, ; Junling Zhuang,
| | - Junling Zhuang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Li Bao, ; Yin Wu, ; Wenming Chen, ; Junling Zhuang,
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9
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Hussain M, Khan F, Al Hadidi S. The use of bone-modifying agents in multiple myeloma. Blood Rev 2023; 57:100999. [PMID: 36050125 DOI: 10.1016/j.blre.2022.100999] [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: 06/14/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 01/28/2023]
Abstract
Multiple myeloma is a hematological neoplasm characterized by abnormal proliferation of plasma cells in the bone marrow and is usually associated with increased bone pain and skeletal-related events such as pathological fracture and/or spinal cord compression. Myeloma bone disease results in changes in the bone-marrow microenvironment evidenced by increased osteoclastic activity and/or decreased osteoblastic activity, which negatively affect quality of life. Treatment of myeloma bone disease includes bisphosphonates or denosumab (bone-modifying agents). These agents do not induce the formation of new bone or repair existing bone damage, but they can decrease bone pain and the risk of pathological fracture. While these agents improve quality of life, it is not known whether they improve overall survival. This review focuses on different classes of bone-modifying agents, their mechanisms of action, time of initiation, duration of therapy, and potential survival benefits.
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Affiliation(s)
- Munawwar Hussain
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Fatima Khan
- Department of Hematology Oncology, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Samer Al Hadidi
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
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10
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Zhi Y, Bao S, Mao J, Chai G, Zhu J, Liu C, Chen X. Efficacy of maintenance treatment in patients with multiple myeloma: a systematic review and network meta-analysis. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2022; 27:1069-1088. [PMID: 36125238 DOI: 10.1080/16078454.2022.2121900] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite conspicuous advances in innovating novel drugs and combination regimens in multiple myeloma (MM) in recent decades, the most appropriate maintenance regimens after inductive therapy are still controversial and opaque. OBJECTIVE We aimed to identify the most effective maintenance treatment for newly diagnosed multiple myeloma (NDMM) patients via network meta-analysis. METHOD We searched PubMed, Embase, Cochrane Library, Scopus, and Google Scholars from inception to April, 2022. Odds ratios (ORs) were generated for dichotomous variants. The primary endpoint was overall survival (OS). RESULTS Eventually a total of 19 trials, including 11 treatments and 8337 patients, were included in this analysis. For OS, lenalidomide (OR ranged from 1.61 to 1.99) and daratumumab (OR ranged from 1.83 to 2.41) showed significant efficacy over placebo. Maintenance therapy comprising lenalidomide-carfilzomib (OR ranged from 3.19 to 6.95), lenalidomide-prednisone (OR ranged from 2.62 to 4.44), bortezomib-thalidomide (OR ranged from 2.48 to 3.64), daratumumab (OR ranged from 2.0 to 2.98), lenalidomide (OR ranged from 1.4 to 3.19), ixazomib (OR ranged from 1.36 to 2.05), thalidomide (OR ranged from 1.5 to 1.86) demonstrated significant effects in prolonging PFS compared with placebo; Among the efficient therapies, lenalidomide-carfilzomib was significantly superior to lenalidomide (OR ranged from 2.18 to 2.20), daratumumab (OR ranged from 1.49 to 2.66) and ixazomib (OR ranged from 2.75 to 3.57). CONCLUSION Considering OS and PFS, lenalidomide-carfilzomib should be recommended as the best therapy. In clinical practice, this must be weighed against the increased risk of adverse events and financial burden. However, more head-to-head studies are needed to confirm these findings.
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Affiliation(s)
- Yongjin Zhi
- Department of Hematology, The People's Hospital of Tai Zhou, Nanjing Medical University, Nanjing, People's Republic of China
| | - Shuojing Bao
- The People's Hospital of Zhang Dian, Jiangyan, People's Republic of China
| | - Jingcheng Mao
- Department of Hematology, The People's Hospital of Tai Zhou, Nanjing Medical University, Nanjing, People's Republic of China
| | - Gufan Chai
- Department of Hematology, The People's Hospital of Tai Zhou, Nanjing Medical University, Nanjing, People's Republic of China
| | - Jianfeng Zhu
- Department of Hematology, The People's Hospital of Tai Zhou, Nanjing Medical University, Nanjing, People's Republic of China
| | - Chengjiang Liu
- Department of General Practice, Anhui Medical University, Hefei, People's Republic of China
| | - Xi Chen
- Department of Epidemiology and Statistics, School of Public Health, Medical College, Zhejiang University, Hangzhou, People's Republic of China.,School of Health, Brooks College, Sunnyvale, CA, USA
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11
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Efficace F, Cottone F, Sparano F, Caocci G, Vignetti M, Chakraborty R. Patient-Reported Outcomes in Randomized Controlled Trials of Patients with Multiple Myeloma: A Systematic Literature Review of Studies Published Between 2014 and 2021. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:442-459. [PMID: 35183476 DOI: 10.1016/j.clml.2022.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND We performed a systematic literature review to identify the most recently published randomized controlled trials (RCTs) in multiple myeloma (MM) with a patient-reported outcome (PRO) endpoint, and to summarize both clinical and PRO results, as well as to examine the quality of reporting by phase of disease. We also aimed to describe main type of PRO analysis used and interpretation of clinical significance of PRO findings. MATERIALS AND METHODS We searched PubMed and the Cochrane Central Register of Controlled Trials to identify RCTs of cancer-directed therapy in patients with MM published between January 2014 and April 2021. RESULTS Thirty-two RCTs with a total of 19,798 patients enrolled were identified in our review. In all studies, PROs were secondary or exploratory endpoints. Half of the studies (n = 16) included newly diagnosed patients, 15 RCTs included patients with relapsed/refractory MM, and one study included patients with smoldering MM. Progression-free survival was the most frequently used primary endpoint. All studies provided unique PRO information that could be used to more comprehensively assess the risk/benefit of the newly tested drugs. However, the identified RCTs were heterogeneous regarding the presentation, and interpretation of PRO results. CONCLUSION The number of RCTs including PROs in MM research has notably increased in recent years. However, more consistency in the methodological approach to PRO assessment, and interpretation of outcomes is needed to ensure that PRO findings will be more impactful on patient care.
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Affiliation(s)
- Fabio Efficace
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy.
| | - Francesco Cottone
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Francesco Sparano
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Giovanni Caocci
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Marco Vignetti
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Rajshekhar Chakraborty
- Division of Hematology and Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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12
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Abstract
The nitrogen mustards are powerful cytotoxic and lymphoablative agents and have been used for more than 60 years. They are employed in the treatment of cancers, sarcomas, and hematologic malignancies. Cyclophosphamide, the most versatile of the nitrogen mustards, also has a place in stem cell transplantation and the therapy of autoimmune diseases. Adverse effects caused by the nitrogen mustards on the central nervous system, kidney, heart, bladder, and gonads remain important issues. Advances in analytical techniques have facilitated the investigation of the pharmacokinetics of the nitrogen mustards, especially the oxazaphosphorines, which are prodrugs requiring metabolic activation. Enzymes involved in the metabolism of cyclophosphamide and ifosfamide are very polymorphic, but a greater understanding of the pharmacogenomic influences on their activity has not yet translated into a personalized medicine approach. In addition to damaging DNA, the nitrogen mustards can act through other mechanisms, such as antiangiogenesis and immunomodulation. The immunomodulatory properties of cyclophosphamide are an area of current exploration. In particular, cyclophosphamide decreases the number and activity of regulatory T cells, and the interaction between cyclophosphamide and the intestinal microbiome is now recognized as an important factor. New derivatives of the nitrogen mustards continue to be assessed. Oxazaphosphorine analogs have been synthesized in attempts to both improve efficacy and reduce toxicity, with varying degrees of success. Combinations of the nitrogen mustards with monoclonal antibodies and small-molecule targeted agents are being evaluated. SIGNIFICANCE STATEMENT: The nitrogen mustards are important, well-established therapeutic agents that are used to treat a variety of diseases. Their role is continuing to evolve.
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Affiliation(s)
- Martin S Highley
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Bart Landuyt
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Hans Prenen
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Peter G Harper
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
| | - Ernst A De Bruijn
- Plymouth Oncology Centre, Derriford Hospital, and Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom (M.S.H.); Department of Animal Physiology and Neurobiology (B.L.) and Laboratory for Experimental Oncology (E.A.D.B.), University of Leuven, Leuven, Belgium; Oncology Department, University Hospital Antwerp, Edegem, Belgium (H.P.); and London Oncology Clinic, London, United Kingdom (P.G.H.)
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13
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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.
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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
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14
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Russo S, Scotto di Carlo F, Gianfrancesco F. The Osteoclast Traces the Route to Bone Tumors and Metastases. Front Cell Dev Biol 2022; 10:886305. [PMID: 35646939 PMCID: PMC9139841 DOI: 10.3389/fcell.2022.886305] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/24/2022] [Indexed: 12/31/2022] Open
Abstract
Osteoclasts are highly specialized cells of the bone, with a unique apparatus responsible for resorption in the process of bone remodeling. They are derived from differentiation and fusion of hematopoietic precursors, committed to form mature osteoclasts in response to finely regulated stimuli produced by bone marrow-derived cells belonging to the stromal lineage. Despite a highly specific function confined to bone degradation, emerging evidence supports their relevant implication in bone tumors and metastases. In this review, we summarize the physiological role of osteoclasts and then focus our attention on their involvement in skeletal tumors, both primary and metastatic. We highlight how osteoclast-mediated bone erosion confers increased aggressiveness to primary tumors, even those with benign features. We also outline how breast and pancreas cancer cells promote osteoclastogenesis to fuel their metastatic process to the bone. Furthermore, we emphasize the role of osteoclasts in reactivating dormant cancer cells within the bone marrow niches for manifestation of overt metastases, even decades after homing of latent disseminated cells. Finally, we point out the importance of counteracting tumor progression and dissemination through pharmacological treatments based on a better understanding of molecular mechanisms underlying osteoclast lytic activity and their recruitment from cancer cells.
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Affiliation(s)
| | | | - Fernando Gianfrancesco
- Institute of Genetics and Biophysics “Adriano Buzzati-Traverso”, National Research Council of Italy, Naples, Italy
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15
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Miki H, Nakamura S, Oura M, Nakamura M, Sumitani R, Sogabe K, Takahashi M, Maruhashi T, Harada T, Fujii S, Hamano H, Kondo M, Okada N, Endo I, Abe M. The importance of retaining physical functions to prevent skeletal-related events in multiple myeloma patients with bone disease. EJHAEM 2022; 3:480-483. [PMID: 35846024 PMCID: PMC9175803 DOI: 10.1002/jha2.402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/11/2022] [Accepted: 02/13/2022] [Indexed: 06/15/2023]
Abstract
This study was undertaken to identify baseline conditions and triggering factors for skeletal-related events (SRE) in multiple myeloma (MM) patients treated with denosumab. During the median follow-up of 17 months, SRE occurred in 6 out of 52 newly diagnosed patients and in 5 out of 23 relapsed/refractory patients. Bone fractures occurred by falling down due to orthostatic hypotension and/or muscle weakness in three out of four cases with amyloid light-chain (AL) amyloidosis. A loss of balance and falling down appear to be triggering factors for SRE, especially in frail MM patients with AL amyloidosis, indicating the importance of retaining physical functions to prevent SRE.
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Affiliation(s)
- Hirokazu Miki
- Division of Transfusion Medicine and Cell TherapyTokushima University HospitalTokushimaJapan
| | - Shingen Nakamura
- Department of Community Medicine and Medical ScienceTokushima University Graduate School of Biomedical SciencesTokushimaJapan
| | - Masahiro Oura
- Department of HematologyEndocrinology and Metabolism, Institute of Biomedical Sciences Tokushima University Graduate SchoolTokushimaJapan
| | - Masafumi Nakamura
- Department of HematologyEndocrinology and Metabolism, Institute of Biomedical Sciences Tokushima University Graduate SchoolTokushimaJapan
| | - Ryohei Sumitani
- Department of HematologyEndocrinology and Metabolism, Institute of Biomedical Sciences Tokushima University Graduate SchoolTokushimaJapan
| | - Kimiko Sogabe
- Department of HematologyEndocrinology and Metabolism, Institute of Biomedical Sciences Tokushima University Graduate SchoolTokushimaJapan
| | - Mamiko Takahashi
- Department of HematologyEndocrinology and Metabolism, Institute of Biomedical Sciences Tokushima University Graduate SchoolTokushimaJapan
| | - Tomoko Maruhashi
- Department of HematologyEndocrinology and Metabolism, Institute of Biomedical Sciences Tokushima University Graduate SchoolTokushimaJapan
| | - Takeshi Harada
- Department of HematologyEndocrinology and Metabolism, Institute of Biomedical Sciences Tokushima University Graduate SchoolTokushimaJapan
| | - Shiro Fujii
- Department of HematologyEndocrinology and Metabolism, Institute of Biomedical Sciences Tokushima University Graduate SchoolTokushimaJapan
| | - Hirofumi Hamano
- Clinical Research Center for Developmental TherapeuticsTokushima University HospitalTokushimaJapan
| | - Masateru Kondo
- Department of PharmacyTokushima University HospitalTokushimaJapan
| | - Naoto Okada
- Department of PharmacyTokushima University HospitalTokushimaJapan
| | - Itsuro Endo
- Department of HematologyEndocrinology and Metabolism, Institute of Biomedical Sciences Tokushima University Graduate SchoolTokushimaJapan
| | - Masahiro Abe
- Department of HematologyEndocrinology and Metabolism, Institute of Biomedical Sciences Tokushima University Graduate SchoolTokushimaJapan
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16
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Management of Adverse Events and Supportive Therapy in Relapsed/Refractory Multiple Myeloma. Cancers (Basel) 2021; 13:cancers13194978. [PMID: 34638462 PMCID: PMC8508369 DOI: 10.3390/cancers13194978] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Multiple myeloma (MM) patients with relapsing and/or refractory (RR) disease are exposed for a prolonged time to multiple drugs, which increase the risk of toxicity. In addition to tumor response, preserving the quality of life represents an important goal for this patient population. Therefore, supportive therapy plays a pivotal role in their treatment by limiting disease- and drug-related complications. The aim of this review is to outline current standards and future strategies to prevent and treat renal insufficiency, anemia, bone disease, and infection, including COVID-19, in RRMM patients. In addition, the incidence and treatment of side effects of novel anti-MM agents will be discussed. Abstract Relapsed/refractory (RR) multiple myeloma (MM) patients are a fragile population because of prolonged drug exposure and advanced age. Preserving a good quality of life is of high priority for these patients and the treatment of disease- and treatment-related complications plays a key role in their management. By preventing and limiting MM-induced complications, supportive care improves patients’ outcome. Erythropoietin-stimulating agents and bisphosphonates are well-established supportive strategies, yet novel agents are under investigation, such as anabolic bone agents and activin receptor-like kinase (ALK) inhibitors. The recent dramatic changes in the treatment landscape of MM pose an additional challenge for the routine care of RRMM patients. Multidrug combinations in first and later lines increase the risk for long-lasting toxicities, including adverse cardiovascular and neurological events. Moreover, recently approved first-in-class drugs have unique side-effect profiles, such as ocular toxicity of belantamab mafodotin or gastrointestinal toxicity of selinexor. This review discusses current standards in supportive treatment of RRMM patients, including recommendations in light of the recent SARS-CoV-19 pandemic, and critically looks at the incidence and management of side effects of standard as well as next generation anti-MM agents.
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Bird S, Cairns D, Menzies T, Boyd K, Davies F, Cook G, Drayson M, Gregory W, Jenner M, Jones J, Kaiser M, Owen R, Jackson G, Morgan G, Pawlyn C. Sex Differences in Multiple Myeloma Biology but not Clinical Outcomes: Results from 3894 Patients in the Myeloma XI Trial. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2021; 21:667-675. [PMID: 34059488 PMCID: PMC8528179 DOI: 10.1016/j.clml.2021.04.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/16/2021] [Indexed: 12/05/2022]
Abstract
BACKGROUND Sex differences in the incidence and outcomes of several cancers are well established. Multiple myeloma (MM) is a malignant plasma cell dyscrasia accounting for 2% of all new cancer cases in the UK. There is a clear sex disparity in MM incidence, with 57% of cases in males and 43% in females. The mechanisms behind this are not well understood and the impact of sex on patient outcomes has not been thoroughly explored. PATIENTS AND METHODS We investigated the association of sex with baseline disease characteristics and outcome in 3894 patients recruited to the phase III UK NCRI Myeloma XI trial, in which treatment exposure to lenalidomide predominated. RESULTS Females were significantly more likely to have the molecular lesions t(14;16) and del(17p) and were more likely to meet the cytogenetic classification of high-risk (HiR) or ultra-high-risk disease (UHiR). There was no difference in progression-free survival (PFS) or overall survival (OS) between the sexes in the overall population. CONCLUSION Our data suggest that the genetic lesions involved in the initiation and progression of MM may be different between the sexes. Although females were more likely to have the poor prognosis lesions t(14;16) and del(17p), and were more likely to be assessed as having HiR or UHiR disease, this was not associated with reduced PFS or OS. In female patients the trial treatment may have been able to overcome some of the adverse effects of high-risk cytogenetic lesions. MicroAbstract Multiple myeloma (MM) is more common in males compared to females but the reasons behind this are not well understood and the impact of sex on patient outcomes is unclear. This study demonstrates fundamental differences in genetic lesions underlying the biology of MM between males and females. However, we found that progression-free survival and overall survival were the same in both sexes.
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Affiliation(s)
- Sarah Bird
- The Institute of Cancer Research, London; The Royal Marsden Hospital, London
| | - David Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - Tom Menzies
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - Kevin Boyd
- The Institute of Cancer Research, London; The Royal Marsden Hospital, London
| | - Faith Davies
- Perlmutter Cancer Center, NY Langone Health, New York, USA
| | - Gordon Cook
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - Mark Drayson
- Clinical Immunology, University of Birmingham, Birmingham
| | - Walter Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - Matthew Jenner
- University Hospital Southampton NHS Foundation Trust, Southampton
| | - John Jones
- The Institute of Cancer Research, London
| | - Martin Kaiser
- The Institute of Cancer Research, London; The Royal Marsden Hospital, London
| | | | - Graham Jackson
- Department of Haematology, Newcastle University, Newcastle
| | - Gareth Morgan
- Perlmutter Cancer Center, NY Langone Health, New York, USA
| | - Charlotte Pawlyn
- The Institute of Cancer Research, London; The Royal Marsden Hospital, London.
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Charliński G, Vesole DH, Jurczyszyn A. Rapid Progress in the Use of Immunomodulatory Drugs and Cereblon E3 Ligase Modulators in the Treatment of Multiple Myeloma. Cancers (Basel) 2021; 13:4666. [PMID: 34572892 PMCID: PMC8468542 DOI: 10.3390/cancers13184666] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 12/20/2022] Open
Abstract
Over the past two decades, the improvement in our understanding of the biology of MM and the introduction of new drug classes, including immunomodulatory drugs (IMiDs), proteasome inhibitors (PI), and monoclonal antibodies (MoAb), have significantly improved outcomes. The first IMiD introduced to treat MM was thalidomide. The side effects observed during treatment with thalidomide initiated work on the synthesis of IMiD analogs. Subsequently, lenalidomide and pomalidomide were developed, both with different safety profiles, and they have better tolerability than thalidomide. In 2010, the cereblon (CRBN) protein was discovered as a direct target of IMiDs. By binding to CRBN, IMiDs change the substrate specificity of the CRBN E3 ubiquitin ligase complex, which results in the breakdown of internal Ikaros and Aiolos proteins. Most clinical trials conducted, both in newly diagnosed, post-transplant maintenance and relapsed/refractory MM, report a beneficial effect of IMiDs on the extension of progression-free survival and overall survival in patients with MM. Due to side effects, thalidomide is used less frequently. Currently, lenalidomide is used at every phase of MM treatment. Lenalidomide is used in conjunction with other agents such as PIs and MoAb as induction and relapsed therapy. Pomalidomide is currently used to treat relapsed/refractory MM, also with PIs and monoclonal antibodies. Current clinical trials are evaluating the efficacy of IMiD derivatives, the CRBN E3 ligase modulators (CELMoDs). This review focuses on the impact of IMiDs for the treatment of MM.
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Affiliation(s)
- Grzegorz Charliński
- Department of Hematology, Warmian-Masurian Cancer Center of The Ministry of The Interior and Administration’s Hospital, 10-228 Olsztyn, Poland;
| | - David H. Vesole
- John Theurer Cancer Center at Hackensack Meridian School of Medicine, Hackensack, NJ 07601, USA;
| | - Artur Jurczyszyn
- Plasma Cell Dyscrasia Center, Department of Hematology, Faculty of Medicine, Jagiellonian University Medical College, 31-501 Kraków, Poland
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Review of Myeloma Therapies and Their Potential for Oral and Maxillofacial Side Effects. Cancers (Basel) 2021; 13:cancers13174479. [PMID: 34503289 PMCID: PMC8431464 DOI: 10.3390/cancers13174479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 08/29/2021] [Accepted: 09/02/2021] [Indexed: 02/08/2023] Open
Abstract
Simple Summary Myeloma is a common cancer involving the bone marrow. Some of the medications used in the treatment of myeloma, including those that reduce the risk of bone fractures, can increase the chance of side effects occurring in the jawbone. The most serious complication in the jawbone is called medication-related osteonecrosis, meaning part of the jawbone dies. The aim of this review is to highlight some of the medications that are implicated and other risk factors that can contribute to osteonecrosis. Suggestions to prevent this complication from occurring are described. Conventional methods of treating established medication-related osteonecrosis of the jawbone are outlined as well as emerging new treatments. Abstract Myeloma is a common haematological malignancy in which adverse skeletal related events are frequently seen. Over recent years, treatment for myeloma has evolved leading to improved survival. Antiresorptive therapy is an important adjunct therapy to reduce the risk of bone fractures and to improve the quality of life for myeloma patients; however, this has the potential for unwanted side effects in the oral cavity and maxillofacial region. Osteonecrosis of the jaw related to antiresorptive medications and other myeloma therapies is not uncommon. This review serves to highlight the risk of osteonecrosis of the jaw for myeloma patients, with some suggestions for prevention and management.
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Derman BA, Kosuri S, Jakubowiak A. Knowing the unknowns in high risk multiple myeloma. Blood Rev 2021; 51:100887. [PMID: 34479756 DOI: 10.1016/j.blre.2021.100887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 12/28/2022]
Abstract
High risk multiple myeloma (HRMM) continues to portend worse outcomes despite the many advances in anti-myeloma therapeutics. The optimal approach to treatment is not clearly defined on account of the variable definitions of HRMM and the paucity of studies dedicated to the treatment of HRMM. In this review, we use a case-based approach to review the definitions of HRMM, and evaluate the evidence for induction, stem cell transplantation, and post-transplant therapy approaches for HRMM.
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Affiliation(s)
- Benjamin A Derman
- Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, United States of America.
| | - Satyajit Kosuri
- Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, United States of America
| | - Andrzej Jakubowiak
- Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, United States of America
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21
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The Roadmap of RANKL/RANK Pathway in Cancer. Cells 2021; 10:cells10081978. [PMID: 34440747 PMCID: PMC8393235 DOI: 10.3390/cells10081978] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 01/02/2023] Open
Abstract
The receptor activator of the nuclear factor-κB ligand (RANKL)/RANK signaling pathway was identified in the late 1990s and is the key mediator of bone remodeling. Targeting RANKL with the antibody denosumab is part of the standard of care for bone loss diseases, including bone metastases (BM). Over the last decade, evidence has implicated RANKL/RANK pathway in hormone and HER2-driven breast carcinogenesis and in the acquisition of molecular and phenotypic traits associated with breast cancer (BCa) aggressiveness and poor prognosis. This marked a new era in the research of the therapeutic use of RANKL inhibition in BCa. RANKL/RANK pathway is also an important immune mediator, with anti-RANKL therapy recently linked to improved response to immunotherapy in melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC). This review summarizes and discusses the pre-clinical and clinical evidence of the relevance of the RANKL/RANK pathway in cancer biology and therapeutics, focusing on bone metastatic disease, BCa onset and progression, and immune modulation.
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22
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Jackson GH, Davies FE, Pawlyn C, Cairns DA, Striha A, Collett C, Waterhouse A, Jones JR, Kishore B, Garg M, Williams CD, Karunanithi K, Lindsay J, Allotey D, Shafeek S, Jenner MW, Cook G, Russell NH, Kaiser MF, Drayson MT, Owen RG, Gregory WM, Morgan GJ. Lenalidomide before and after autologous stem cell transplantation for transplant-eligible patients of all ages in the randomized, phase III, Myeloma XI trial. Haematologica 2021; 106:1957-1967. [PMID: 32499244 PMCID: PMC8252959 DOI: 10.3324/haematol.2020.247130] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 05/28/2020] [Indexed: 01/28/2023] Open
Abstract
The optimal way to use immunomodulatory drugs as components of induction and maintenance therapy for multiple myeloma is unresolved. We addressed this question in a large phase III randomized trial, Myeloma XI. Patients with newly diagnosed multiple myeloma (n = 2042) were randomized to induction therapy with cyclophosphamide, thalidomide, and dexamethasone (CTD) or cyclophosphamide, lenalidomide, and dexamethasone (CRD). Additional intensification therapy with cyclophosphamide, bortezomib and dexamethasone (CVD) was administered before ASCT to patients with a suboptimal response to induction therapy using a response-adapted approach. After receiving high-dose melphalan with autologous stem cell transplantation (ASCT), eligible patients were further randomized to receive either lenalidomide alone or observation alone. Co-primary endpoints were progression-free survival (PFS) and overall survival (OS). The CRD regimen was associated with significantly longer PFS (median: 36 vs. 33 months; hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.75-0.96; P = 0.0116) and OS (3-year OS: 82.9% vs. 77.0%; HR, 0.77; 95% CI, 0.63-0.93; P = 0.0072) compared with CTD. The PFS and OS results favored CRD over CTD across all subgroups, including patients with International Staging System stage III disease (HR for PFS, 0.73; 95% CI, 0.58-0.93; HR for OS, 0.78; 95% CI, 0.56-1.09), high-risk cytogenetics (HR for PFS, 0.60; 95% CI, 0.43-0.84; HR for OS, 0.70; 95% CI, 0.42-1.15) and ultra high-risk cytogenetics (HR for PFS, 0.67; 95% CI, 0.41-1.11; HR for OS, 0.65; 95% CI, 0.34-1.25). Among patients randomized to lenalidomide maintenance (n = 451) or observation (n = 377), maintenance therapy improved PFS (median: 50 vs. 28 months; HR, 0.47; 95% CI, 0.37-0.60; P < 0.0001). Optimal results for PFS and OS were achieved in the patients who received CRD induction and lenalidomide maintenance. The trial was registered with the EU Clinical Trials Register (EudraCT 2009-010956-93) and ISRCTN49407852.
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Affiliation(s)
- Graham H. Jackson
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Faith E. Davies
- Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Charlotte Pawlyn
- The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - David A. Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Alina Striha
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Corinne Collett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Anna Waterhouse
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - John R. Jones
- King’s College Hospital NHS Foundation Trust, London, UK
| | | | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
| | - Cathy D. Williams
- Centre for Clinical Haematology, Nottingham University Hospital, Nottingham, UK
| | | | | | - David Allotey
- Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Salim Shafeek
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Matthew W. Jenner
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gordon Cook
- Section of Experimental Haematology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - Nigel H. Russell
- Centre for Clinical Haematology, Nottingham University Hospital, Nottingham, UK
| | - Martin F. Kaiser
- The Institute of Cancer Research and The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Mark T. Drayson
- Clinical Immunology, School of Immunity and Infection, University of Birmingham, Birmingham, UK
| | - Roger G. Owen
- St James's University Hospital, Haematological Malignancy Diagnostic Service (HMDS), Leeds, UK
| | - Walter M. Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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23
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Jones JR, Pawlyn C, Jackson GH. Safety of lenalidomide for maintenance treatment of patients with multiple myeloma following autologous stem cell transplantation. Expert Opin Drug Saf 2021; 20:1137-1145. [PMID: 34184970 DOI: 10.1080/14740338.2021.1945578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Myeloma is the second most common hematological cancer, with 5800 cases per year diagnosed in the UK. Despite improved treatment it is still considered non-curable, although the median survival has increased from 3 to 8 years over the past 20 years. Treatment involves the use of induction therapy and consolidation with autologous stem cell transplant (ASCT) in patients deemed fit enough. Further attempts to improve outcomes include the use of maintenance therapy. AREAS COVERED This review details all trials in which lenalidomide has been used as maintenance following ASCT. PubMed searches included randomized control trials, observational cohort, reviews, and meta-analysis. EXPERT OPINION Lenalidomide is a well-tolerated, oral agent that is associated with increased overall and progression free survival when used as maintenance following ASCT. Its use in this setting is FDA and EMA approved and is standard of care in Europe and North America. The early link between lenalidomide and second hematological cancers appears to be associated with use in combination with melphalan. There is an increase in non-melanoma skin cancers and solid tumors in the elderly but this has minimal impact on mortality. Lenalidomide use as part of combination maintenance is underway and may further improve outcomes.
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Affiliation(s)
- John R Jones
- Brighton and Sussex Medical School, Brighton, UK.,Department of Haematology, Eastbourne District General Hospital, Eastbourne, UK.,Department of Haematology, King's College Hospital, London, UK
| | - Charlotte Pawlyn
- The Institute of Cancer Research, London, UK.,Royal Marsden Hospital, London, UK
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Lu H, Pundole X, Lee HC. The role of bone-modifying agents in myeloma bone disease. JBMR Plus 2021; 5:e10518. [PMID: 34368608 PMCID: PMC8328802 DOI: 10.1002/jbm4.10518] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 01/23/2023] Open
Abstract
Bone disease is common in patients with multiple myeloma (MM), which manifests as bone pain and skeletal-related events (SREs) such as pathological fractures and spinal cord compression. Myeloma bone disease (MBD) can adversely affect the quality of life of patients and have negative effects on morbidity and mortality. The pathogenesis of MBD is complex, and several factors are involved in the dysregulation of bone metabolism and uncoupling of bone remodeling, which result in net bone loss and devastating SREs. Broadly speaking, elevated osteoclast activity, suppressed osteoblast activity, and an aberrant marrow microenvironment play a role in MBD. Interaction of MM cells with the main bone cell osteocytes also promote further bone destruction. This review focuses on the role of bone-modifying agents in the prevention and treatment of MBD. The mainstay of MBD prevention are antiresorptive agents, bisphosphonates and denosumab. However, these agents do not play a direct role in bone formation and repair of existing MBD. Newer agents with anabolic effects such as anti-sclerostin antibodies, parathyroid hormone, anti-Dickkopf-1 antibodies, and others have shown potential in repair of MBD lesions. With the development of several new agents, the treatment landscape of MBD is likely to evolve in the coming years. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Huifang Lu
- Department of General Internal Medicine Section of Rheumatology and Clinical Immunology Houston Texas USA
| | - Xerxes Pundole
- Department of Health Services Research The University of Texas MD Anderson Cancer Center Houston Texas USA.,Present address: Amgen Inc. Thousand Oaks CA USA
| | - Hans C Lee
- Department of Lymphoma/Myeloma The University of Texas MD Anderson Cancer Center Houston Texas USA
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Mohan M, Kumar M, Samant R, Van Hemert R, Tian E, Desai S, van Rhee F, Thanendrarajan S, Schinke C, Suva LJ, Sharma S, Milad M, Kendrick S, Zangari M. Bone remineralization of lytic lesions in multiple myeloma - The Arkansas experience. Bone 2021; 146:115876. [PMID: 33556629 PMCID: PMC8627246 DOI: 10.1016/j.bone.2021.115876] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/29/2021] [Accepted: 01/31/2021] [Indexed: 12/11/2022]
Abstract
Multiple myeloma (MM) patients frequently present with extensive osteolytic bone lesions. However, the impact of myeloma treatment on focal lytic lesion remineralization has not been extensively studied. In this study, the effect of anti-myeloma treatment on the extent of bone remineralization was examined and potential mediators identified. Newly diagnosed MM patients enrolled in the Total Therapy 4 and 5 (TT4; n = 231, TT5; n = 64) protocols were longitudinally evaluated for changes in radiological parameters for a median of 6.1 years. Bone remineralization was defined as a sclerotic CT change within the lytic lesion and quantified as a percentage of remineralization, using the initial lesion size as a reference. Such changes were correlated to clinical and biochemical parameters, and the gene expression profile of bone marrow biopsy. Overall, remineralization occurred in 72% of patients (213/295). Of those patients that experienced remineralization, 36% (107/295) achieved at least 25% of bone remineralization. Patients with high-risk disease defined by gene expression profile signature (GEP70 ≥ 0.66) experienced significant remineralization compared to low-risk MM. Female patients were also more likely to experience bone remineralization and in a shorter median time (2.0 vs. 3.3 y). Factors such as serum alkaline phosphatase along with high levels of RUNX2 and SOX4 gene expression correlated with increasing extent of bone remineralization. This analysis demonstrated significant remineralization of lytic lesions in MM patients treated on TT clinical trials. While the underlying mechanism remains elusive these findings support the hypothesis that patient baseline bone-related factors play a fundamental role in the skeletal repair of bone lesions in MM that provide new opportunities for improving patient outcomes.
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Affiliation(s)
- Meera Mohan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Manoj Kumar
- Department of Radiodiagnosis, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Rohan Samant
- Department of Radiodiagnosis, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Rudy Van Hemert
- Department of Radiodiagnosis, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Erming Tian
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Shivang Desai
- Department of Radiodiagnosis, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Frits van Rhee
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Sharmilan Thanendrarajan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Carolina Schinke
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Larry J Suva
- Department of Veterinary Physiology and Pharmacology, Texas A&M University, College Station, TX, United States of America
| | - Shobhit Sharma
- Department of Radiodiagnosis, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Mohamed Milad
- Department of Bioinformatics, Arkansas State University, Jonesboro, AR, United States of America
| | - Samantha Kendrick
- Department of Biochemisty and Molecular Biology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
| | - Maurizio Zangari
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
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Mithraprabhu S, Kalff A, Gartlan KH, Savvidou I, Khong T, Ramachandran M, Cooke RE, Bowen K, Hill GR, Reynolds J, Spencer A. Phase II trial of single-agent panobinostat consolidation improves responses after sub-optimal transplant outcomes in multiple myeloma. Br J Haematol 2021; 193:160-170. [PMID: 32945549 PMCID: PMC8048685 DOI: 10.1111/bjh.17080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/11/2020] [Indexed: 01/23/2023]
Abstract
Panobinostat is a pan-deacetylase inhibitor that modulates the expression of oncogenic and immune-mediating genes involved in tumour cell growth and survival. We evaluated panobinostat-induced post-transplant responses and identified correlative biomarkers in patients with multiple myeloma who had failed to achieve a complete response after autologous transplantation. Patients received panobinostat 45 mg administered three-times weekly (TIW) on alternate weeks of 28-day cycles commencing 8-12 weeks post-transplant. Twelve of 25 patients (48%) improved their depth of response after a median (range) of 4·3 (1·9-9·7) months of panobinostat. In responders, T-lymphocyte histone acetylation increased after both three cycles (P < 0·05) and six cycles (P < 0·01) of panobinostat when compared to baseline, with no differences in non-responders. The reduction in the proportion of CD127+ CD8+ T cells and CD4:CD8 ratio was significantly greater, after three and six cycles of panobinostat compared to pre-transplant, in non-responders when compared to responders. Whole marrow RNA-seq revealed widespread transcriptional changes only in responders with baseline differences in genes involved in ribosome biogenesis, oxidative phosphorylation and metabolic pathways. This study confirmed the efficacy of panobinostat as a single agent in multiple myeloma and established acetylation of lymphocyte histones, modulation of immune subsets and transcriptional changes as pharmacodynamic biomarkers of clinical benefit.
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Affiliation(s)
- Sridurga Mithraprabhu
- Myeloma Research GroupAustralian Centre for Blood DiseasesAlfred Hospital‐Monash UniversityMelbourneVictoriaAustralia
- Malignant Haematology and Stem Cell TransplantationAlfred HospitalMelbourneVictoriaAustralia
| | - Anna Kalff
- Myeloma Research GroupAustralian Centre for Blood DiseasesAlfred Hospital‐Monash UniversityMelbourneVictoriaAustralia
- Malignant Haematology and Stem Cell TransplantationAlfred HospitalMelbourneVictoriaAustralia
| | - Kate H. Gartlan
- QIMR Berghofer Medical Research InstituteHerstonQueenslandAustralia
| | - Ioanna Savvidou
- Myeloma Research GroupAustralian Centre for Blood DiseasesAlfred Hospital‐Monash UniversityMelbourneVictoriaAustralia
- Malignant Haematology and Stem Cell TransplantationAlfred HospitalMelbourneVictoriaAustralia
| | - Tiffany Khong
- Myeloma Research GroupAustralian Centre for Blood DiseasesAlfred Hospital‐Monash UniversityMelbourneVictoriaAustralia
- Malignant Haematology and Stem Cell TransplantationAlfred HospitalMelbourneVictoriaAustralia
| | - Malarmathy Ramachandran
- Myeloma Research GroupAustralian Centre for Blood DiseasesAlfred Hospital‐Monash UniversityMelbourneVictoriaAustralia
- Malignant Haematology and Stem Cell TransplantationAlfred HospitalMelbourneVictoriaAustralia
| | - Rachel E. Cooke
- Malignant Haematology and Stem Cell TransplantationAlfred HospitalMelbourneVictoriaAustralia
- Haematology DepartmentNorthern HealthMelbourneVictoriaAustralia
| | - Kathryn Bowen
- Malignant Haematology and Stem Cell TransplantationAlfred HospitalMelbourneVictoriaAustralia
| | - Geoffrey R. Hill
- Clinical Research DivisionFred Hutchinson Cancer Research CentreSeattle, WashingtonUnited States
| | - John Reynolds
- Epidemiology and Preventive MedicineAlfred Health – Monash UniversityMelbourneVictoriaAustralia
| | - Andrew Spencer
- Myeloma Research GroupAustralian Centre for Blood DiseasesAlfred Hospital‐Monash UniversityMelbourneVictoriaAustralia
- Malignant Haematology and Stem Cell TransplantationAlfred HospitalMelbourneVictoriaAustralia
- Department of Clinical HaematologyMonash UniversityClaytonVictoriaAustralia
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27
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Jackson GH, Pawlyn C, Cairns DA, Striha A, Collett C, Waterhouse A, Jones JR, Wilson J, Taylor C, Kishore B, Garg M, Williams CD, Karunanithi K, Lindsay J, Jenner MW, Cook G, Russell NH, Drayson MT, Kaiser MF, Owen RG, Gregory WM, Davies FE, Morgan GJ. Optimising the value of immunomodulatory drugs during induction and maintenance in transplant ineligible patients with newly diagnosed multiple myeloma: results from Myeloma XI, a multicentre, open-label, randomised, Phase III trial. Br J Haematol 2021; 192:853-868. [PMID: 32656799 DOI: 10.1111/bjh.16945] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/13/2020] [Indexed: 11/28/2022]
Abstract
Second-generation immunomodulatory agents, such as lenalidomide, have a more favourable side-effect profile than the first-generation thalidomide, but their optimum combination and duration for patients with newly diagnosed transplant-ineligible myeloma (ND-TNE-MM) has not been defined. The most appropriate delivery and dosing regimens of these therapies for patients at advanced age and frailty status is also unclear. The Myeloma XI study compared cyclophosphamide, thalidomide and dexamethasone (CTDa) to cyclophosphamide, lenalidomide and dexamethasone (CRDa) as induction therapy, followed by a maintenance randomisation between ongoing therapy with lenalidomide or observation for patients with ND-TNE-MM. CRDa deepened response but did not improve progression-free (PFS) or overall survival (OS) compared to CTDa. However, analysis by age group highlighted significant differences in tolerability in older, frailer patients that may have limited treatment delivery and impacted outcome. Deeper responses and PFS and OS benefits with CRDa over CTDs were seen in patients aged ≤70 years, with an increase in toxicity and discontinuation observed in older patients. Our results highlight the importance of considering age and frailty in the approach to therapy for patients with ND-TNE-MM, highlighting the need for prospective validation of frailty adapted therapy approaches, which may improve outcomes by tailoring treatment to the individual.
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Affiliation(s)
- Graham H Jackson
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Charlotte Pawlyn
- The Institute of Cancer Research, London, UK
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - David A Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Alina Striha
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Corinne Collett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Anna Waterhouse
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - John R Jones
- Kings College Hospital NHS Foundation Trust, London, UK
| | - Jamie Wilson
- Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | | | - Bhuvan Kishore
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mamta Garg
- Leicester Royal Infirmary, Leicester, UK
| | - Cathy D Williams
- Centre for Clinical Haematology, Nottingham University Hospital, Nottingham, UK
| | | | - Jindriska Lindsay
- E1ast Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - Matthew W Jenner
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gordon Cook
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Cancer Centre, University of Leeds, Leeds, UK
| | - Nigel H Russell
- Centre for Clinical Haematology, Nottingham University Hospital, Nottingham, UK
| | - Mark T Drayson
- Clinical Immunology Service, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Martin F Kaiser
- The Institute of Cancer Research, London, UK
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Roger G Owen
- Haematological Malignancy Diagnostic Service (HMDS), St James's University Hospital, Leeds, UK
| | - Walter M Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Faith E Davies
- Perlmutter Cancer Center, NY Langone Health, New York, NY, USA
| | - Gareth J Morgan
- Perlmutter Cancer Center, NY Langone Health, New York, NY, USA
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28
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Richter J, Sanchez L, Biran N, Wang C, Tanenbaum K, DeVincenzo V, Grunman B, Vesole DH, Siegel DS, Pecora A, Goldberg SL. Prevalence and Survival Impact of Self-Reported Symptom and Psychological Distress Among Patients With Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e284-e289. [DOI: 10.1016/j.clml.2020.11.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 12/25/2022]
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29
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Devarakonda S, Efebera Y, Sharma N. Role of Stem Cell Transplantation in Multiple Myeloma. Cancers (Basel) 2021; 13:863. [PMID: 33670709 PMCID: PMC7922596 DOI: 10.3390/cancers13040863] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/09/2021] [Accepted: 02/12/2021] [Indexed: 12/11/2022] Open
Abstract
Autologous stem cell transplantation (auto-SCT) has been the standard of care in eligible newly diagnosed multiple myeloma (MM) patients. Outcomes of patients with MM have improved significantly due to the advent of several novel drugs. Upfront use of these drugs in induction therapy has significantly increased the rate and depth of responses that have translated into longer remission and survival. This has now raised a debate regarding the role and relevance of auto-SCT in the management of myeloma. However, clinical trials have confirmed the utility of auto-SCT even in the era of novel drugs. Tandem auto-SCT followed by maintenance has shown a progression-free survival (PFS) benefit in high-risk MM, and hence can be considered in young and fit patients with high-risk disease. Auto-SCT has the advantages of resetting the bone marrow microenvironment, short-lived toxicity compared to the long-term physical and financial toxicities of continued chemotherapy in the absence of SCT, very low transplant-related mortality (TRM) in high volume centers, and providing longer disease-free survival when followed by maintenance therapy. Allogeneic SCT is one potentially curative option for MM, albeit with an increased risk of death due to high TRM. Strategies to modulate the graft-versus-host disease (GVHD) while maintaining or improving the graft-versus-myeloma (GVM) effect could place allogeneic SCT back in the treatment armamentarium of MM.
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Affiliation(s)
| | - Yvonne Efebera
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center Columbus, Columbus, OH 43210, USA; (S.D.); (N.S.)
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Abstract
Two early observations about the first generation bisphosphonate, clodronate, suggested that it would likely have clinical utility; specifically, it was a more potent anti-resorptive but a less potent inhibitor of mineralisation than its predecessor etidronate. The known mechanism of action differs from that of the later nitrogen-containing bisphosphonates, as clodronate is metabolised intracellularly to a toxic analog of adenosine triphosphate, AppCCl2p, which causes mitochondrial dysfunction, impaired cellular energy metabolism and osteoclast apoptosis. For pre-clinical studies in a variety of disease models, liposomal clodronate has become the agent of choice for macrophage depletion, for example in a recent study to enhance haematopoietic chimerism and donor-specific skin allograft tolerance in a mouse model. For clinical use, clodronate was developed in oral and injectable formulations; while poorly absorbed from the gastro-intestinal tract, its absorption at 1-3% of the administered dose is approximately three-fold higher than for nitrogen-containing bisphosphonates. Following an early setback due to an erroneous association with toxic adverse events, a number of successful clinical studies have established clodronate, predominantly in its oral formulations, as a highly successful treatment in Paget's disease, hypercalcaemia (benign and malignant), multiple myeloma, and early or metastatic breast cancer. Novel uses in other disease areas, including veterinary use, continue to be explored.
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Affiliation(s)
- Eugene McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK; Centre for Integrated Research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK.
| | | | - Trevor Powles
- Cancer Centre London, 49 Parkside, Wimbledon, London SW19 5NB, UK
| | - John A Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield, Sheffield, UK; Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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31
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Kumar SK, Callander NS, Adekola K, Anderson L, Baljevic M, Campagnaro E, Castillo JJ, Chandler JC, Costello C, Efebera Y, Faiman M, Garfall A, Godby K, Hillengass J, Holmberg L, Htut M, Huff CA, Kang Y, Hultcrantz M, Larson S, Liedtke M, Martin T, Omel J, Shain K, Sborov D, Stockerl-Goldstein K, Weber D, Keller J, Kumar R. Multiple Myeloma, Version 3.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:1685-1717. [PMID: 33285522 DOI: 10.6004/jnccn.2020.0057] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Multiple myeloma is a malignant neoplasm of plasma cells that accumulate in bone marrow, leading to bone destruction and marrow failure. This manuscript discusses the management of patients with solitary plasmacytoma, smoldering multiple myeloma, and newly diagnosed multiple myeloma.
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Affiliation(s)
| | | | - Kehinde Adekola
- 3Robert H. Lurie Comprehensive Cancer of Center Northwestern University
| | | | | | | | - Jorge J Castillo
- 7Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | - Jason C Chandler
- 8St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Yvonne Efebera
- 10The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Matthew Faiman
- 11Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Alfred Garfall
- 12Abramson Cancer Center at the University of Pennsylvania
| | | | | | - Leona Holmberg
- 15Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Myo Htut
- 16City of Hope National Medical Center
| | - Carol Ann Huff
- 17The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - Thomas Martin
- 22UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | - Donna Weber
- 27The University of Texas MD Anderson Cancer Center; and
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32
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Coleman R, Hadji P, Body JJ, Santini D, Chow E, Terpos E, Oudard S, Bruland Ø, Flamen P, Kurth A, Van Poznak C, Aapro M, Jordan K. Bone health in cancer: ESMO Clinical Practice Guidelines. Ann Oncol 2020; 31:1650-1663. [PMID: 32801018 DOI: 10.1016/j.annonc.2020.07.019] [Citation(s) in RCA: 224] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
- R Coleman
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
| | - P Hadji
- Frankfurt Centre of Bone Health, Frankfurt, Germany; Philipps University of Marburg, Marburg, Germany
| | - J-J Body
- CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - D Santini
- Medical Oncology Department, University Campus Bio-Medico, Rome, Italy
| | - E Chow
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - E Terpos
- National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - S Oudard
- Department of Medical Oncology, Georges Pompidou Hospital, Paris Descartes University, Paris, France
| | - Ø Bruland
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Oncology, Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - P Flamen
- Department of Nuclear Medicine, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - A Kurth
- Department of Orthopaedic and Trauma Surgery, Campus Kemperhof, Community Clinics Middle Rhine, Koblenz, Germany; Major Teaching Hospital of the University Medicine Mainz, Mainz, Germany
| | | | - M Aapro
- Genolier Cancer Centre, Genolier, Switzerland
| | - K Jordan
- Department of Medicine V, Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
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33
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Shah V, Sherborne AL, Johnson DC, Ellis S, Price A, Chowdhury F, Kendall J, Jenner MW, Drayson MT, Owen RG, Gregory WM, Morgan GJ, Davies FE, Cook G, Cairns DA, Houlston RS, Jackson G, Kaiser MF. Predicting ultrahigh risk multiple myeloma by molecular profiling: an analysis of newly diagnosed transplant eligible myeloma XI trial patients. Leukemia 2020; 34:3091-3096. [PMID: 32157174 PMCID: PMC7584474 DOI: 10.1038/s41375-020-0750-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Vallari Shah
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - Amy L Sherborne
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - David C Johnson
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - Sidra Ellis
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - Amy Price
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - Farzana Chowdhury
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - Jack Kendall
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - Matthew W Jenner
- Department of Haematology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mark T Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Roger G Owen
- Haematological Malignancy Diagnostic Service, St. James's University Hospital, Leeds, UK
| | - Walter M Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, Leeds, UK
| | - Gareth J Morgan
- Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Faith E Davies
- Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Gordon Cook
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - David A Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, Leeds, UK
| | - Richard S Houlston
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
- Molecular and Population Genetics, The Institute of Cancer Research, London, UK
| | - Graham Jackson
- Department of Haematology, University of Newcastle, Newcastle Upon Tyne, UK
| | - Martin F Kaiser
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK.
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34
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Parrondo RD, Reljic T, Iqbal M, Ayala E, Kharfan-Dabaja MA, Kumar A, Murthy HS. Efficacy of proteasome inhibitor-based maintenance following autologous transplantation in multiple myeloma: A systematic review and meta-analysis. Eur J Haematol 2020; 106:40-48. [PMID: 32799387 DOI: 10.1111/ejh.13506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Lenalidomide maintenance, commonly prescribed in the postautologous transplantation (AHCT) setting for multiple myeloma (MM), is associated with development of secondary primary malignancies (SPM). Proteasome inhibitor maintenance (PIM) has also been evaluated in MM. We conduct a systematic review/meta-analysis to assess the efficacy of PIM in MM. METHODS Performing a comprehensive search of the medical literature using PubMed/Medline and EMBASE on September 11, 2019, we extracted data on clinical outcomes related to benefits (OS, PFS, and depth of hematologic response [DOHR]) and harms (SPM and adverse events). 2144 references were identified; three studies were eligible for inclusion. RESULTS A total of 1760 patients were included in the analysis; 507 patients received bortezomib and 395 received ixazomib maintenance. Control arms were either placebo (n = 261) or thalidomide (n = 358). PIM did not improve OS (HR 0.88, 95% CI 0.73-1.05, P = .15) but improved PFS (HR 0.77, 95% CI 0.69-0.86, P ≤ .00001) and DOHR (HR 0.88, 95% CI 0.79-0.98, P = .02) compared with control. There were no significant differences between PIM and control regarding SPM (p = NS) and ≥grade 3 peripheral neuropathy (PN) (p = NS). CONCLUSIONS PIM following AHCT in MM improves PFS and DOHR without an increase in development of SPM or severe PN compared with placebo/thalidomide.
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Affiliation(s)
- Ricardo D Parrondo
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Tea Reljic
- Program for Comparative Effectiveness Research, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Madiha Iqbal
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Ernesto Ayala
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Ambuj Kumar
- Program for Comparative Effectiveness Research, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Hemant S Murthy
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
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Abstract
Bone is the most frequent site for metastasis for many cancers, notably for tumours originating in the breast and the prostate. Tumour cells can escape from the primary tumour site and colonize the bone microenvironment. Within the bone, these disseminated tumour cells, as well as those arising in the context of multiple myeloma, may assume a state of dormancy, remaining quiescent for years before resuming proliferation and causing overt metastasis, which causes bone destruction via activation of osteoclast-mediated osteolysis. This structural damage can lead to considerable morbidity, including pain, fractures and impaired quality of life. Although treatment of bone metastases and myeloma bone disease is rarely curative, disease control is often possible for many years through the use of systemic anticancer treatments on a background of multidisciplinary supportive care. This care should include bone-targeted agents to inhibit tumour-associated osteolysis and prevent skeletal morbidity as well as use of appropriate local treatments such as radiation therapy, orthopaedic surgery and specialist palliative care to minimize the impact of metastatic bone disease on physical functioning. In this Primer, we provide an overview of the clinical features, the pathophysiology and the specific treatment approaches to prevent and treat bone metastases from solid tumours as well as myeloma bone disease.
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36
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Bradbury CA, Craig Z, Cook G, Pawlyn C, Cairns DA, Hockaday A, Paterson A, Jenner MW, Jones JR, Drayson MT, Owen RG, Kaiser MF, Gregory WM, Davies FE, Child JA, Morgan GJ, Jackson GH. Thrombosis in patients with myeloma treated in the Myeloma IX and Myeloma XI phase 3 randomized controlled trials. Blood 2020; 136:1091-1104. [PMID: 32438407 PMCID: PMC7453153 DOI: 10.1182/blood.2020005125] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/23/2020] [Indexed: 12/16/2022] Open
Abstract
Newly diagnosed multiple myeloma (NDMM) patients treated with immunomodulatory drugs are at high risk of venous thromboembolism (VTE), but data are lacking from large prospective cohorts. We present thrombosis outcome data from Myeloma IX (n = 1936) and Myeloma XI (n = 4358) phase 3 randomized controlled trials for NDMM that treated transplant-eligible and transplant-ineligible patients before and after publication of thrombosis prevention guidelines. In Myeloma IX, transplant-eligible patients randomly assigned to cyclophosphamide, vincristine, doxorubicin, and dexamethasone (CVAD) induction had higher risk of VTE compared with patients treated with cyclophosphamide, thalidomide, and dexamethasone (CTD) (22.5% [n = 121 of 538] vs 16.1% [n = 89 of 554]; adjusted hazard ratio [aHR],1.46; 95% confidence interval [95% CI], 1.11-1.93). For transplant-ineligible patients, those randomly assigned to attenuated CTD (CTDa) induction had a higher risk of VTE compared with those treated with melphalan and prednisolone (MP) (16.0% [n = 68 of 425] vs 4.1% [n = 17 of 419]; aHR, 4.25; 95% CI, 2.50-7.20). In Myeloma XI, there was no difference in risk of VTE (12.2% [n = 124 of 1014] vs 13.2% [n = 133 of 1008]; aHR, 0.92; 95% CI, 0.72-1.18) or arterial thrombosis (1.2% [n = 12 of 1014] vs 1.5% [n = 15 of 1008]; aHR, 0.80; 95% CI, 0.37-1.70) between transplant-eligible pathways for patients treated with cyclophosphamide, lenalidomide, and dexamethasone (CRD) or CTD. For transplant-ineligible patients, there was no difference in VTEs between attenuated CRD (CRDa) and CTDa (10.4% [n = 95 of 916] vs 10.7% [n = 97 of 910]; aHR, 0.97; 95% CI, 0.73-1.29). However, arterial risk was higher with CRDa than with CTDa (3.1% [n = 28 of 916] vs 1.6% [n = 15 of 910]; aHR, 1.91; 95% CI, 1.02-3.57). Thrombotic events occurred almost entirely within 6 months of treatment initiation. Thrombosis was not associated with inferior progression-free survival (PFS) or overall survival (OS), apart from inferior OS for patients with arterial events (aHR, 1.53; 95% CI, 1.12-2.08) in Myeloma XI. The Myeloma XI trial protocol incorporated International Myeloma Working Group (IMWG) thrombosis prevention recommendations and compared with Myeloma IX, more patients received thromboprophylaxis (80.5% vs 22.3%) with lower rates of VTE for identical regimens (CTD, 13.2% vs 16.1%; CTDa, 10.7% vs 16.0%). However, thrombosis remained frequent in spite of IMWG-guided thromboprophylaxis, suggesting that new approaches are needed.
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Affiliation(s)
- Charlotte A Bradbury
- School of Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Zoe Craig
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Gordon Cook
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
- Leeds Cancer Centre, Leeds, United Kingdom
| | - Charlotte Pawlyn
- The Institute of Cancer Research, London, United Kingdom
- The Royal Marsden Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - David A Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Andrea Paterson
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Matthew W Jenner
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - John R Jones
- Kings College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark T Drayson
- Clinical Immunology, School of Immunity and Infection, University of Birmingham, Birmingham, United Kingdom
| | - Roger G Owen
- Haematological Malignancy Diagnostic Service, St James's University Hospital, Leeds, United Kingdom
| | - Martin F Kaiser
- The Institute of Cancer Research, London, United Kingdom
- The Royal Marsden Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom
| | - Walter M Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Faith E Davies
- Perlmutter Cancer Center, New York University Langone Health, New York, NY; and
| | - J Anthony Child
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Gareth J Morgan
- Perlmutter Cancer Center, New York University Langone Health, New York, NY; and
| | - Graham H Jackson
- Freeman Hospital, University of Newcastle, Newcastle Upon Tyne, United Kingdom
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Fang Y, Hou J. [Multiple-Hit myeloma]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 40:620-622. [PMID: 32397033 PMCID: PMC7364890 DOI: 10.3760/cma.j.issn.0253-2727.2019.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Y Fang
- Department of Hematology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
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38
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Dimopoulos MA, Jakubowiak AJ, McCarthy PL, Orlowski RZ, Attal M, Bladé J, Goldschmidt H, Weisel KC, Ramasamy K, Zweegman S, Spencer A, Huang JSY, Lu J, Sunami K, Iida S, Chng WJ, Holstein SA, Rocci A, Skacel T, Labotka R, Palumbo A, Anderson KC. Developments in continuous therapy and maintenance treatment approaches for patients with newly diagnosed multiple myeloma. Blood Cancer J 2020; 10:17. [PMID: 32054831 PMCID: PMC7018731 DOI: 10.1038/s41408-020-0273-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/13/2019] [Accepted: 09/18/2019] [Indexed: 12/30/2022] Open
Abstract
The evolving paradigm of continuous therapy and maintenance treatment approaches in multiple myeloma (MM) offers prolonged disease control and improved outcomes compared to traditional fixed-duration approaches. Potential benefits of long-term strategies include sustained control of disease symptoms, as well as continued cytoreduction and clonal control, leading to unmeasurable residual disease and the possibility of transforming MM into a chronic or functionally curable condition. "Continuous therapy" commonly refers to administering a doublet or triplet regimen until disease progression, whereas maintenance approaches typically involve single-agent or doublet treatment following more intensive prior therapy with autologous stem cell transplant (ASCT) or doublet, triplet, or even quadruplet induction therapy. However, the requirements for agents and regimens within these contexts are similar: treatments must be tolerable for a prolonged period of time, should not be associated with cumulative or chronic toxicity, should not adversely affect patients' quality of life, should ideally be convenient with a minimal treatment burden for patients, and should not impact the feasibility or efficacy of subsequent treatment at relapse. Multiple agents have been and are being investigated as long-term options in the treatment of newly diagnosed MM (NDMM), including the immunomodulatory drugs lenalidomide and thalidomide, the proteasome inhibitors bortezomib, carfilzomib, and ixazomib, and the monoclonal antibodies daratumumab, elotuzumab, and isatuximab. Here we review the latest results with long-term therapy approaches in three different settings in NDMM: (1) maintenance treatment post ASCT; (2) continuous frontline therapy in nontransplant patients; (3) maintenance treatment post-frontline therapy in the nontransplant setting. We also discuss evidence from key phase 3 trials. Our review demonstrates how the paradigm of long-term treatment is increasingly well-established across NDMM treatment settings, potentially resulting in further improvements in patient outcomes, and highlights key clinical issues that will need to be addressed in order to provide optimal benefit.
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Affiliation(s)
- Meletios A Dimopoulos
- Hematology & Medical Oncology, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
| | | | | | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michel Attal
- Hematology Department, University Hospital Purpan, Toulouse, France
| | - Joan Bladé
- Hematology Department, Hospital Clinic, Institut de Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Hartmut Goldschmidt
- Department of Internal Medicine V, University Medical Hospital and National Center of Tumor Diseases, University of Heidelberg, Heidelberg, Germany
| | - Katja C Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Sonja Zweegman
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Center, VU University Amsterdam, Amsterdam, The Netherlands
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health-Monash University, Melbourne, Australia
| | | | - Jin Lu
- Department of Hematology, Peking University People's Hospital and Peking University Institute of Hematology, Beijing, China
| | - Kazutaka Sunami
- Department of Hematology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Wee-Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, and Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Sarah A Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Alberto Rocci
- Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Faculty of Biology, Medicine and Health, School of Medical Science, Division of Cancer Science, University of Manchester, Manchester, UK
| | - Tomas Skacel
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Richard Labotka
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Antonio Palumbo
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
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Monocytic Myeloid Derived Suppressor Cells in Hematological Malignancies. Int J Mol Sci 2019; 20:ijms20215459. [PMID: 31683978 PMCID: PMC6862591 DOI: 10.3390/ijms20215459] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 10/27/2019] [Accepted: 10/30/2019] [Indexed: 12/13/2022] Open
Abstract
In the era of novel agents and immunotherapies in solid and liquid tumors, there is an emerging need to understand the cross-talk between the neoplastic cells, the host immune system, and the microenvironment to mitigate proliferation, survival, migration and resistance to drugs. In the microenvironment of hematological tumors there are cells belonging to the normal bone marrow, extracellular matrix proteins, adhesion molecules, cytokines, and growth factors produced by both stromal cells and neoplastic cells themselves. In this context, myeloid suppressor cells are an emerging sub-population of regulatory myeloid cells at different stages of differentiation involved in cancer progression and chronic inflammation. In this review, monocytic myeloid derived suppressor cells and their potential clinical implications are discussed to give a comprehensive vision of their contribution to lymphoproliferative and myeloid disorders.
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Palumbo GA, Parrinello NL, Giallongo C, D'Amico E, Zanghì A, Puglisi F, Conticello C, Chiarenza A, Tibullo D, Raimondo FD, Romano A. Monocytic Myeloid Derived Suppressor Cells in Hematological Malignancies. Int J Mol Sci 2019. [PMID: 31683978 DOI: 10.3390/ijms20215459.pmid:31683978;pmcid:pmc6862591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023] Open
Abstract
In the era of novel agents and immunotherapies in solid and liquid tumors, there is an emerging need to understand the cross-talk between the neoplastic cells, the host immune system, and the microenvironment to mitigate proliferation, survival, migration and resistance to drugs. In the microenvironment of hematological tumors there are cells belonging to the normal bone marrow, extracellular matrix proteins, adhesion molecules, cytokines, and growth factors produced by both stromal cells and neoplastic cells themselves. In this context, myeloid suppressor cells are an emerging sub-population of regulatory myeloid cells at different stages of differentiation involved in cancer progression and chronic inflammation. In this review, monocytic myeloid derived suppressor cells and their potential clinical implications are discussed to give a comprehensive vision of their contribution to lymphoproliferative and myeloid disorders.
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Affiliation(s)
- Giuseppe Alberto Palumbo
- Division of Hematology, AOU "Policlinico-Vittorio Emanuele", 95125 Catania, Italy.
- Department of Clinical and Molecular Biomedicine Ingrassia, University of Catania, 95125 Catania, Italy.
| | - Nunziatina Laura Parrinello
- Division of Hematology, AOU "Policlinico-Vittorio Emanuele", 95125 Catania, Italy.
- Department of Clinical and Molecular Biomedicine Ingrassia, University of Catania, 95125 Catania, Italy.
| | - Cesarina Giallongo
- Division of Hematology, AOU "Policlinico-Vittorio Emanuele", 95125 Catania, Italy.
| | - Emanuele D'Amico
- Department of Clinical and Molecular Biomedicine Ingrassia, University of Catania, 95125 Catania, Italy.
| | - Aurora Zanghì
- Department of Clinical and Molecular Biomedicine Ingrassia, University of Catania, 95125 Catania, Italy.
| | - Fabrizio Puglisi
- Division of Hematology, AOU "Policlinico-Vittorio Emanuele", 95125 Catania, Italy.
- Dipartimento di Chirurgia generale e specialità medico-chirurgiche, CHIRMED, University of Catania, 95125 Catania, Italy.
| | - Concetta Conticello
- Division of Hematology, AOU "Policlinico-Vittorio Emanuele", 95125 Catania, Italy.
| | - Annalisa Chiarenza
- Division of Hematology, AOU "Policlinico-Vittorio Emanuele", 95125 Catania, Italy.
| | - Daniele Tibullo
- BIOMETEC, Dipartimento di Scienze Biomediche e Biotecnologiche, University of Catania, 95125 Catania, Italy.
| | - Francesco Di Raimondo
- Division of Hematology, AOU "Policlinico-Vittorio Emanuele", 95125 Catania, Italy.
- Dipartimento di Chirurgia generale e specialità medico-chirurgiche, CHIRMED, University of Catania, 95125 Catania, Italy.
| | - Alessandra Romano
- Division of Hematology, AOU "Policlinico-Vittorio Emanuele", 95125 Catania, Italy.
- Dipartimento di Chirurgia generale e specialità medico-chirurgiche, CHIRMED, University of Catania, 95125 Catania, Italy.
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Merz AMA, Merz M, Hillengass J, Holstein SA, McCarthy P. The evolving role of maintenance therapy following autologous stem cell transplantation in multiple myeloma. Expert Rev Anticancer Ther 2019; 19:889-898. [DOI: 10.1080/14737140.2019.1674142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Almuth Maria Anni Merz
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
- Division of Multiple Myeloma, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Maximilian Merz
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
- Division of Multiple Myeloma, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jens Hillengass
- Division of Multiple Myeloma, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Sarah A. Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Philip McCarthy
- Transplant & Cellular Therapy Center, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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Gay F, Jackson G, Rosiñol L, Holstein SA, Moreau P, Spada S, Davies F, Lahuerta JJ, Leleu X, Bringhen S, Evangelista A, Hulin C, Panzani U, Cairns DA, Di Raimondo F, Macro M, Liberati AM, Pawlyn C, Offidani M, Spencer A, Hájek R, Terpos E, Morgan GJ, Bladé J, Sonneveld P, San-Miguel J, McCarthy PL, Ludwig H, Boccadoro M, Mateos MV, Attal M. Maintenance Treatment and Survival in Patients With Myeloma: A Systematic Review and Network Meta-analysis. JAMA Oncol 2019; 4:1389-1397. [PMID: 30098165 DOI: 10.1001/jamaoncol.2018.2961] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Importance Several trials demonstrated the impact of novel agent-based maintenance in newly diagnosed multiple myeloma (NDMM), but there is no current evidence demonstrating the superiority of one regimen over the other, owing to the lack of direct/indirect comparisons. Objective To analyze and compare the effectiveness of different maintenance regimens in NDMM via a network meta-analysis. Data Sources We performed 2 independent searches in PubMed and Cochrane databases, and then we identified all the records registered after 1999 and on or before November 20, 2017. Study Selection By blinded review, we identified prospective phase 3 randomized trials evaluating novel agent-based maintenance in patients with NDMM; the included studies compared at least 2 maintenance approaches; comparators included placebo and no maintenance. From 364 screened records, 11 studies were included. Data Extraction and Synthesis We followed (independent extraction) the guidelines provided by the PRISMA Report and the EQUATOR Network. The evidence was synthesized using a network meta-analysis (NMA). To allow comparison of all treatments, no maintenance was selected as common comparator and the effect of placebo was assumed to be the same as no treatment. The best option was identified by a Bayesian consistency model based on hazard ratio (HR), 95% credible interval (CrI), probability of being the best treatment (PbBT), and median ranking distribution (MedR). Main Outcomes and Measures Outcomes of interest were progression-free survival (PFS) and overall survival (OS). Results Eleven trials and 8 treatments including a total of 5073 participants were included. By PFS analysis, lenalidomide-based regimens (lenalidomide-prednisone, lenalidomide alone) were identified as the most effective options (HR, 0.39 [95% CrI, 0.28-0.53] and 0.47 [95% CrI, 0.39-0.55], respectively; MedR, 1 and 2; overall PbBT, 74%). Four treatments (thalidomide-interferon, thalidomide-bortezomib, bortezomib-prednisone, thalidomide alone) showed an HR in favor of maintenance. By OS analysis, lenalidomide alone was identified as the best option (HR, 0.76; 95% CrI, 0.51-1.16; MedR, 2; PbBT, 38%), followed by bortezomib-thalidomide and bortezomib-prednisone. Similar features were noticed in the restricted network including transplant trials, in the sensitivity analysis, and in most of the prognostic subgroups. Conclusions and Relevance Based on PFS and OS results of this NMA, lenalidomide maintenance appears to be the best treatment option, by synthesizing the available evidence of novel agent-based maintenance in the past 20 years.
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Affiliation(s)
- Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Laura Rosiñol
- Hematology Department, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Sarah A Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Philippe Moreau
- Hematology Department, University Hospital Hôtel-Dieu, Nantes, France
| | - Stefano Spada
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Faith Davies
- The Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock
| | - Juan José Lahuerta
- Hospital Universitario 12 de Octubre, Madrid, Spain. PETHEMA/Grupo Español de Mieloma
| | - Xavier Leleu
- Hématologie and Inserm CIC 1082, Poitiers, France
| | - Sara Bringhen
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Andrea Evangelista
- Unit of Clinical Epidemiology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
| | - Cyrille Hulin
- Service d'Hématologie, Hôpital Haut-Lévêque, CHU Bordeaux, 33600 Pessac, France
| | - Ugo Panzani
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - David A Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | | | - Margaret Macro
- Institut d'Hématologie de Basse Normandie, University Hospital of Caen, Côte de Nacre, 14033 Caen Cedex 9, France
| | - Anna Marina Liberati
- Università degli Studi di Perugia, Struttura Complessa Universitaria Oncoematologia - Azienda Ospedaliera Santa Maria di Terni, Italy
| | | | - Massimo Offidani
- Clinica di Ematologia, AOU Ospedali Riuniti di Ancona, Ancona, Italy
| | - Andrew Spencer
- Department of Haematology, Alfred Health-Monash University, Melbourne, Australia
| | - Roman Hájek
- Department of Haematooncology, University Hospital Ostrava, Czech Republic and Faculty of Medicine, University of Ostrava, Czech Republic
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Gareth J Morgan
- The Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock
| | - Joan Bladé
- Hematology Department, IDIBAPS, Hospital Clinic, Barcelona, Spain.,Hematology Department, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jesús San-Miguel
- Clínica Universidad de Navarra-CIMA, IDISNA, CIBERONC, Pamplona, Spain
| | - Philip L McCarthy
- Blood and Marrow Transplant Program, Department of Medicine, Roswell Park Comprehensive Cancer Center, State University at Buffalo, Buffalo, New York
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, Vienna, Austria
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Maria-Victoria Mateos
- University Hospital of Salamanca-Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
| | - Michel Attal
- Department of Hematology, Institut Universitaire du Cancer Toulouse Oncopole, Toulouse, France
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Olszewski AJ, Barth PM, Reagan JL. Use of bone-modifying agents and clinical outcomes in older adults with multiple myeloma. Cancer Med 2019; 8:6945-6954. [PMID: 31566898 PMCID: PMC6853813 DOI: 10.1002/cam4.2591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/04/2019] [Accepted: 09/04/2019] [Indexed: 12/28/2022] Open
Abstract
Background Guidelines recommend bone‐modifying agents (BMAs) for all patients initiating treatment for myeloma. We examined adherence to this recommendation, and BMA effectiveness in the era of bortezomib/lenalidomide‐based therapy among Medicare beneficiaries. Methods From the linked Surveillance, Epidemiology, and End Results‐Medicare registry, we selected beneficiaries receiving anti‐myeloma chemotherapy in 2007‐2013. We matched BMA recipients (within 90 days of first chemotherapy) to nonrecipients using a propensity score, balancing patient‐, disease‐, and therapy‐related confounders. Cumulative incidence of skeletal‐related events (SREs) and overall survival (OS) was compared in proportional hazard models accounting for competing risks and immortal‐time bias. Results Among 4611 patients with median age of 76 years, 51% received BMA. Bone‐modifying agents use remained steady over time (P = .87) and was significantly less frequent for patients who were older, with comorbidities, without prior SRE, and those treated without bortezomib or lenalidomide. In a propensity score‐matched cohort, BMA recipients experienced a lower incidence of SRE (11.0% vs 14.6% at 3 years; subhazard ratio, 0.73; 95% CI, 0.60‐0.89) and better OS (53.3% vs 47.8% at 3 years; hazard ratio, 0.86; 95% CI, 0.77‐0.95). The results were consistent in the subgroup (76%) treated with bortezomib and/or immunomodulatory drugs (IMiDs). The incidence of osteonecrosis of the jaw (ONJ) was 3.2% at 3 years. Conclusions In this observational study, the observed benefits of early BMA administration among patients treated with contemporary anti‐myeloma regimens were similar to historical clinical trials. Frequent omission of BMA highlights a remediable deficiency in the quality of supportive care, and suggests that timely administration may be a useful indicator of quality care in myeloma.
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Affiliation(s)
- Adam J Olszewski
- Alpert Medical School of Brown University, Providence, RI, USA.,Division of Hematology-Oncology, Lifespan Cancer Institute, Providence, RI, USA
| | - Peter M Barth
- Alpert Medical School of Brown University, Providence, RI, USA.,Division of Hematology-Oncology, Lifespan Cancer Institute, Providence, RI, USA
| | - John L Reagan
- Alpert Medical School of Brown University, Providence, RI, USA.,Division of Hematology-Oncology, Lifespan Cancer Institute, Providence, RI, USA
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Ludwig H, Poenisch W, Knop S, Egle A, Schreder M, Lechner D, Hajek R, Gunsilius E, Krenosz KJ, Petzer A, Weisel K, Niederwieser D, Einsele H, Willenbacher W, Melchardt T, Greil R, Zojer N. Ixazomib-Thalidomide-Dexamethasone for induction therapy followed by Ixazomib maintenance treatment in patients with relapsed/refractory multiple myeloma. Br J Cancer 2019; 121:751-757. [PMID: 31558804 PMCID: PMC6889132 DOI: 10.1038/s41416-019-0581-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/11/2019] [Accepted: 08/27/2019] [Indexed: 12/16/2022] Open
Abstract
Background Ixazomib-revlimid-dexamethason showed significant activity in relapsed/refractory multiple myeloma (RRMM). Here, we evaluate ixazomib in combination with thalidomide and dexamethasone for induction treatment followed by ixazomib maintenance therapy in RRMM patients. Methods Ninety patients have been included. Ixazomib–thalidomide–dexamethasone (4 mg, day 1, 8, 15; 100 mg daily; and 40 mg weekly) was scheduled for eight cycles followed by maintenance with ixazomib for one year. Results The overall response rate was 51.1%, 23.3% achieved CR or VGPR and 10% MR resulting in a clinical benefit rate of 61.1%. In patients completing ≥2 cycles, the rates were 60.5%, 27.6% and 68.4%, respectively. Median progression-free survival (PFS) was 8.5 months in all, and 9.4 months in those completing ≥2 cycles. Response rates, PFS and overall survival (OS) were similar in patients with and without t(4;14) and/or del(17p), but PFS and OS was significantly shorter in patients with gain of 1q21. Multivariate regression analysis revealed gain of 1q21 as the most important factor associated with OS. Ixazomib maintenance resulted in an upgrade in the depth of response in 12.4% of patients. Grade 3/4 toxicities were relatively rare. Conclusions Ixazomib–thalidomide–dexamethasone followed by ixazomib maintenance therapy is active and well tolerated in patients with RRMM. Trial registration number NCT02410694
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Affiliation(s)
- Heinz Ludwig
- Wilhelminen Cancer Research Institute, Department of Medicine I, Center for Oncology and Hematology, Wilhelminenspital, Vienna, Austria.
| | - Wolfram Poenisch
- Department of Hematology, University of Leipzig, Leipzig, Germany
| | - Stefan Knop
- Division of Hematology and Medical Oncology, Department of Internal Medicine II, Wuerzburg University Medical Center, Wuerzburg, Germany
| | - Alexander Egle
- Department of Internal Medicine III with Haematology, Medical Oncology, Hemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute-Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Paracelsus Medical University, Salzburg, Cancer Cluster Salzburg, Austria
| | - Martin Schreder
- Department of Medicine I, Center for Oncology and Hematology, Wilhelminenspital, Vienna, Austria
| | - Daniel Lechner
- Department of Medicine I-Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Roman Hajek
- Fakultní Nemocnice Ostrava, Ostrava, Czech Republic
| | - Eberhard Gunsilius
- Department of Internal Medicine V, Hematology and Oncology, Medical University Innsbruck, Innsbruck, Austria
| | - Karl Jochen Krenosz
- Department of Internal Medicine 3, Kepler Universitaetsklinikum GmbH, Med Campus III, Linz, Austria
| | - Andreas Petzer
- Department of Internal Medicine I, Ordensklinikum Linz-Barmherzige Schwestern, Linz, Austria
| | - Katja Weisel
- University Medical Center of Hamburg-Eppendorf, Hamburg, Germany and University of Tuebingen, Tuebingen, Germany
| | | | - Hermann Einsele
- Division of Hematology and Medical Oncology, Department of Internal Medicine II, Wuerzburg University Medical Center, Wuerzburg, Germany
| | - Wolfgang Willenbacher
- Department of Internal Medicine V, Hematology and Oncology, Medical University Innsbruck, Innsbruck, Austria.,Oncotyrol, Center for personalized Cancer Medicine, Innsbruck, Austria
| | - Thomas Melchardt
- Department of Internal Medicine III with Haematology, Medical Oncology, Hemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute-Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Paracelsus Medical University, Salzburg, Cancer Cluster Salzburg, Austria
| | - Richard Greil
- Department of Internal Medicine III with Haematology, Medical Oncology, Hemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute-Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Paracelsus Medical University, Salzburg, Cancer Cluster Salzburg, Austria
| | - Niklas Zojer
- Department of Medicine I, Center for Oncology and Hematology, Wilhelminenspital, Vienna, Austria
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Toller CS, Charlesworth S, Mihalyo M, Howard P, Wilcock A. Bisphosphonates: AHFS 92:24. J Pain Symptom Manage 2019; 57:1018-1030. [PMID: 30738144 DOI: 10.1016/j.jpainsymman.2019.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 11/20/2022]
Abstract
Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available via www.medicinescomplete.com. The series editors welcome feedback on the articles (hq@palliativedrugs.com).
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Affiliation(s)
- Claire Stark Toller
- Countess Mountbatten House (C.S.T.), University Hospital Southampton; Pharmaceutical Press (S.C.), London, United Kingdom; Mylan School of Pharmacy (M.M.), Duquesne University, Pittsburgh, Pennsylvania, USA; Mountbatten Hospice (P.H.), Isle of Wight, United Kingdom; and University of Nottingham (A.W.), Nottingham, United Kingdom
| | - Sarah Charlesworth
- Countess Mountbatten House (C.S.T.), University Hospital Southampton; Pharmaceutical Press (S.C.), London, United Kingdom; Mylan School of Pharmacy (M.M.), Duquesne University, Pittsburgh, Pennsylvania, USA; Mountbatten Hospice (P.H.), Isle of Wight, United Kingdom; and University of Nottingham (A.W.), Nottingham, United Kingdom
| | - Mary Mihalyo
- Countess Mountbatten House (C.S.T.), University Hospital Southampton; Pharmaceutical Press (S.C.), London, United Kingdom; Mylan School of Pharmacy (M.M.), Duquesne University, Pittsburgh, Pennsylvania, USA; Mountbatten Hospice (P.H.), Isle of Wight, United Kingdom; and University of Nottingham (A.W.), Nottingham, United Kingdom
| | - Paul Howard
- Countess Mountbatten House (C.S.T.), University Hospital Southampton; Pharmaceutical Press (S.C.), London, United Kingdom; Mylan School of Pharmacy (M.M.), Duquesne University, Pittsburgh, Pennsylvania, USA; Mountbatten Hospice (P.H.), Isle of Wight, United Kingdom; and University of Nottingham (A.W.), Nottingham, United Kingdom
| | - Andrew Wilcock
- Countess Mountbatten House (C.S.T.), University Hospital Southampton; Pharmaceutical Press (S.C.), London, United Kingdom; Mylan School of Pharmacy (M.M.), Duquesne University, Pittsburgh, Pennsylvania, USA; Mountbatten Hospice (P.H.), Isle of Wight, United Kingdom; and University of Nottingham (A.W.), Nottingham, United Kingdom.
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Blommestein HM, van Beurden-Tan CHY, Franken MG, Uyl-de Groot CA, Sonneveld P, Zweegman S. Efficacy of first-line treatments for multiple myeloma patients not eligible for stem cell transplantation: a network meta-analysis. Haematologica 2019; 104:1026-1035. [PMID: 30606791 PMCID: PMC6518894 DOI: 10.3324/haematol.2018.206912] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/02/2019] [Indexed: 12/15/2022] Open
Abstract
Decision making for patients with multiple myeloma (MM) not transplant eligible (NTE) is complicated by a lack of head-to-head comparisons of standards of care, the increase in the choice of treatment modalities, and the promising results that are rapidly evolving from studies with novel regimens. To support evidence-based decision making, we performed a network meta-analysis for NTE MM patients that synthesizes direct and indirect evidence and enables a comparison of all treatments. Relevant randomized clinical trials were identified by a systematic literature review in EMBASE®, MEDLINE®, MEDLINE®-in-Process and the Cochrane Central Register of Controlled Trials for January 1999 to March 2016. Efficacy outcomes [i.e. the hazard ratio (HR) and 95% confidence interval (95%CI) for progression-free survival] were extracted and synthesized in a random effects network-meta analysis. In total, 24 studies were identified including 21 treatments. According to the network-meta analysis, the HR for progression-free survival was favorable for all NTE MM treatments compared to dexamethasone (HR: 0.19-0.90). Daratumumab-bortezomib-melphalan-prednisone and bortezomib-melphalan-prednisone-thalidomide with bortezomib-thalidomide maintenance were identified as the most effective treatments (HR: 0.19, 95%CI: 0.08-0.45 and HR: 0.22, 95%CI: 0.10-0.51, respectively). HR and 95%CI for currently recommended treatments, bortezomib-lenalidomide-dexamethasone, bortezomib-melphalan-prednisone, and lenalidomide-dexamethasone compared to dexamethasone, were 0.31 (0.16-0.59), 0.39 (0.20-0.75), and 0.44 (0.29-0.65), respectively. In addition to identifying the most effective treatment options, we illustrate the additional value and evidence of network meta-analysis in clinical practice. In the current treatment landscape, the results of network meta-analysis may support evidence-based decisions and ultimately help to optimize treatment and outcomes of NTE MM patients.
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Affiliation(s)
- Hedwig M Blommestein
- Erasmus School of Health Policy & Management, Institute for Medical Technology Assessment, Erasmus University Rotterdam
- Comprehensive Cancer Organisation, Utrecht
| | | | - Margreet G Franken
- Erasmus School of Health Policy & Management, Institute for Medical Technology Assessment, Erasmus University Rotterdam
| | - Carin A Uyl-de Groot
- Erasmus School of Health Policy & Management, Institute for Medical Technology Assessment, Erasmus University Rotterdam
- Comprehensive Cancer Organisation, Utrecht
| | | | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, the Netherlands
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48
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Affiliation(s)
- Sarah A. Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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D'Oronzo S, Coleman R, Brown J, Silvestris F. Metastatic bone disease: Pathogenesis and therapeutic options: Up-date on bone metastasis management. J Bone Oncol 2019; 15:004-4. [PMID: 30937279 PMCID: PMC6429006 DOI: 10.1016/j.jbo.2018.10.004] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/22/2018] [Accepted: 10/28/2018] [Indexed: 12/17/2022] Open
Abstract
Bone metastases (BM) are a common complication of cancer, whose management often requires a multidisciplinary approach. Despite the recent therapeutic advances, patients with BM may still experience skeletal-related events and symptomatic skeletal events, with detrimental impact on quality of life and survival. A deeper knowledge of the mechanisms underlying the onset of lytic and sclerotic BM has been acquired in the last decades, leading to the development of bone-targeting agents (BTA), mainly represented by anti-resorptive drugs and bone-seeking radiopharmaceuticals. Recent pre-clinical and clinical studies have showed promising effects of novel agents, whose safety and efficacy need to be confirmed by prospective clinical trials. Among BTA, adjuvant bisphosphonates have also been shown to reduce the risk of BM in selected breast cancer patients, but failed to reduce the incidence of BM from lung and prostate cancer. Moreover, adjuvant denosumab did not improve BM free survival in patients with breast cancer, suggesting the need for further investigation to clarify BTA role in early-stage malignancies. The aim of this review is to describe BM pathogenesis and current treatment options in different clinical settings, as well as to explore the mechanism of action of novel potential therapeutic agents for which further investigation is needed.
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Key Words
- ActRIIA, activin-A type IIA receptor
- BC, breast cancer
- BM, bone metastases
- BMD, bone mineral density
- BMPs, bone morphogenetic proteins
- BMSC, bone marrow stromal cells
- BPs, bisphosphonates
- BTA, bone targeting agents
- BTM, bone turnover markers
- Bone metastases
- Bone targeting agents
- CCR, chemokine-receptor
- CRPC, castration-resistant PC
- CXCL-12, C–X–C motif chemokine-ligand-12
- CXCR-4, chemokine-receptor-4
- DFS, disease-free survival
- DKK1, dickkopf1
- EBC, early BC
- ECM, extracellular matrix
- ET-1, endothelin-1
- FDA, food and drug administration
- FGF, fibroblast growth factor
- GAS6, growth-arrest specific-6
- GFs, growth factors
- GnRH, gonadotropin-releasing hormone
- HER-2, human epidermal growth factor receptor 2
- HR, hormone receptor
- IL, interleukin
- LC, lung cancer
- MAPK, mitogen-activated protein kinase
- MCSF, macrophage colony-stimulating factor
- MCSFR, MCSF receptor
- MIP-1α, macrophage inflammatory protein-1 alpha
- MM, multiple myeloma
- MPC, malignant plasma cells
- N-BPs, nitrogen-containing BPs
- NF-κB, nuclear factor-κB
- ONJ, osteonecrosis of the jaw
- OS, overall survival
- Osteotropic tumors
- PC, prostate cancer
- PDGF, platelet-derived growth factor
- PFS, progression-free survival
- PIs, proteasome inhibitors
- PSA, prostate specific antigen
- PTH, parathyroid hormone
- PTH-rP, PTH related protein
- QoL, quality of life
- RANK-L, receptor activator of NF-κB ligand
- RT, radiation therapy
- SREs, skeletal-related events
- SSEs, symptomatic skeletal events
- Skeletal related events
- TGF-β, transforming growth factor β
- TK, tyrosine kinase
- TKIs, TK inhibitors
- TNF, tumornecrosis factor
- VEGF, vascular endothelial growth factor
- VEGFR, VEGF receptor
- mTOR, mammalian target of rapamycin
- non-N-BPs, non-nitrogen containing BPs
- v-ATPase, vacuolar-type H+ ATPase
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Affiliation(s)
- Stella D'Oronzo
- Medical Oncology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, P.za Giulio Cesare, 11, 70124 Bari, Italy
| | - Robert Coleman
- Academic Unit of Clinical Oncology, Weston Park Hospital, University of Sheffield, Whitham Rd, Sheffield S10 2SJ, England, UK
| | - Janet Brown
- Academic Unit of Clinical Oncology, Weston Park Hospital, University of Sheffield, Whitham Rd, Sheffield S10 2SJ, England, UK
| | - Francesco Silvestris
- Medical Oncology Unit, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro, P.za Giulio Cesare, 11, 70124 Bari, Italy
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50
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Cook G, Royle KL, Pawlyn C, Hockaday A, Shah V, Kaiser MF, Brown SR, Gregory WM, Child JA, Davies FE, Morgan GJ, Cairns DA, Jackson GH. A clinical prediction model for outcome and therapy delivery in transplant-ineligible patients with myeloma (UK Myeloma Research Alliance Risk Profile): a development and validation study. Lancet Haematol 2019; 6:e154-e166. [PMID: 30738834 PMCID: PMC6391517 DOI: 10.1016/s2352-3026(18)30220-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/30/2018] [Accepted: 11/30/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Tolerability of treatments for multiple myeloma can depend on the characteristics of the patient being treated. We aimed to develop and validate a risk profile, using routinely collected data, that could predict overall survival in patients with multiple myeloma who were ineligible for stem-cell transplantation. METHODS We used patient data from two randomised controlled trials done in patients with newly diagnosed multiple myeloma who were ineligible for stem-cell transplantation (the NCRI Myeloma XI study [NCRI-XI, n=1852] and the MRC Myeloma IX study [MRC-IX, n=520]), to develop the UK Myeloma Research Alliance Risk Profile (MRP) for overall survival. We used multivariable Cox regression with a least absolute shrinkage and selection operator penalty term. Multiple imputation by chained equations was used to account for missing data in the development and internal validation of the model. The MRP was internally validated in NCRI-XI and externally validated in MRC-IX. The D-statistic was estimated in the developed model and used to internally and externally validate the model according to prespecified criteria. FINDINGS The MRP included WHO performance status, International Staging System, age, and C-reactive protein concentration as prognostic variables. The MRP was prognostic of overall survival and was successfully internally validated in NCRI-XI and externally validated in MRC-IX (D-statistic NCRI-XI: 0·840 [95% CI 0·718-0·963] and MRC-IX: 0·654 [0·497-0·811]). The MRP groups defining low-risk, medium-risk, and high-risk patients were associated with progression-free survival and early mortality. A decrease in the percentage of protocol dose delivered and quality of life at baseline were associated with increased risk. The MRP groups remained prognostic in patients exposed to different therapeutic combinations and in patients with genetic high-risk disease defined according to both the UK and International Myeloma Working Group definitions. INTERPRETATION We have developed and externally validated a risk profile for overall survival containing widely available clinical parameters. This risk profile could aid decision making in patients with multiple myeloma ineligible for stem-cell transplantation, but further external validation is required. FUNDING Medical Research Council, Novartis, Schering Health Care, Chugai, Pharmion, Celgene, Ortho Biotech, Cancer Research UK, Celgene, Merck Sharp & Dohme, and Amgen.
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Affiliation(s)
- Gordon Cook
- Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK; Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
| | - Kara-Louise Royle
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | | | - Sarah R Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Walter M Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - J Anthony Child
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Faith E Davies
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gareth J Morgan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - David A Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Graham H Jackson
- Department of Haematology, Newcastle University, Newcastle-upon-Tyne, UK
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