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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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Facon T, San-Miguel J, Dimopoulos MA, Mateos MV, Cavo M, van Beekhuizen S, Yuan Z, Mendes J, Lam A, He J, Ammann E, Kumar S. Treatment Regimens for Transplant-Ineligible Patients With Newly Diagnosed Multiple Myeloma: A Systematic Literature Review and Network Meta-analysis. Adv Ther 2022; 39:1976-1992. [PMID: 35246820 PMCID: PMC9056460 DOI: 10.1007/s12325-022-02083-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/09/2022] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Many treatment regimens have been evaluated in transplant-ineligible (TIE) patients with newly diagnosed multiple myeloma (NDMM). The objective of this study was to compare the efficacy of relevant therapies for the treatment of TIE patients with NDMM. METHODS Progression-free survival (PFS) and overall survival (OS) from large randomised controlled trials (RCTs) evaluating different treatment options for TIE patients with NDMM were compared in a network meta-analysis (NMA). The NMA includes recent primary and long-term OS readouts from SWOG S0777, ENDURANCE, MAIA, and ALCYONE. Relevant trials were identified through a systematic literature review. Relative efficacy measures (i.e., hazard ratios [HRs] for PFS and OS) were extracted and synthesised in random-effects NMAs. RESULTS A total of 122 publications describing 45 unique RCTs was identified. Continuous lenalidomide/dexamethasone (Rd) was selected as the referent comparator. Daratumumab-containing treatments (daratumumab/lenalidomide/dexamethasone [D-Rd], daratumumab/bortezomib/melphalan/prednisone [D-VMP]) and bortezomib/lenalidomide/dexamethasone (VRd) had the highest probabilities of being more effective than Rd continuous for PFS (HR: D-Rd, 0.53; D-VMP, 0.57, VRd, 0.77) and OS (HR: D-Rd, 0.68; VRd, 0.77, D-VMP, 0.78). D-Rd had the highest chance of being ranked as the most effective treatment with respect to PFS and OS. Results using a smaller network focusing on only those regimens that are relevant in Europe were consistent with the primary analysis. CONCLUSIONS These comparative effectiveness data may help inform treatment selection in TIE patients with NDMM.
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Affiliation(s)
- Thierry Facon
- Department of Haematology, Lille University Hospital, Lille, France
| | - Jesús San-Miguel
- Clínica Universidad de Navarra-CIMA, IDISNA, CIBERONC, Pamplona, Spain
| | | | | | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Seràgnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy
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Efficacy of first-line treatment options in transplant-ineligible multiple myeloma: A network meta-analysis. Crit Rev Oncol Hematol 2021; 168:103504. [PMID: 34673218 DOI: 10.1016/j.critrevonc.2021.103504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/30/2021] [Accepted: 10/10/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite major therapeutic advances, the rational choice of the most appropriate first-line regimen in newly diagnosed transplant-ineligible multiple myeloma (TIE-MM) is currently undefined. AIM We aimed to identify the most effective first-line treatment for TIE-MM patients. METHODS A total of 37 articles, including 34 treatments and 16,681 patients, were included in this Bayesian network meta-analysis. The outcomes of interest were risk ratios (RR) for progression-free survival (PFS) and overall survival (OS). RESULTS Based on surface under cumulative ranking curve values, daratumumab-bortezomib-melphalan-prednisone (Dara-VMP) and daratumumab-lenalidomide-dexamethasone (Dara-Rd28) showed superiority compared to other combinations regarding 12-, 24-, 36-, and 48-month PFS. Dara-VMP also ranked first for 12-, 24-, 36-, and 48-month OS. CONCLUSION Our finding supports the incorporation of daratumumab into first-line regimens. Additionally, these results highlight the relative benefit of incorporating novel agents like monoclonal antibodies, immunomodulatory derivatives, and proteasome inhibitors in combination with the currently existing treatment options.
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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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Sandecká V, Pour L, Špička I, Minařík J, Radocha J, Jelínek T, Heindorfer A, Pavlíček P, Sýkora M, Jungová A, Kessler P, Wróbel M, Starostka D, Ullrychová J, Stejskal L, Štork M, Straub J, Pika T, Brožová L, Ševčíková S, Maisnar V, Hájek R. Bortezomib-based therapy for newly diagnosed multiple myeloma patients ineligible for autologous stem cell transplantation: Czech Registry Data. Eur J Haematol 2021; 107:466-474. [PMID: 34272773 DOI: 10.1111/ejh.13683] [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: 04/03/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study compared the use of bortezomib in different combination regimens in newly diagnosed multiple myeloma (NDMM) patients who were transplant ineligible. PATIENTS AND METHODS We analyzed data from the Registry of Monoclonal Gammopathies (RMG) of the Czech Myeloma Group (CMG) to provide real-world evidence of outcome for 794 newly diagnosed MM transplant ineligible patients. The most frequently used regimen was VCd (bortezomib-cyclophosphamide-dexamethasone) (47.5%) over VMP (bortezomib-melphalan-prednisone) (21.7%), BDd (bortezomib-doxorubicin-dexamethasone) (9.8%), and VTd (bortezomib-thalidomide-dexamethasone) (2.9%). RESULTS The overall response rate (ORR) was 69.2% (478/691), including 12.6% (≥ CR); 34.7% very good partial responses (VGPR); and 21.9% partial responses (PR). Among triplet regimens, VMP was the most effective regimen compared to VCd, BDd, and VTd. Median PFS was 22.3 vs. 18.5 vs. 13.7 vs. 13.8 mo, (P = .275), respectively, and median OS was 49 vs. 41.7 vs. 37.9 vs. 32.2 mo (P = .004), respectively. The most common grade 3-4 toxicities were anemia in 17.4% and infections in 18% of patients. CONCLUSION Our study confirmed that bortezomib-based treatment is effective and safe in NDMM transplant ineligible patients, especially VMP, which was identified as superior between bortezomib-based induction regimens not only in clinical trials, but also in real clinical practice.
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Affiliation(s)
- Viera Sandecká
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Luděk Pour
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Ivan Špička
- 1st Department of Medicine, Department of Hematology, Charles University and General Hospital, Prague, Czech Republic
| | - Jiří Minařík
- Department of Hemato-Oncology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Jakub Radocha
- 4th Department of Internal Medicine, Hematology, University Hospital and Charles University in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Tomáš Jelínek
- Department of Hematooncology, University Hospital Ostrava, University of Ostrava, Ostrava, Czech Republic
| | | | - Petr Pavlíček
- Department of Internal Medicine and Hematology, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Michal Sýkora
- Department of Clinical Hematology, Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Alexandra Jungová
- Hematology and Oncology Department, Charles University Hospital Pilsen, Pilsen, Czech Republic
| | - Petr Kessler
- Department of Hematology and Transfusion Medicine, Hospital Pelhrimov, Czech Republic
| | - Marek Wróbel
- Department of Clinical Hematology, Hospital Novy Jicin, Czech Republic
| | - David Starostka
- Department of Clinical Hematology, Hospital Havirov, Czech Republic
| | - Jana Ullrychová
- Department of Clinical Hematology, Regional Health Corporation, Masaryk Hospital, Usti nad Labem, Czech Republic
| | - Lukáš Stejskal
- Department of Hematology, Silesian Hospital in Opava, Opava, Czech Republic
| | - Martin Štork
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Jan Straub
- 1st Department of Medicine, Department of Hematology, Charles University and General Hospital, Prague, Czech Republic
| | - Tomáš Pika
- Department of Hemato-Oncology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Lucie Brožová
- Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic
| | - Sabina Ševčíková
- Babak Myeloma Group, Department of Pathophysiology, Masaryk University, Brno, Czech Republic
| | - Vladimír Maisnar
- 4th Department of Internal Medicine, Hematology, University Hospital and Charles University in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Roman Hájek
- Department of Hematooncology, University Hospital Ostrava, University of Ostrava, Ostrava, Czech Republic
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Prognostic and predictive performance of R-ISS with SKY92 in older patients with multiple myeloma: the HOVON-87/NMSG-18 trial. Blood Adv 2021; 4:6298-6309. [PMID: 33351127 DOI: 10.1182/bloodadvances.2020002838] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/02/2020] [Indexed: 02/06/2023] Open
Abstract
The standard prognostic marker for multiple myeloma (MM) patients is the revised International Staging System (R-ISS). However, there is room for improvement in guiding treatment. This applies particularly to older patients, in whom the benefit/risk ratio is reduced because of comorbidities and subsequent side effects. We hypothesized that adding gene-expression data to R-ISS would generate a stronger marker. This was tested by combining R-ISS with the SKY92 classifier (SKY-RISS). The HOVON-87/NMSG-18 trial (EudraCT: 2007-004007-34) compared melphalan-prednisone-thalidomide followed by thalidomide maintenance (MPT-T) with melphalan-prednisone-lenalidomide followed by lenalidomide maintenance (MPR-R). From this trial, 168 patients with available R-ISS status and gene-expression profiles were analyzed. R-ISS stages I, II, and III were assigned to 8%, 75%, and 7% of patients, respectively (3-year overall survival [OS] rates: 80%, 65%, 33%, P = 8 × 10-3). Using the SKY92 classifier, 13% of patients were high risk (HR) (3-year OS rates: standard risk [SR], 70%; HR, 28%; P < .001). Combining SKY92 with R-ISS resulted in 3 risk groups: SKY-RISS I (SKY-SR + R-ISS-I; 15%), SKY-RISS III (SKY-HR + R-ISS-II/III; 11%), and SKY-RISS II (all other patients; 74%). The 3-year OS rates for SKY-RISS I, II, and III are 88%, 66%, and 26%, respectively (P = 6 × 10-7). The SKY-RISS model was validated in older patients from the CoMMpass dataset. Moreover, SKY-RISS demonstrated predictive potential: HR patients appeared to benefit from MPR-R over MPT-T (median OS, 55 and 14 months, respectively). Combined, SKY92 and R-ISS classify patients more accurately. Additionally, benefit was observed for MPR-R over MPT-T in SKY92-RISS HR patients only.
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Schjesvold F, Oriol A. Current and Novel Alkylators in Multiple Myeloma. Cancers (Basel) 2021; 13:2465. [PMID: 34070213 PMCID: PMC8158783 DOI: 10.3390/cancers13102465] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/22/2021] [Accepted: 05/11/2021] [Indexed: 12/22/2022] Open
Abstract
A large number of novel treatments for myeloma have been developed and approved; however, alkylating drugs continue to be part of standard regimens. Additionally, novel alkylators are currently being developed. We performed a non-systematized literary search for relevant papers and communications at large conferences, as well as exploiting the authors' knowledge of the field, to review the history, current use and novel concepts around the traditional alkylators cyclophosphamide, bendamustine and melphalan and current data on the newly developed pro-drug melflufen. Even in the era of targeted treatment and personalized medicine, alkylating drugs continue to be part of the standard-of-care in myeloma, and new alkylators are coming to the market.
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Affiliation(s)
- Fredrik Schjesvold
- Oslo Myeloma Center, Oslo University Hospital, 0450 Oslo, Norway
- K.G. Jebsen Centre for B-Cell Malignancies, University of Oslo, 4950 Oslo, Norway
| | - Albert Oriol
- Institut Josep Carreras and Institut Català d’Oncologia, Hospital Germans Trias I Pujol, 08916 Badalona, Spain;
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Abstract
PURPOSE OF REVIEW This article reviews the clinical features, prognosis, and treatment of neurotoxicity from anticancer drugs, including conventional cytotoxic chemotherapy, biologics, and targeted therapies, with a focus on the newer immunotherapies (immune checkpoint inhibitors and chimeric antigen receptor T cells). RECENT FINDINGS Whereas neurologic complications from traditional chemotherapy are widely recognized, newer cancer therapies, in particular immunotherapies, have unique and distinct patterns of neurologic adverse effects. Anticancer drugs may cause central or peripheral nervous system complications. Neurologic complications of therapy are being seen with increasing frequency as patients with cancer are living longer and receiving multiple courses of anticancer regimens, with novel agents, combinations, and longer duration. Neurologists must know how to recognize treatment-related neurologic toxicity since discontinuation of the offending agent or dose adjustment may prevent further or permanent neurologic injury. It is also imperative to differentiate neurologic complications of therapy from cancer progression into the nervous system and from comorbid neurologic disorders that do not require treatment dose reduction or discontinuation. SUMMARY Neurotoxicity from cancer therapy is common, with effects seen on both the central and peripheral nervous systems. Immune checkpoint inhibitor therapy and chimeric antigen receptor T-cell therapy are new cancer treatments with distinct patterns of neurologic complications. Early recognition and appropriate management are essential to help prevent further neurologic injury and optimize oncologic management.
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Kaweme NM, Changwe GJ, Zhou F. Approaches and Challenges in the Management of Multiple Myeloma in the Very Old: Future Treatment Prospects. Front Med (Lausanne) 2021; 8:612696. [PMID: 33718400 PMCID: PMC7947319 DOI: 10.3389/fmed.2021.612696] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/03/2021] [Indexed: 12/14/2022] Open
Abstract
The increasing incidence of geriatric patients with multiple myeloma has elevated concerns in clinical practice. While the introduction of novel therapeutic agents has substantially improved outcomes in younger patients with myeloma, poorer outcomes remain in older patients. Managing older patients requires a multidisciplinary team approach to consider factors that may influence both treatment selection and outcomes. Aging is associated with remodeling of vital organs, physiological downregulations of basal metabolism, susceptibility to multiple comorbidities with ultimate frailty, thereby contributing to the underrepresentation and exclusion of very old patients from clinical trials. Therefore, timely confirmation of a precise diagnosis is crucial for prompt initiation of treatment if the desired outcome is to be achieved. Adequate and judicious assessment using comprehensive geriatric assessment tools minimizes toxicities and treatment discontinuation. Initiating treatment with combinational therapy requires knowledge of indications and anticipated outcomes, as well as individualized therapy with appropriate dose-adjustment. Individualized therapy based on good clinical acumen and best practices obverts unwanted polypharmacy, preventing iatrogenic harm. This review will therefore address the approaches and challenges faced in managing myeloma in geriatric patients aged 80 years and older, highlighting recommended therapeutic strategies and future prospective regimens.
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Affiliation(s)
| | | | - Fuling Zhou
- Department of Hematology, Zhongnan Hospital, Wuhan University, Wuhan, China
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Derudas D, Capraro F, Martinelli G, Cerchione C. Old and new generation immunomodulatory drugs in multiple myeloma. Panminerva Med 2020; 62:207-219. [PMID: 32955182 DOI: 10.23736/s0031-0808.20.04125-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Over the last two decades, the outcomes of patients with multiple myeloma (MM), a malignant plasma cells dyscrasia, have dramatically improved. The development and the introduction of the immunomodulatory drugs (IMiDs) which include thalidomide, lenalidomide, and pomalidomide, have contributed significantly to these improvements. EVIDENCE ACQUISITION The IMiDs have been shown a multitude of mechanisms of action, including antiangiogenic, cytotoxic and immunomodulatory. The more recent discoveries that the IMiDs bind to cereblon and thus regulate the ubiquitination of key transcription factors including IKZF1 and IKZF3, have provided new insight about their activities. EVIDENCE SYNTHESIS The IMIDs are widely used in the treatment of the different setting of MM patients and particularly lenalidomide represents the backbone in the therapy of newly diagnosed transplant eligible and transplant ineligible patients, in the maintenance setting post-transplant and in the relapsed/refractory setting, while pomalidomide is currently utilized in the relapsed/refractory setting. CONCLUSIONS Here the mechanisms of action, the clinical efficacy and the management of side effects are reviewed as well as the new classes of cereblon E3 ligase modulator (CELMoD) and their promising clinical data are described.
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Affiliation(s)
- Daniele Derudas
- Department of Hematology and Bone Marrow Transplant Center, A. Businco Cancer Hospital, Cagliari, Italy -
| | - Francesca Capraro
- Department of Hematology and Bone Marrow Transplant Center, A. Businco Cancer Hospital, Cagliari, Italy
| | - Giovanni Martinelli
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
| | - Claudio Cerchione
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
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Derudas D, Capraro F, Martinelli G, Cerchione C. How I manage frontline transplant-ineligible multiple myeloma. Hematol Rep 2020; 12:8956. [PMID: 33042505 PMCID: PMC7520858 DOI: 10.4081/hr.2020.8956] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Indexed: 12/24/2022] Open
Abstract
The Multiple Myeloma (MM) is a plasma cells hematological malignancy with a median age of 69 years at diagnosis. The autologous stem cell transplantation is the standard of care for this disease but less than half of newly diagnosed patients are assessed for this treatment due to comorbidities or complications of disease. The management of transplant ineligible MM patients is based on the balance safety and efficacy of the new available regimen and a careful assessment of the frailty status is mandatory to define the goals. In this review we discuss of the clinical dilemmas in the management and define how to manage them based on the evidence from clinical trials and "real life" experience.
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Affiliation(s)
- Daniele Derudas
- S.C. di Ematologia e C.T.M.O., Ospedale Oncologico di Riferimento Regionale “A. Businco”, Cagliari
| | - Francesca Capraro
- S.C. di Ematologia e C.T.M.O., Ospedale Oncologico di Riferimento Regionale “A. Businco”, Cagliari
| | - Giovanni Martinelli
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (FC), Italy
| | - Claudio Cerchione
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (FC), Italy
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Atrash S, Bhutani M, Paul B, Voorhees PM, Usmani SZ. Management of newly diagnosed transplant ineligible multiple myeloma. Leuk Lymphoma 2020; 61:2549-2560. [PMID: 32623918 DOI: 10.1080/10428194.2020.1786558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multiple myeloma (MM) is a chronically managed blood cancer with a median age of 69 years at the time of diagnosis. Although high dose melphalan and autologous stem cell transplantation (ASCT) remains a standard of care for eligible patients, more than half of the newly diagnosed MM patients are deemed ineligible due to comorbidities or complications of the disease by itself. In this setting, where ASCT is deemed inappropriate, patients could still achieve durable and deep responses if given the appropriate treatment plan. The key concepts of optimizing induction and maintenance strategies while minimizing side-effects are discussed in this review, especially in the context of employing novel agent combinations. It is important to understand the balance between safety and efficacy for each regimen, utilizing maintenance strategy and the best supportive care measures (bone health, infection prevention, and treatment, pain management, etc.). Here, we examine the evidence behind each of those principles and review results from clinical trials for transplant-ineligible (TI) MM.
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Affiliation(s)
- Shebli Atrash
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Manisha Bhutani
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Barry Paul
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Peter M Voorhees
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Saad Z Usmani
- Department of Hematologic Oncology & Blood Disorders, Division of Plasma Cell Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
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Zanwar S, Abeykoon JP, Kapoor P. Challenges and Strategies in the Management of Multiple Myeloma in the Elderly Population. Curr Hematol Malig Rep 2020; 14:70-82. [PMID: 30820879 DOI: 10.1007/s11899-019-00500-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Approximately one half of the patient-population in multiple myeloma (MM) is > 70 years at diagnosis. Despite notable strides in the management and improved survival, MM remains incurable, with an increasing proportion of elderly patients comprising the relapsed-refractory cohort. RECENT FINDINGS The arbitrary age cutoff at 65 years to define the elderly patient-population has evolved to a more nuanced categorization, incorporating a comprehensive assessment for determining frailty prior to commencing treatment. This step is critical in determining the therapy-intensity, including transplant-eligibility, to minimize toxicity. Dose-modifications are crucial, as the merits of continuous therapy are becoming evident in this patient-population. Bortezomib, lenalidomide, and dexamethasone (VRd) combination has emerged as standard of care for newly diagnosed MM. Fixed-duration Rd followed by reduced-dosed continuous R may be considered in select frail patients with standard-risk MM. Herein, we review the unique challenges encountered in elderly MM and discuss strategies for optimal management.
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Affiliation(s)
- Saurabh Zanwar
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Prashant Kapoor
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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14
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Giri S, Aryal MR, Yu H, Grimshaw A, Pathak R, Huntington SP, Dhakal B. Efficacy and safety of frontline regimens for older transplant-ineligible patients with multiple myeloma: A systematic review and meta-analysis. J Geriatr Oncol 2020; 11:1285-1292. [PMID: 32513568 DOI: 10.1016/j.jgo.2020.05.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/28/2020] [Accepted: 05/27/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Several treatment options are available for the management of older adults with newly diagnosed patients with Multiple Myeloma (MM) who are ineligible for hematopoietic cell transplantation (tiMM). We aimed to identify treatment options that provide the best balance in terms of efficacy and safety. METHODS We searched bibliographic databases and meeting libraries for search terms reflecting newly diagnosed and older and/or transplant-ineligible patients from inception to October 21, 2018. Phase II/III randomized trials comparing at least two first line treatment regimens for newly diagnosed tiMM were included. We extracted data on efficacy (progression free survival, PFS, overall survival and overall response rate) and safety (grade ¾ toxicities) and conducted network meta-analysis using Bayesian methods and random effects models. Relative ranking of treatment regimens was assessed using Surface under the cumulative ranking (SUCRA) probabilities. RESULTS We identified 27 trials involving 12,194 patients. For PFS, the four most effective regimens were: Daratumumab, Bortezomib, Melphalan and Prednisone (SUCRA 0.960) followed by Daratumumab, lenalidomide and dexamethasone (Dara_RD, SUCRA 0.847), Bortezomib, melphalan, prednisone, thalidomide maintenance with bortezomib-thalidomide (SUCRA 0.834) and Bortezomib, Lenalidomide and Dexamethasone (SUCRA 0.739). Among these four most efficacious regimens, toxicity profile was most favorable for Dara_RD (median additional AEs per patient vs dexamethasone = 0.74; 95% CrI 0.51-1.17; SUCRA 0.430). CONCLUSION Among first line tiMM regimens, increasing efficacy is associated with increased toxicity. We provide relative ranking of these regimens for both efficacy and safety. Future studies should incorporate geriatric assessments and frailty biomarkers to refine treatment decision-making for each individual patient.
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Affiliation(s)
- Smith Giri
- Division of Hematology-Oncology, University of Alabama at Birmingham, Birmingham, AL, United States of America.
| | - Madan Raj Aryal
- Division of Hematology-Medical Oncology, Roswell Park Cancer Institute, Buffalo, NY, United States of America
| | - Han Yu
- Department of Biostatistics, Roswell Park Comprehensive Cancer Institute, Buffalo, NY, United States of America
| | - Alyssa Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, United States of America
| | - Ranjan Pathak
- Division of Hematology, Yale University School of Medicine, New Haven, CT, United States of America
| | - Scott P Huntington
- Division of Hematology, Yale University School of Medicine, New Haven, CT, United States of America
| | - Binod Dhakal
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, United States of America
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15
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Hanashima Y, Sano E, Sumi K, Ozawa Y, Yagi C, Tatsuoka J, Yoshimura S, Yamamuro S, Ueda T, Nakayama T, Hara H, Yoshino A. Antitumor effect of lenalidomide in malignant glioma cell lines. Oncol Rep 2020; 43:1580-1590. [PMID: 32323826 PMCID: PMC7108053 DOI: 10.3892/or.2020.7543] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 01/29/2020] [Indexed: 02/05/2023] Open
Abstract
Glioblastoma is a malignant brain tumor exhibiting highly aggressive proliferation and invasion capacities. Despite treatment by aggressive surgical resection and adjuvant therapy including temozolomide and radiation therapy, patient prognosis remains poor. Lenalidomide, a derivative of thalidomide, is known to be an immunomodulatory agent that has been used to treat hematopoietic malignancies. There are numerous studies revealing an antitumor effect of lenalidomide in hematopoietic cells, but not in glioma cells. The present study aimed to demonstrate the antitumor effect of lenalidomide on malignant glioma cell lines. The growth inhibition of malignant glioma cells (A-172, AM-38, T98G, U-138MG, U-251MG, and YH-13) by lenalidomide was assessed using a Coulter counter. The mechanism of the antitumor effect of lenalidomide was examined employing a fluorescence-activated cell sorter, western blot analysis, and quantitative real-time reverse transcriptional polymerase chain reaction (RT-qPCR) in malignant glioma cell lines (A-172, AM-38). The results revealed that the number of malignant glioma cells was decreased in a concentration-dependent manner by lenalidomide. DNA flow cytometric analysis demonstrated an increase in the ratio of cells at the G0/G1 phase following lenalidomide treatment. Western blot analysis and RT-qPCR revealed that p53 activation and the expression of p21 were increased in glioma cells treated with lenalidomide. Western blot analysis revealed that cleavage of PARP did not occur; however, increased expression of Bax protein, cleavage of caspase-9 and cleavage of caspase-3 were confirmed. Analysis by FACS also supported the conclusion that little apoptosis induction occurred following lenalidomide treatment of malignant glioma cell lines. In conclusion, lenalidomide exerts an antitumor effect on glioma cells due to alterations in cell cycle distribution.
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Affiliation(s)
- Yuya Hanashima
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo 173‑8610, Japan
| | - Emiko Sano
- Department of Computational Biology and Medical Sciences, Graduate School of Frontier Sciences, The University of Tokyo, Kashiwa, Chiba 277‑8562, Japan
| | - Koichiro Sumi
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo 173‑8610, Japan
| | - Yoshinari Ozawa
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo 173‑8610, Japan
| | - Chihiro Yagi
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo 173‑8610, Japan
| | - Juri Tatsuoka
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo 173‑8610, Japan
| | - Sodai Yoshimura
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo 173‑8610, Japan
| | - Shun Yamamuro
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo 173‑8610, Japan
| | - Takuya Ueda
- Department of Computational Biology and Medical Sciences, Graduate School of Frontier Sciences, The University of Tokyo, Kashiwa, Chiba 277‑8562, Japan
| | - Tomohiro Nakayama
- Division of Companion Diagnostics, Department of Pathology and Microbiology, Nihon University School of Medicine, Tokyo 173‑8610, Japan
| | - Hiroyuki Hara
- Division of Anatomical Science, Department of Functional Morphology, Nihon University School of Medicine, Tokyo 173‑8610, Japan
| | - Atsuo Yoshino
- Division of Neurosurgery, Department of Neurological Surgery, Nihon University School of Medicine, Tokyo 173‑8610, Japan
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16
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Larsen RF, Jarden M, Minet LR, Frølund UC, Möller S, Abildgaard N. Physical function in patients newly diagnosed with multiple myeloma; a Danish cohort study. BMC Cancer 2020; 20:169. [PMID: 32126972 PMCID: PMC7055017 DOI: 10.1186/s12885-020-6637-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 02/17/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Multiple myeloma is a cancer in the bone marrow causing bone destruction. Patients experience various symptoms related to the disease and/or treatment, such as pain and fatigue, leading to poorer quality of life. The symptom burden might affect physical function and physical activity levels, posing a risk of physical deterioration. The aim was to investigate whether physical function in newly diagnosed patients with multiple myeloma differs from the reference values of the normal population and other cancer patients. METHODS The study is a cross sectional descriptive analysis of a prospective cohort of 100 patients newly diagnosed with multiple myeloma. Four physical function tests were carried out; Six-Minute-Walk-Test, Sit-to-Stand-Test, grip strength and knee extension strength. Age and gender specific results of physical function from the multiple myeloma population were compared to normative data and to data from other cancer populations. RESULTS Of the 100 patients included, 73% had bone disease and 55% received pain relieving medicine. Mean age was 67.7 years (SD 10.3). Patients with multiple myeloma had significantly poorer physical function compared to normative data, both regarding aerobic capacity and muscle strength, although not grip strength. No differences in physical function were found between patients with multiple myeloma and other cancer populations. CONCLUSIONS Physical function in newly diagnosed Danish patients with multiple myeloma is lower than in the normal population. Exercise intervention studies are warranted to explore the value of physical exercise on physical function. TRIAL REGISTRATION ClinicalTrials.gov, ID NCT02439112, registered 8 May 2015.
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Affiliation(s)
- Rikke Faebo Larsen
- Department of Physiotherapy and Occupational Therapy, Zealand University Hospital, Roskilde, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark.
| | - Mary Jarden
- Department of Haematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lisbeth Rosenbek Minet
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Rehabilitation, Odense University Hospital, Odense, Denmark.,Health Science Research Centre, UCL University College, Odense, Denmark
| | | | - Sören Möller
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Niels Abildgaard
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
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17
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Abe Y, Ishida T. Immunomodulatory drugs in the treatment of multiple myeloma. Jpn J Clin Oncol 2020; 49:695-702. [PMID: 31187860 DOI: 10.1093/jjco/hyz083] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/26/2019] [Indexed: 11/15/2022] Open
Abstract
The prognosis of multiple myeloma was quite poor in the last century, but it has significantly improved with the incorporation of novel agents, immunomodulatory drugs (IMiDs) and proteasome inhibitors. Thalidomide was first developed as a sedative in 1950s, but it was withdrawn from the market because of teratogenicity. In 1990s, however, thalidomide received attention due to the discovery of its anticancer potential derived from antiangiogenic and immunomodulatory activities, and its therapeutic effect on myeloma. In 2006, the U.S. Food and Drug Administration approved the use of thalidomide under strict control for the treatment of multiple myeloma. After that, two new IMiDs, lenalidomide and pomalidomide, were developed for the sake of more antitumor activity and less adverse events than thalidomide. The molecular mechanism of action of IMiDs remained unclear for a long time until 2010 when the protein cereblon (CRBN) was identified as a primary direct target. IMiDs binds to CRBN and alters the substrate specificity of the CRBN E3 ubiquitin ligase complex, resulting in breakdown of intrinsic downstream proteins such as IKZF1 (Ikaros) and IKZF3 (Aiolos). There are many clinical trials of multiple myeloma using IMiDs under various conditions, and most of them show the efficacy of IMiDs. Nowadays lenalidomide plays a central role in both newly diagnosed and relapsed/refractory settings, mainly in combination with other novel agents such as proteasome inhibitors and monoclonal antibodies. This review presents an overview of recent advances in immunomodulatory drugs in the treatment of multiple myeloma.
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Affiliation(s)
- Yu Abe
- Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Tadao Ishida
- Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
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18
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Piechotta V, Jakob T, Langer P, Monsef I, Scheid C, Estcourt LJ, Ocheni S, Theurich S, Kuhr K, Scheckel B, Adams A, Skoetz N. Multiple drug combinations of bortezomib, lenalidomide, and thalidomide for first-line treatment in adults with transplant-ineligible multiple myeloma: a network meta-analysis. Cochrane Database Syst Rev 2019; 2019:CD013487. [PMID: 31765002 PMCID: PMC6876545 DOI: 10.1002/14651858.cd013487] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Multiple myeloma is a bone marrow-based hematological malignancy accounting for approximately two per cent of cancers. First-line treatment for transplant-ineligible individuals consists of multiple drug combinations of bortezomib (V), lenalidomide (R), or thalidomide (T). However, access to these medicines is restricted in many countries worldwide. OBJECTIVES To assess and compare the effectiveness and safety of multiple drug combinations of V, R, and T for adults with newly diagnosed transplant-ineligible multiple myeloma and to inform an application for the inclusion of these medicines into the World Health Organization's (WHO) list of essential medicines. SEARCH METHODS We searched CENTRAL and MEDLINE, conference proceedings and study registries on 14 February 2019 for randomised controlled trials (RCTs) comparing multiple drug combinations of V, R and T for adults with newly diagnosed transplant-ineligible multiple myeloma. SELECTION CRITERIA We included RCTs comparing combination therapies of V, R, and T, plus melphalan and prednisone (MP) or dexamethasone (D) for first-line treatment of adults with transplant-ineligible multiple myeloma. We excluded trials including adults with relapsed or refractory disease, trials comparing drug therapies to other types of therapy and trials including second-generation novel agents. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias of included trials. As effect measures we used hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS) and risk ratios (RRs) for adverse events. An HR or RR < 1 indicates an advantage for the intervention compared to the main comparator MP. Where available, we extracted quality of life (QoL) data (scores of standardised questionnaires). Results quoted are from network meta-analysis (NMA) unless stated. MAIN RESULTS We included 25 studies (148 references) comprising 11,403 participants and 21 treatment regimens. Treatments were differentiated between restricted treatment duration (treatment with a pre-specified amount of cycles) and continuous therapy (treatment administered until disease progression, the person becomes intolerant to the drug, or treatment given for a prolonged period). Continuous therapies are indicated with a "c". Risk of bias was generally high across studies due to the open-label study design. Overall survival (OS) Evidence suggests that treatment with RD (HR 0.63 (95% confidence interval (CI) 0.40 to 0.99), median OS 55.2 months (35.2 to 87.0)); TMP (HR 0.75 (95% CI 0.58 to 0.97), median OS: 46.4 months (35.9 to 60.0)); and VRDc (HR 0.49 (95% CI 0.26 to 0.92), median OS 71.0 months (37.8 to 133.8)) probably increases survival compared to median reported OS of 34.8 months with MP (moderate certainty). Treatment with VMP may result in a large increase in OS, compared to MP (HR 0.70 (95% CI 0.45 to 1.07), median OS 49.7 months (32.5 to 77.3)), low certainty). Progression-free survival (PFS) Treatment withRD (HR 0.65 (95% CI0.44 to 0.96), median PFS: 24.9 months (16.9 to 36.8)); TMP (HR 0.63 (95% CI 0.50 to 0.78), median PFS:25.7 months (20.8 to 32.4)); VMP (HR 0.56 (95% CI 0.35 to 0.90), median PFS: 28.9 months (18.0 to 46.3)); and VRDc (HR 0.34 (95% CI 0.20 to 0.58), median PFS: 47.6 months (27.9 to 81.0)) may result in a large increase in PFS (low certainty) compared to MP (median reported PFS: 16.2 months). Adverse events The risk of polyneuropathies may be lower with RD compared to treatment with MP (RR 0.57 (95% CI 0.16 to 1.99), risk for RD: 0.5% (0.1 to 1.8), mean reported risk for MP: 0.9% (10 of 1074 patients affected), low certainty). However, the CIs are also compatible with no difference or an increase in neuropathies. Treatment with TMP (RR 4.44 (95% CI1.77 to 11.11), risk: 4.0% (1.6 to 10.0)) and VMP (RR 88.22 (95% CI 5.36 to 1451.11), risk: 79.4% (4.8 to 1306.0)) probably results in a large increase in polyneuropathies compared to MP (moderate certainty). No study reported the amount of participants with grade ≥ 3 polyneuropathies for treatment with VRDc. VMP probably increases the proportion of participants with serious adverse events (SAEs) compared to MP (RR 1.28 (95% CI 1.06 to 1.54), risk for VMP: 46.2% (38.3 to 55.6), mean risk for MP: 36.1% (177 of 490 patients affected), moderate certainty). RD, TMP, and VRDc were not connected to MP in the network and the risk of SAEs could not be compared. Treatment with RD (RR 4.18 (95% CI 2.13 to 8.20), NMA-risk: 38.5% (19.6 to 75.4)); and TMP (RR 4.10 (95% CI 2.40 to 7.01), risk: 37.7% (22.1 to 64.5)) results in a large increase of withdrawals from the trial due to adverse events (high certainty) compared to MP (mean reported risk: 9.2% (77 of 837 patients withdrew)). The risk is probably slightly increased with VMP (RR 1.06 (95% CI 0.63 to 1.81), risk: 9.75% (5.8 to 16.7), moderate certainty), while it is much increased with VRDc (RR 8.92 (95% CI 3.82 to 20.84), risk: 82.1% (35.1 to 191.7), high certainty) compared to MP. Quality of life QoL was reported in four studies for seven different treatment regimens (MP, MPc, RD, RMP, RMPc, TMP, TMPc) and was measured with four different tools. Assessment and reporting differed between studies and could not be meta-analysed. However, all studies reported an improvement of QoL after initiation of anti-myeloma treatment for all assessed treatment regimens. AUTHORS' CONCLUSIONS Based on our four pre-selected comparisons of interest, continuous treatment with VRD had the largest survival benefit compared with MP, while RD and TMP also probably considerably increase survival. However, treatment combinations of V, R, and T also substantially increase the incidence of AEs, and lead to a higher risk of treatment discontinuation. Their effectiveness and safety profiles may best be analysed in further randomised head-to-head trials. Further trials should focus on consistent reporting of safety outcomes and should use a standardised instrument to evaluate QoL to ensure comparability of treatment-combinations.
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Affiliation(s)
- Vanessa Piechotta
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Tina Jakob
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Peter Langer
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Ina Monsef
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Christof Scheid
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Stem Cell Transplantation Program, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Lise J Estcourt
- NHS Blood and Transplant, Haematology/Transfusion Medicine, Level 2, John Radcliffe Hospital, Headington, Oxford, UK, OX3 9BQ
| | - Sunday Ocheni
- University of Nigeria, Department of Haematology & Immunology, Ituku-Ozalla Campus, Enugu, Enugu State, Nigeria
| | - Sebastian Theurich
- University Hospital LMU, Ludwig-Maximilians-Universität München, Department of Medicine III, Marchioninistrasse 15, Munich, Bavaria, Germany, 81377
| | - Kathrin Kuhr
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Medical Statistics and Computational Biology, Kerpener Str. 62, Cologne, Germany, 50937
| | - Benjamin Scheckel
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute of Health Economics and Clinical Epidemiology, Gleueler Str. 176-178, Cologne, NRW, Germany, 50935
| | - Anne Adams
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Medical Statistics and Computational Biology, Kerpener Str. 62, Cologne, Germany, 50937
| | - Nicole Skoetz
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, Germany, 50937
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19
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Ramasamy K, Dhanasiri S, Thom H, Buchanan V, Robinson S, D'Souza VK, Weisel K. Relative efficacy of treatment options in transplant-ineligible newly diagnosed multiple myeloma: results from a systematic literature review and network meta-analysis. Leuk Lymphoma 2019; 61:668-679. [PMID: 31709875 DOI: 10.1080/10428194.2019.1683736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Established treatments for transplant-ineligible (TNE) patients with newly diagnosed multiple myeloma (NDMM) include melphalan and prednisone (MP) combined with either bortezomib (VMP) or thalidomide (MPT), or lenalidomide plus low-dose dexamethasone (Rd). New treatments for TNE NDMM include Rd plus bortezomib (RVd) and daratumumab plus VMP (VMP + D), daratumumab plus lenalidomide and dexamethasone (D + Rd). Relative efficacy of these treatments was compared using a network meta-analysis. Eight trials identified by a systematic literature review were included in the primary analysis; hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS) were used. Rd was superior to other MP-based regimens for OS and PFS. There was strong evidence that, compared with Rd, both D + Rd and RVd improved PFS (HR 0.57; 95% credible interval (CrI) 0.43, 0.73 and HR 0.72; 95% CrI 0.56, 0.91, respectively). However, there was strong evidence only for RVd in respect to OS (HR 0.72; 95% CrI 0.52, 0.96).
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Affiliation(s)
- Karthik Ramasamy
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Howard Thom
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | | | - Katja Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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20
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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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21
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Nielsen LK, Stege C, Lissenberg-Witte B, van der Holt B, Mellqvist UH, Salomo M, Bos G, Levin MD, Visser-Wisselaar H, Hansson M, van der Velden A, Deenik W, Coenen J, Hinge M, Klein S, Tanis B, Szatkowski D, Brouwer R, Westerman M, Leys R, Sinnige H, Haukås E, van der Hem K, Durian M, Gimsing P, van de Donk N, Sonneveld P, Waage A, Abildgaard N, Zweegman S. Health-related quality of life in transplant ineligible newly diagnosed multiple myeloma patients treated with either thalidomide or lenalidomide-based regimen until progression: a prospective, open-label, multicenter, randomized, phase 3 study. Haematologica 2019; 105:1650-1659. [PMID: 31515355 PMCID: PMC7271593 DOI: 10.3324/haematol.2019.222299] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 09/11/2019] [Indexed: 11/12/2022] Open
Abstract
Data on the impact of long term treatment with immunomodulatory drugs (IMiD) on health-related quality of life (HRQoL) is limited. The HOVON-87/NMSG18 study was a randomized, phase 3 study in newly diagnosed transplant ineligible patients with multiple myeloma, comparing melphalan-prednisolone in combination with thalidomide or lenalidomide, followed by maintenance therapy until progression (MPT-T or MPR-R). The EORTC QLQ-C30 and MY20 questionnaires were completed at baseline, after three and nine induction cycles and six and 12 months of maintenance therapy. Linear mixed models and minimal important differences were used for evaluation. 596 patients participated in HRQoL reporting. Patients reported clinically relevant improvement in global quality of life (QoL), future perspective and role and emotional functioning, and less fatigue and pain in both arms. The latter being of large effect size. In general, improvement occurred after 6–12 months of maintenance only and was independent of the World Health Organisation performance at baseline. Patients treated with MPR-R reported clinically relevant worsening of diarrhea, and patients treated with MPT-T reported a higher incidence of neuropathy. Patients who remained on lenalidomide maintenance therapy for at least three months reported clinically meaningful improvement in global QoL and role functioning at six months, remaining stable thereafter. There were no clinically meaningful deteriorations, but patients on thalidomide reported clinically relevant worsening in neuropathy. In general, HRQoL improves both during induction and maintenance therapy with immunomodulatory drugs. The side effect profile of treatment did not negatively affect global QoL, but it was, however, clinically relevant for the patients. (Clinicaltrials.gov identifier: NTR1630).
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Affiliation(s)
- Lene Kongsgaard Nielsen
- Quality of Life Research Center, Department of Haematology, Odense University Hospital, Odense, Denmark
| | - Claudia Stege
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Hematology, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Birgit Lissenberg-Witte
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam, the Netherlands
| | - Bronno van der Holt
- HOVON Data Center, Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Ulf-Henrik Mellqvist
- Section of Hematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital, Gotheborg, Sweden
| | - Morten Salomo
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - Gerard Bos
- Department of Haematology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Heleen Visser-Wisselaar
- HOVON Data Center, Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Markus Hansson
- Department of Haematology and Wallenberg Center for Molecular Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | | | - Wendy Deenik
- Department of Internal Medicine, Tergooi Ziekenhuis, Hilversum, the Netherlands
| | - Juleon Coenen
- Department of Internal Medicine, Isala, Zwolle, the Netherlands
| | - Maja Hinge
- Department of Internal Medicine, Division of Hematology, Vejle Hospital, Vejle, Denmark
| | - Saskia Klein
- Department of Internal Medicine, Meander Medisch Centrum, Amersfoort, the Netherlands
| | - Bea Tanis
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, the Netherlands
| | - Damian Szatkowski
- Department of Oncology, Haematology and Palliative Care, Førde Central Hospital, Førde, Norway
| | - Rolf Brouwer
- Department of Internal Medicine, Reinier de Graaf Ziekenhuis, Delft, the Netherlands
| | - Matthijs Westerman
- Department of Internal Medicine, Northwest Clinics, Alkmaar, the Netherlands
| | - Rineke Leys
- Department of Internal Medicine, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Harm Sinnige
- Department of Internal Medicine, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - Einar Haukås
- Department of Haematology, Stavanger University Hospital, Stavanger, Norway
| | - Klaas van der Hem
- Department of Internal Medicine, Zaans Medisch Centrum, Zaandam, the Netherlands
| | - Marc Durian
- Department of Internal Medicine, Tweesteden Ziekenhuis, Tilburg, the Netherlands
| | - Peter Gimsing
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
| | - Niels van de Donk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Hematology, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Pieter Sonneveld
- Department of Haematology, Erasmus Medical Center Cancer Center, Rotterdam, the Netherlands
| | - Anders Waage
- Department of Haematology, St Olavs Hospital and Norwegian University of Science and Technology, Trondheim, Norway
| | - Niels Abildgaard
- Quality of Life Research Center, Department of Haematology, Odense University Hospital, Odense, Denmark
| | - Sonja Zweegman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Hematology, Cancer Center Amsterdam, Amsterdam, the Netherlands
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22
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Cao Y, Wan N, Liang Z, Xie J, Wang S, Lin T, Zhang T, Jiang J. Treatment Outcomes in Patients With Newly Diagnosed Multiple Myeloma Who Are Ineligible for Stem-Cell Transplantation: Systematic Review and Network Meta-analysis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:e478-e488. [DOI: 10.1016/j.clml.2019.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/22/2019] [Accepted: 04/19/2019] [Indexed: 12/12/2022]
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23
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Report of phase I and II trials of melphalan, prednisolone, and thalidomide triplet combination therapy versus melphalan and prednisolone doublet combination therapy in Japanese patients with newly diagnosed multiple myeloma ineligible for autologous stem cell transplantation. Int J Hematol 2019; 110:447-457. [PMID: 31325152 DOI: 10.1007/s12185-019-02700-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 12/12/2022]
Abstract
We conducted a phase I study to determine the recommended dose of thalidomide combined with melphalan plus prednisolone (MPT) and a phase II study evaluating the efficacy and safety of this MPT regimen in transplant-ineligible Japanese patients with untreated multiple myeloma. The recommended dose was determined to be 100 mg/day in the phase I study. In the phase II, randomized, double-blind, parallel-group study, patients were allocated to either MPT (n = 52) or MP (n = 51), with 21 and 29 patients completing the study, respectively. Overall response rate, the primary endpoint, was significantly higher in the MPT [40.4% (21/52 patients), 95% confidence interval (CI) 27.0-54.9%] than in the MP [19.6% (10/51 patients), 95% CI 9.8-33.1%] group (P = 0.022). Time to response was also significantly shorter in the MPT group. Incidences of hematological toxicities were similar in the two groups, suggesting that addition of thalidomide did not increase hematological toxicity. Although incidences of some non-hematological toxicities tended to be higher in the MPT group, the low incidence of ≥ Grade 3 toxicities suggests that MPT therapy was well tolerated. These results support the safety and efficacy of MPT therapy in untreated Japanese multiple myeloma patients.
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24
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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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25
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Murakami H, Kasamatsu T, Murakami J, Kiguchi T, Kanematsu T, Ogawa D, Takamatsu H, Handa H, Ozaki S, Miki H, Takahashi T, Takeo T, Yamauchi T, Morishita T, Kosugi H, Shimizu K. Thalidomide maintenance therapy in Japanese myeloma patients: a multicenter, phase II clinical trial (COMET study). Int J Hematol 2019; 109:409-417. [PMID: 30701467 DOI: 10.1007/s12185-019-02607-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/20/2019] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
Abstract
A prospective, multicenter, phase II study was performed to assess the efficacy and safety of thalidomide maintenance therapy at different doses in Japanese multiple myeloma (MM) patients. This study included 34 patients (median age, 74 years) who were previously treated with not more than three prior therapies and whose response status was evaluated as at least stable disease. They were randomized into Group A (no maintenance; 12 patients), Group B (50 mg thalidomide maintenance; 12 patients), and Group C (100 mg thalidomide maintenance; 10 patients), respectively. Thalidomide maintenance therapy resulted in improved depth of response in three cases (13.6%) and sustained response after induction therapy in eight cases (36.4%). Two-year progression-free survival (PFS) was 25.0%, 33.3%, and 77.8% in Groups A, B, and C, respectively, and was significantly higher in Group C than in Group A (p = 0.005). There was no difference in the incidence of hematological or non-hematological adverse events between Groups B and C. The current study demonstrates that maintenance with daily thalidomide at 100 mg, but not 50 mg, improved depth of response and prolonged PFS, and that this treatment was feasible for use in Japanese MM patients.
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Affiliation(s)
- Hirokazu Murakami
- Department of Laboratory Sciences, Gunma University Graduate School of Health Sciences, Maebashi, Japan.
| | - Tetsuhiro Kasamatsu
- Department of Laboratory Sciences, Gunma University Graduate School of Health Sciences, Maebashi, Japan
| | - Jun Murakami
- Department of Hematology, Toyama University Hospital, Toyama, Japan
| | - Toru Kiguchi
- Department of Hematology, Chugoku Central Hospital, Fukuyama, Japan
| | - Takeshi Kanematsu
- Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Daisuke Ogawa
- Department of Hematology, Nagasaki Prefectural Shimabara Hospital, Shimabara, Japan
| | | | - Hiroshi Handa
- Department of Hematology, Gunma University, Maebashi, Japan
| | - Shuji Ozaki
- Department of Hematology, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Hirokazu Miki
- Division of Transfusion Medicine and Cell Therapy, Tokushima University Hospital, Tokushima, Japan
| | | | - Takaaki Takeo
- Department of Hematology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Tatsuya Yamauchi
- Department of Hematology, Toki Municipal General Hospital, Toki, Japan
| | - Takanobu Morishita
- Department of Hematology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Hiroshi Kosugi
- Department of Hematology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kazuyuki Shimizu
- Department of Hematology/Oncology, Higashi Nagoya National Hospital, Nagoya, Japan
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26
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Nielsen LK, Abildgaard N, Jarden M, Klausen TW. Methodological aspects of health-related quality of life measurement and analysis in patients with multiple myeloma. Br J Haematol 2019; 185:11-24. [PMID: 30656677 DOI: 10.1111/bjh.15759] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Multiple myeloma (MM) is an incurable but treatment-sensitive cancer. For most patients, this means treatment with multiple lines of anti-myeloma therapy and a life with disease- and treatment-related symptoms and complications. Health-related quality of life (HRQoL) issues play an important role in treatment decision-making. Methodological challenges in longitudinal HRQoL measurements and analyses have been identified, including non-responses (NR) to scheduled questionnaires. Publications were identified for inclusion in a systematic review of longitudinal HRQoL studies in MM, focussing on methodological aspects of HRQoL measurement and analysis. Diversity in timing of HRQoL data collection and applied statistical methods were noted. We observed a high rate of NR, but the impact of NR was investigated in only 8/23 studies. Thus, evidence-based knowledge of HRQoL in patients with MM is compromised. To improve quality of HRQoL results and their implementation in daily practice, future studies should follow established guidelines.
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Affiliation(s)
- Lene Kongsgaard Nielsen
- Quality of Life Research Center, Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
| | - Niels Abildgaard
- Quality of Life Research Center, Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
| | - Mary Jarden
- Department of Haematology, Copenhagen University Hospital, Copenhagen, Denmark
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27
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Manapuram S, Hashmi H. Treatment of Multiple Myeloma in Elderly Patients: A Review of Literature and Practice Guidelines. Cureus 2018; 10:e3669. [PMID: 30761222 PMCID: PMC6364954 DOI: 10.7759/cureus.3669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/30/2018] [Indexed: 11/25/2022] Open
Abstract
Multiple myeloma (MM) is a clonal disorder of malignant plasma cells that comprises approximately 10% of hematologic malignancies. With median age of 66 at the time of presentation, multiple myeloma is predominantly a disease of the elderly. The availability of new combination regimens and the enhanced safety of autologous hematopoietic stem cell transplant has increased the treatment options for elderly patients with multiple myeloma. We provide a summary of data supporting the current management of elderly patients with newly diagnosed multiple myeloma.
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Affiliation(s)
- Suresh Manapuram
- Internal Medicine, Saint Francis Hospital and Medical Center, Grand Island, USA
| | - Hamza Hashmi
- Oncology, University of Louisville School of Medicine, Louisville, USA
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28
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Hathi DK, DeLassus EN, Achilefu S, McConathy J, Shokeen M. Imaging Melphalan Therapy Response in Preclinical Extramedullary Multiple Myeloma with 18F-FDOPA and 18F-FDG PET. J Nucl Med 2018; 59:1551-1557. [PMID: 29700126 PMCID: PMC6167538 DOI: 10.2967/jnumed.118.208744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/16/2018] [Indexed: 01/31/2023] Open
Abstract
Multiple myeloma (MM) is a debilitating neoplasm of terminally differentiated plasma B cells that resulted in over 13,000 deaths in 2017 alone. Combination therapies involving melphalan, a small-molecule DNA alkylating agent, are commonly prescribed to patients with relapsed or refractory MM, necessitating the stratification of responding patients to minimize toxicities and improve quality of life. Here, we evaluated the use of 3,4-dihydroxy-6-18F-fluoro-l-phenylalanine (18F-FDOPA), a clinically available PET radiotracer with specificity to the L-type amino acid transporter 1 (LAT1), which also mediates melphalan uptake, for imaging melphalan therapy response in a preclinical immunocompetent model of MM. Methods: C57BL/KaLwRij mice were implanted subcutaneously with unilateral murine green fluorescent protein-expressing 5TGM1 tumors and divided into 3 independent groups: untreated, treated beginning week 2 after tumor implantation, and treated beginning week 3 after tumor implantation. The untreated and week 2 treated groups were imaged with preclinical MRI and dynamic 18F-FDG and 18F-FDOPA PET/CT at week 4 on separate, contiguous days, whereas the week 3 treated group was longitudinally imaged weekly for 3 wk. Metabolic tumor volume, total lesion avidity, SUVmax, and total uptake were calculated for both tracers. Immunohistochemistry was performed on representative tissue from all groups for LAT1 and glucose transporter 1 (GLUT1) expression. Results: Melphalan therapy induced a statistically significant reduction in lesion avidity and uptake for both 18F-FDG and 18F-FDOPA. There was no visible effect on GLUT1 expression, but LAT1 density increased in the week 2 treated group. Longitudinal imaging of the week 3 treated group showed variable changes in 18F-FDG and 18F-FDOPA uptake, with an increase in 18F-FDOPA lesion avidity in the second week relative to baseline. LAT1 and GLUT1 surface density in the untreated and week 3 treated groups were qualitatively similar. Conclusion:18F-FDOPA PET/CT complemented 18F-FDG PET/CT in imaging melphalan therapy response in preclinical extramedullary MM. 18F-FDOPA uptake was linked to LAT1 expression and melphalan response, with longitudinal imaging suggesting stabilization of LAT1 levels and melphalan tumor cytotoxicity. Future work will explore additional MM cell lines with heterogeneous LAT1 expression and response to melphalan therapy.
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Affiliation(s)
- Deep K Hathi
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri
| | - Elizabeth N DeLassus
- Department of Biochemistry and Biophysics, Washington University in St. Louis, St. Louis, Missouri; and
| | - Samuel Achilefu
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri
- Department of Biochemistry and Biophysics, Washington University in St. Louis, St. Louis, Missouri; and
| | - Jonathan McConathy
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Monica Shokeen
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri
- Department of Radiology, Washington University in St. Louis, St. Louis, Missouri
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29
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Li JL, Fan GY, Liu YJ, Zeng ZH, Huang JJ, Yang ZM, Meng XY. Long-Term Efficacy of Maintenance Therapy for Multiple Myeloma: A Quantitative Synthesis of 22 Randomized Controlled Trials. Front Pharmacol 2018; 9:430. [PMID: 29760659 PMCID: PMC5936780 DOI: 10.3389/fphar.2018.00430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/12/2018] [Indexed: 12/18/2022] Open
Abstract
We aimed to quantitatively synthesize data from randomized controlled trials (RCTs) concerning maintenance for multiple myeloma (MM). We searched electronic literature databases and conference proceedings to identify relevant RCTs. We selected eligible RCTs using predefined selection criteria. We conducted meta-analysis comparing maintenance containing new agents and conventional maintenance, and subgroup analysis by transplantation status and mainstay agent as well. We performed trial sequential analysis (TSA) to determine adequacy of sample size for overall and subgroup meta-analyses. We performed network meta-analysis (NMA) to compare and rank included regimens. A total of 22 RCTs involving 9,968 MM patients and 15 regimens were included, the overall quality of which was adequate. Significant heterogeneity was detected for progression-free survival (PFS) but not overall survival (OS). Meta-analyses showed that maintenance containing new agents significantly improved PFS but not OS [PFS: Hazard Ratio (HR) = 0.59, 95% Confidence Interval (CI) = 0.54 to 0.64; OS: HR = 0.93, 95% CI = 0.87 to 1.00], compared with controls. Subgroup analyses revealed lenalidomide (Len)-based therapies better than thalidomide-based ones (HR = 0.50 and 0.66, respectively; P = 0.001). NMA revealed that most of the maintenance regimens containing new agents were significantly better than simple observation in terms of PFS but not OS. Len single agent was the most effective, considering PFS and OS both. We concluded that conventional maintenance has very limited effect. Maintenance containing new agents is highly effective in improving PFS, but has very limited effect on OS. Maintenance with Len may have the largest survival benefits. Emerging strategies may further change the landscape of maintenance of MM.
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Affiliation(s)
- Jie-Li Li
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Guang-Yu Fan
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Evidence-Based Medicine and Clinical Epidemiology, Second Clinical College of Wuhan University, Wuhan, China
| | - Yu-Jie Liu
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Evidence-Based Medicine and Clinical Epidemiology, Second Clinical College of Wuhan University, Wuhan, China
| | - Zi-Hang Zeng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Evidence-Based Medicine and Clinical Epidemiology, Second Clinical College of Wuhan University, Wuhan, China
| | - Jing-Juan Huang
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zong-Ming Yang
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiang-Yu Meng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China.,Department of Evidence-Based Medicine and Clinical Epidemiology, Second Clinical College of Wuhan University, Wuhan, China
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30
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Immunomodulatory drugs and the risk of serious infection in multiple myeloma: systematic review and meta-analysis of randomized and observational studies. Ann Hematol 2018; 97:925-944. [PMID: 29500711 DOI: 10.1007/s00277-018-3284-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 02/25/2018] [Indexed: 01/11/2023]
Abstract
The effect of immunomodulatory drugs (IMiDs) on serious infection remains uncertain. We therefore conducted a systematic review and meta-analysis to assess the possible impact of IMiDs on serious infection in patients with multiple myeloma (MM). We searched randomized controlled trials (RCTs) and observational studies from databases that addressed the effect of IMiDs on serious infection in patients with MM. We pooled data from RCTs and observational studies separately and used the GRADE approach to rate the quality of evidence. Rates in patients with individual IMiDs at different treatment status ranged from 7.00 to 23.00%. The use of thalidomide- or lenalidomide-based regimen induction therapy for autologous stem cell transplantation (ASCT)-ineligible patients suggests increase in serious infection (RR = 1.59, 95% CI 1.31-1.93, p < 0.01). Compared to conventional therapy, IMiDs' induction in ASCT-eligible patients significantly decreases the risk of serious infection (RR = 0.82, 95% CI 0.72-0.94, p < 0.01). Lenalidomide-based therapy was associated with a significant increase in risk of serious infection in patients treated compared with conventional therapy (RR = 2.45, 95% CI 1.57-3.83, p < 0.01). The current evidence suggests that patients with MM treated with IMiDs are at a high risk of serious infection.
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31
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Elsayed HG, Alabdulwahab AS. Upfront treatment of elderly myeloma patients: an overview and update. Expert Rev Hematol 2018; 11:99-108. [DOI: 10.1080/17474086.2018.1419861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Hussein G. Elsayed
- Haematology Department, King Abdulla Medical City HC, Saudi Arabia
- Medical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
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Olszewski AJ, Dusetzina SB, Eaton CB, Davidoff AJ, Trivedi AN. Subsidies for Oral Chemotherapy and Use of Immunomodulatory Drugs Among Medicare Beneficiaries With Myeloma. J Clin Oncol 2017; 35:3306-3314. [PMID: 28541791 PMCID: PMC5652870 DOI: 10.1200/jco.2017.72.2447] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose The low-income subsidy (LIS) substantially lowers out-of-pocket costs for qualifying Medicare Part D beneficiaries who receive orally administered chemotherapy. We examined the association of LIS with the use of novel oral immunomodulatory drugs (IMiDs; lenalidomide and thalidomide) among beneficiaries with myeloma, who can receive either orally administered or parenteral (bortezomib-based) therapy. Methods Using SEER-Medicare data, we identified Part D beneficiaries diagnosed with myeloma in 2007 to 2011. In multivariable models adjusted for sociodemographic and clinical characteristics, we analyzed associations between the LIS and use of IMiD-based therapy, delays between IMiD refills, and select health outcomes during the first year of therapy. Results Among 3,038 beneficiaries, 41% received first-line IMiDs. Median out-of-pocket cost for the first IMiD prescription was $3,178 for LIS nonrecipients and $3 for LIS recipients, whereas the respective median costs for the first year of therapy were $5,623 and $6, respectively. Receipt of the LIS was associated with a 32% higher (95% CI, 16% to 47%) probability of receiving IMiDs among beneficiaries age 75 to 84 years and a significantly lower risk of delays between refills in all age groups (adjusted relative risk, 0.54; 95% CI, 0.32 to 0.92). Duration of therapy did not significantly differ between LIS recipients and nonrecipients (median, 7.6 months). Patients treated with IMiDs had significantly fewer emergency department visits and hospitalizations compared with patients receiving bortezomib (without IMiDs), but 1-year overall survival and cumulative Medicare costs were similar. Conclusion Medicare beneficiaries with myeloma who do not receive LISs face a substantial financial barrier to accessing orally administered anticancer therapy, warranting urgent attention from policymakers. Limiting out-of-pocket costs for expensive anticancer drugs like the IMiDs may improve access to oral therapy for patients with myeloma.
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Affiliation(s)
- Adam J. Olszewski
- Adam J. Olszewski, Charles B. Eaton, and Amal N. Trivedi, Alpert Medical School of Brown University; Adam J. Olszewski, Rhode Island Hospital; Charles B. Eaton, Brown University School of Public Health; Amal N. Trivedi, Providence Veterans Affairs Medical Center and Brown University School of Public Health, Providence, RI; Stacie B. Dusetzina, Eshelman School of Pharmacy, Gillings School of Global Public Health, and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Amy J. Davidoff, Yale School of Public Health and Yale Cancer Center, Yale University, New Haven, CT
| | - Stacie B. Dusetzina
- Adam J. Olszewski, Charles B. Eaton, and Amal N. Trivedi, Alpert Medical School of Brown University; Adam J. Olszewski, Rhode Island Hospital; Charles B. Eaton, Brown University School of Public Health; Amal N. Trivedi, Providence Veterans Affairs Medical Center and Brown University School of Public Health, Providence, RI; Stacie B. Dusetzina, Eshelman School of Pharmacy, Gillings School of Global Public Health, and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Amy J. Davidoff, Yale School of Public Health and Yale Cancer Center, Yale University, New Haven, CT
| | - Charles B. Eaton
- Adam J. Olszewski, Charles B. Eaton, and Amal N. Trivedi, Alpert Medical School of Brown University; Adam J. Olszewski, Rhode Island Hospital; Charles B. Eaton, Brown University School of Public Health; Amal N. Trivedi, Providence Veterans Affairs Medical Center and Brown University School of Public Health, Providence, RI; Stacie B. Dusetzina, Eshelman School of Pharmacy, Gillings School of Global Public Health, and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Amy J. Davidoff, Yale School of Public Health and Yale Cancer Center, Yale University, New Haven, CT
| | - Amy J. Davidoff
- Adam J. Olszewski, Charles B. Eaton, and Amal N. Trivedi, Alpert Medical School of Brown University; Adam J. Olszewski, Rhode Island Hospital; Charles B. Eaton, Brown University School of Public Health; Amal N. Trivedi, Providence Veterans Affairs Medical Center and Brown University School of Public Health, Providence, RI; Stacie B. Dusetzina, Eshelman School of Pharmacy, Gillings School of Global Public Health, and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Amy J. Davidoff, Yale School of Public Health and Yale Cancer Center, Yale University, New Haven, CT
| | - Amal N. Trivedi
- Adam J. Olszewski, Charles B. Eaton, and Amal N. Trivedi, Alpert Medical School of Brown University; Adam J. Olszewski, Rhode Island Hospital; Charles B. Eaton, Brown University School of Public Health; Amal N. Trivedi, Providence Veterans Affairs Medical Center and Brown University School of Public Health, Providence, RI; Stacie B. Dusetzina, Eshelman School of Pharmacy, Gillings School of Global Public Health, and Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC; and Amy J. Davidoff, Yale School of Public Health and Yale Cancer Center, Yale University, New Haven, CT
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Efficacy and safety of bortezomib maintenance in patients with newly diagnosed multiple myeloma: a meta-analysis. Biosci Rep 2017; 37:BSR20170304. [PMID: 28706008 PMCID: PMC5529203 DOI: 10.1042/bsr20170304] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 07/11/2017] [Accepted: 07/12/2017] [Indexed: 11/18/2022] Open
Abstract
Multiple myeloma (MM) is a B-cell neoplasm with a high incidence of relapse. Bortezomib has been extensively studied for the maintenance treatment of MM. Here, we carried out a meta-analysis to determine the efficacy and safety of maintenance therapy with bortezomib. We searched for clinical trials in PubMed (Medline), Embase (OVID), and the Cochrane Library. Two randomized controlled trials (RCTs) enrolling a total of 1338 patients were included. Bortezomib maintenance statistically significantly improved both progression-free survival (PFS) (hazard ratio (HR) 0.67, 95% confidence interval (CI) = 0.51 to 0.87, P=0.003) and overall survival (OS) (HR = 0.75 therapy, 95% CI = 0.63 to 0.89, P=0.001) more than did non-bortezomib maintenance therapy. Our analysis revealed higher incidence of neutropenia (risks ratios (RR) = 1.39; 95% CI = 1.08 to 1.79), peripheral neuropathy (PN) (RR = 2.23; 95% CI = 1.38 to 3.61, P=0.001), and cardiologic events (RR = 1.91; 95% CI = 1.12 to 3.28, P=0.02) in patients with bortezomib maintenance therapy. Our meta-analysis demonstrates OS and PFS benefits of bortezomib maintenance therapy in patients with newly diagnosed MM. However, the therapy is associated with increased risk of adverse events. Additionally, more RCTs are needed for better understanding and determination of optimal bortezomib maintenance therapy in MM.
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Esma F, Salvini M, Troia R, Boccadoro M, Larocca A, Pautasso C. Melphalan hydrochloride for the treatment of multiple myeloma. Expert Opin Pharmacother 2017; 18:1127-1136. [DOI: 10.1080/14656566.2017.1349102] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Fabrizio Esma
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Marco Salvini
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Rossella Troia
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Alessandra Larocca
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Chiara Pautasso
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
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Nielsen LK, Jarden M, Andersen CL, Frederiksen H, Abildgaard N. A systematic review of health-related quality of life in longitudinal studies of myeloma patients. Eur J Haematol 2017; 99:3-17. [PMID: 28322018 DOI: 10.1111/ejh.12882] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Multiple myeloma (MM) patients report high symptom burden and reduced health-related quality of life (HRQoL) compared to patients with other haematological malignancies. The aim of this review was to analyse published longitudinal studies including MM patients according to a change in HRQoL scores, which is perceived as beneficial to the patient according to two published guidelines. METHODS A literature search was performed May 2016. Publications with longitudinal follow-up using the EORTC QLQ-C30 instrument for HRQoL measurement of physical functioning, global quality of life, fatigue and/or pain were included. An analysis of mean change from baseline was carried out according to minimal important difference (MID). RESULTS Large and medium HRQoL improvements were reported during first-line treatments. No clinically beneficial change or deteriorations in scores of global QoL or fatigue were reported during relapse treatment. HRQoL data during maintenance therapy are sparse and inconclusive. CONCLUSIONS Guidelines for interpreting changes in HRQoL including definitions of MID have been developed; however, consensus is missing. Improvements in HRQoL are far more likely to occur during first-line compared to relapsed treatment regimens. The background of these findings should be in focus in future studies, and HRQoL measurements should be integrated in maintenance studies.
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Affiliation(s)
- Lene Kongsgaard Nielsen
- Quality of Life Research Centre, Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
| | - Mary Jarden
- University Hospitals Centre for Health Research, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Henrik Frederiksen
- Quality of Life Research Centre, Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
| | - Niels Abildgaard
- Quality of Life Research Centre, Department of Haematology, Odense University Hospital, Odense, Denmark.,The Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Odense, Denmark
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Attal M, Lauwers-Cances V, Hulin C, Leleu X, Caillot D, Escoffre M, Arnulf B, Macro M, Belhadj K, Garderet L, Roussel M, Payen C, Mathiot C, Fermand JP, Meuleman N, Rollet S, Maglio ME, Zeytoonjian AA, Weller EA, Munshi N, Anderson KC, Richardson PG, Facon T, Avet-Loiseau H, Harousseau JL, Moreau P. Lenalidomide, Bortezomib, and Dexamethasone with Transplantation for Myeloma. N Engl J Med 2017; 376:1311-1320. [PMID: 28379796 PMCID: PMC6201242 DOI: 10.1056/nejmoa1611750] [Citation(s) in RCA: 831] [Impact Index Per Article: 118.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND High-dose chemotherapy plus autologous stem-cell transplantation has been the standard treatment for newly diagnosed multiple myeloma in adults up to 65 years of age. However, promising data on the use of combination therapy with lenalidomide, bortezomib, and dexamethasone (RVD) in this population have raised questions about the role and timing of transplantation. METHODS We randomly assigned 700 patients with multiple myeloma to receive induction therapy with three cycles of RVD and then consolidation therapy with either five additional cycles of RVD (350 patients) or high-dose melphalan plus stem-cell transplantation followed by two additional cycles of RVD (350 patients). Patients in both groups received maintenance therapy with lenalidomide for 1 year. The primary end point was progression-free survival. RESULTS Median progression-free survival was significantly longer in the group that underwent transplantation than in the group that received RVD alone (50 months vs. 36 months; adjusted hazard ratio for disease progression or death, 0.65; P<0.001). This benefit was observed across all patient subgroups, including those stratified according to International Staging System stage and cytogenetic risk. The percentage of patients with a complete response was higher in the transplantation group than in the RVD-alone group (59% vs. 48%, P=0.03), as was the percentage of patients in whom minimal residual disease was not detected (79% vs. 65%, P<0.001). Overall survival at 4 years did not differ significantly between the transplantation group and the RVD-alone group (81% and 82%, respectively). The rate of grade 3 or 4 neutropenia was significantly higher in the transplantation group than in the RVD-alone group (92% vs. 47%), as were the rates of grade 3 or 4 gastrointestinal disorders (28% vs. 7%) and infections (20% vs. 9%). No significant between-group differences were observed in the rates of treatment-related deaths, second primary cancers, thromboembolic events, and peripheral neuropathy. CONCLUSIONS Among adults with multiple myeloma, RVD therapy plus transplantation was associated with significantly longer progression-free survival than RVD therapy alone, but overall survival did not differ significantly between the two approaches. (Supported by Celgene and others; IFM 2009 Study ClinicalTrials.gov number, NCT01191060 .).
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Affiliation(s)
- Michel Attal
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Valerie Lauwers-Cances
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Cyrille Hulin
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Xavier Leleu
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Denis Caillot
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Martine Escoffre
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Bertrand Arnulf
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Margaret Macro
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Karim Belhadj
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Laurent Garderet
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Murielle Roussel
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Catherine Payen
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Claire Mathiot
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Jean P Fermand
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Nathalie Meuleman
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Sandrine Rollet
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Michelle E Maglio
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Andrea A Zeytoonjian
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Edie A Weller
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Nikhil Munshi
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Kenneth C Anderson
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Paul G Richardson
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Thierry Facon
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Hervé Avet-Loiseau
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Jean-Luc Harousseau
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
| | - Philippe Moreau
- From the Institut Universitaire du Cancer de Toulouse-Oncopole (M.A., M.R., C.P., S.R., H.A.-L.) and Service d'Epidémiologie, Centre Hospitalier et Universitaire de Toulouse (V.L.-C.), Toulouse, Hôpital Haut-Lévêque, Bordeaux Pessac (C.H.), Centre Hospitalier et Universitaire la Miletrie, Poitiers (X.L.), Centre Hospitalier Le Bocage, Dijon (D.C.), Centre Hospitalier et Universitaire de Rennes, Rennes (M.E.), Hôpital St.-Louis (B.A., J.P.F.), Centre Hospitalier Universitaire, Hôpital St.-Antoine (L.G.), Institut Curie (C.M.), and Haute Autorité de Santé (J.-L.H.), Paris, Institut d'Hématologie de Basse Normandie, Centre Hospitalier et Universitaire de Caen, Caen (M.M.), Centre Hospitalier et Universitaire Henri Mondor, Creteil (K.B.), Hôpital Claude Huriez, Lille (T.F.), and Hôtel Dieu, Nantes (P.M.) - all in France; Institut Jules Bordet, Brussels (N. Meuleman); and Dana-Farber Cancer Institute, Boston (M.E.M., A.A.Z., E.A.W., N. Munshi, K.C.A., P.G.R.)
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Lyu WW, Zhao QC, Song DH, Zhang JJ, Ding ZX, Li BY, Wei CM. Thalidomide-based Regimens for Elderly and/or Transplant Ineligible Patients with Multiple Myeloma: A Meta-analysis. Chin Med J (Engl) 2017; 129:320-5. [PMID: 26831235 PMCID: PMC4799577 DOI: 10.4103/0366-6999.174497] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Thalidomide is an immunomodulatory and anti-angiogenic drug that has shown promise in patients with myeloma. Trials comparing efficacy of standard melphalan and prednisone (MP) therapy with MP plus thalidomide (MPT) in transplant-ineligible or elderly patients with multiple myeloma (MM) have provided conflicting evidence. This meta-analysis aimed to determine the efficacy and toxicity of thalidomide in previously untreated elderly patients with myeloma. Methods: Medline, the Cochrane Controlled Trials register, conference proceedings of the American Society of Hematology (1995–2014), the American Society of Clinical Oncology (1995–2014), and CBM, VIP, and CNKI databases were searched for randomized control trials with the use of the medical subject headings “MM” and “thalidomide”. Trials were assessed by two reviewers for eligibility. Meta-analysis was conducted using a fixed effects model. Sensitivity analysis was performed to test the robustness of the findings. Results: Overall, seven trials were identified, covering a total of 1821 subjects. The summary hazard ratio (thalidomide vs. control) was 0.82 (95% confidence interval [CI]: 0.72–0.94) for overall survival (OS), and 0.65 (95% CI: 0.58–0.73) for progression-free survival, in favor of thalidomide treated group. The risk ratio of complete response with induction thalidomide was 3.48 (95% CI: 2.24–5.41). A higher rate of III/IV adverse events were observed in MPT arm compared with the MP arm. However, analysis of sub-groups administering anticoagulation as venous thromboembolism prophylaxis suggested no difference in relative risk of thrombotic events between two arms (RR = 1.47, 95% CI: 0.43–5.07, P = 0.54). Further analysis of trials on the treatment effects of MPT versus MP on adverse events-related mortality showed no statistical difference between two arms (RR = 1.24, 95% CI: [0.95–1.63], P = 0.120). Conclusion: Thalidomide appears to improve the OS of elderly and/or transplant-ineligible patients with MM when it is added to standard MP therapy.
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Affiliation(s)
| | | | | | | | | | | | - Chuan-Mei Wei
- Department of Pharmacy, Binzhou Medical University Hospital, Binzhou, Shandong 256603, China
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Liu X, Chen J, He YA, Meng X, Li K, He CK, Liu S. Comparing efficacy and survivals of initial treatments for elderly patients with newly diagnosed multiple myeloma: a network meta-analysis of randomized controlled trials. Onco Targets Ther 2016; 10:121-128. [PMID: 28053546 PMCID: PMC5189699 DOI: 10.2147/ott.s123680] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy and clinical outcome of initial therapies for elderly patients with multiple myeloma (MM). METHODS Randomized controlled trials (RCTs) were obtained through a comprehensive search. Response rate, progression-free survival (PFS) and overall survival (OS) were the interested outcome measures. Network meta-analysis (NMA) using graph theory methodology to construct an NMA model, and sensitivity analysis were performed. RESULTS Nineteen RCTs containing 7,235 participants and 17 treatments were included in the NMA. As compared to the classic melphalan plus prednisone (MP) regimen, the majority of other initial regimens showed higher rates of complete response/near complete response, overall response rate (ORR) and better PFS as well as OS. These four outcomes favored the two lenalidomide plus dexamethasone regimens (continuous lenalidomide and 18 cycles of lenalidomide plus dexamethasone), especially continuous lenalidomide plus dexamethasone regimen, over the majority of other regimens including the two established standard treatments (MP plus thalidomide or bortezomib) for elderly patients with newly diagnosed MM. CONCLUSION Continuous lenalidomide plus dexamethasone ranked as the best regimen in terms of ORR and OS for the treatment of elderly patients with newly diagnosed MM.
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Affiliation(s)
- Xiaoping Liu
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University
| | - Jiarui Chen
- School of Basic Medical Science, Wuhan University, Wuhan, Hubei, People's Republic of China
| | - Yuncen A He
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Xiangyu Meng
- Center for Evidence-Based and Translational Medicine, Zhongnan Hospital of Wuhan University
| | - Kaili Li
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
| | | | - Shangqin Liu
- Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, People's Republic of China
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Hulin C, Belch A, Shustik C, Petrucci MT, Dührsen U, Lu J, Song K, Rodon P, Pégourié B, Garderet L, Hunter H, Azais I, Eek R, Gisslinger H, Macro M, Dakhil S, Goncalves C, LeBlanc R, Romeril K, Royer B, Doyen C, Leleu X, Offner F, Leupin N, Houck V, Chen G, Ervin-Haynes A, Dimopoulos MA, Facon T. Updated Outcomes and Impact of Age With Lenalidomide and Low-Dose Dexamethasone or Melphalan, Prednisone, and Thalidomide in the Randomized, Phase III FIRST Trial. J Clin Oncol 2016; 34:3609-3617. [DOI: 10.1200/jco.2016.66.7295] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose This analysis of the FIRST trial in patients with newly diagnosed multiple myeloma (MM) ineligible for stem-cell transplantation examined updated outcomes and impact of patient age. Patients and Methods Patients with untreated symptomatic MM were randomly assigned at a one-to-one-to-one ratio to lenalidomide plus low-dose dexamethasone until disease progression (Rd continuous), Rd for 72 weeks (18 cycles; Rd18), or melphalan, prednisone, and thalidomide (MPT; 72 weeks), stratified by age (≤ 75 v > 75 years), disease stage (International Staging System stage I/II v III), and country. The primary end point was progression-free survival. Rd continuous and MPT were primary comparators. Results Between August 21, 2008, and March 7, 2011, 1,623 patients were enrolled (Rd continuous, n = 535; Rd18, n = 541; MPT, n = 547), including 567 (35%) age older than 75 years. Higher rates of advanced-stage disease and renal impairment were observed in patients older than 75 versus 75 years of age or younger. Rd continuous reduced the risk of progression or death compared with MPT by 31% (hazard ratio [HR], 0.69; 95% CI, 0.59 to 0.80; P < .001) overall, 36% (HR, 0.64; 95% CI, 0.53 to 0.77; P < .001) in patients age 75 years or younger, and 20% (HR, 0.80; 95% CI, 0.62 to 1.03; P = .084) in those age older than 75 years. Median overall survival was longer with Rd continuous than with MPT, including a 14-month difference in patients age older than 75 years. Progression-free survival with Rd18 was similar to that with MPT, and overall survival with Rd18 was marginally inferior to that with Rd continuous. Rates of grade 3 to 4 treatment-emergent adverse events were similar for Rd continuous–treated patients age 75 years or older and those age older than 75 years; however, older patients had more frequent lenalidomide dose reductions. Conclusion Results support Rd continuous treatment as a new standard of care for stem-cell transplantation–ineligible patients with newly diagnosed MM of all ages.
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Affiliation(s)
- Cyrille Hulin
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Andrew Belch
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Chaim Shustik
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Maria Teresa Petrucci
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Ulrich Dührsen
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Jin Lu
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Kevin Song
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Philippe Rodon
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Brigitte Pégourié
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Laurent Garderet
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Hannah Hunter
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Isabelle Azais
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Richard Eek
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Heinz Gisslinger
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Margaret Macro
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Shaker Dakhil
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Cristina Goncalves
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Richard LeBlanc
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Ken Romeril
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Bruno Royer
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Chantal Doyen
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Xavier Leleu
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Fritz Offner
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Nicolas Leupin
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Vanessa Houck
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Guang Chen
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Annette Ervin-Haynes
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Meletios A. Dimopoulos
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
| | - Thierry Facon
- Cyrille Hulin, Bordeaux Hospital University Center, Bourdeaux; Philippe Rodon, Centre Hospitalier de Périgueux, Périgueux; Brigitte Pégourié, Centre Hospitalier Regional Universitaire, Grenoble; Laurent Garderet, Centre Hospitalier Universitaire (CHU) Hôpital St-Antoine, Paris; Isabelle Azais, CHU Institut National de la Santé et de la Recherche Médicale (INSERM); Xavier Leleu, Hôpital de la Milétrie, CHU INSERM, Poitiers; Margaret Macro, CHU de Caen, Caen; Bruno Royer, University Hospital, Amiens
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Offidani M, Corvatta L, Gentili S, Maracci L, Leoni P. Oral ixazomib maintenance therapy in multiple myeloma. Expert Rev Anticancer Ther 2016; 16:21-32. [PMID: 26588946 DOI: 10.1586/14737140.2016.1123627] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Continuous therapy has proven to be an effective therapeutic strategy to improve the outcome of both young and elderly multiple myeloma patients. Remarkably, lenalidomide and bortezomib showed to play a crucial role in this setting due to their safety profile allowing long-term exposure. Ixazomib, the first oral proteasome inhibitor to be evaluated in multiple myeloma, exerts substantial anti-myeloma activity as a single agent and particularly in combination with immunomodulatory drugs and it may be an attractive option for maintenance therapy. Here we address the issue of maintenance therapy as part of a therapeutic approach of multiple myeloma patients focusing on the potential role of ixazomib.
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Affiliation(s)
- Massimo Offidani
- a Azienda Ospedaliero-Universitaria , Ospedali Riuniti di Ancona , Ancona , Italy
| | - Laura Corvatta
- b Dipartimento di Medicina, UOC Medicina , Fabriano , Italy
| | - Silvia Gentili
- a Azienda Ospedaliero-Universitaria , Ospedali Riuniti di Ancona , Ancona , Italy
| | - Laura Maracci
- a Azienda Ospedaliero-Universitaria , Ospedali Riuniti di Ancona , Ancona , Italy
| | - Pietro Leoni
- a Azienda Ospedaliero-Universitaria , Ospedali Riuniti di Ancona , Ancona , Italy
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Teh BW, Harrison SJ, Worth LJ, Thursky KA, Slavin MA. Infection risk with immunomodulatory and proteasome inhibitor-based therapies across treatment phases for multiple myeloma: A systematic review and meta-analysis. Eur J Cancer 2016; 67:21-37. [PMID: 27592069 DOI: 10.1016/j.ejca.2016.07.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/28/2016] [Accepted: 07/29/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND The objective of this review was to determine the impact of immunomodulatory drugs (IMiDs) and proteasome inhibitor (PI)-based therapy on infection risk in patients with myeloma across three treatment periods: induction, maintenance therapy and relapse/refractory disease (RRMM). METHODS A systematic review and meta-analysis of randomised controlled trials (RCT) of IMiD and PI-based therapy versus conventional therapy from 1990 to 2015 using MEDLINE, EMBASE and CENTRAL was conducted. Study methods, characteristics, interventions, outcomes and rate of infection were extracted using a standardised tool. FINDINGS Thirty RCTs of 13,105 patients fulfilled inclusion criteria. The rate of severe infection with the use of IMiD-based therapy was 13.4%, 22.4%, 10.5% and 16.6% for induction therapy for non-transplant- and transplant-eligible patients, maintenance therapy and therapy for RRMM, respectively. Rate of severe infection with PI-based induction in transplant-eligible patients was 19.7%. Compared to conventional therapy, use of IMiD-based induction therapy was associated with reduced risk for transplant patients (RR 0.76, p < 0.01). There was no significant difference with PI-based therapy. For maintenance therapy and RRMM, use of IMiD-based therapy was significantly associated with 74% and 51% increased risk of severe infection, respectively. Compared to thalidomide, bortezomib-based induction therapy and lenalidomide maintenance therapy were associated with increased risk of severe infection (RR 2.03, p < 0.01; RR 1.95, p = 0.03). INTERPRETATION The differential impact of myeloma therapies on risk for infection and the effect of treatment phases upon risk have now been established. Thalidomide is associated with the lowest risk of severe infection when used for induction and maintenance therapy. FUNDING Fight Cancer Foundation.
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Affiliation(s)
- Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Australia; Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, East Melbourne, Australia.
| | - Simon J Harrison
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, East Melbourne, Australia; Department of Haematology, Peter MacCallum Cancer Centre, East Melbourne, Australia
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Australia; Department of Medicine, University of Melbourne, Parkville, Australia
| | - Karin A Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Australia; Department of Medicine, University of Melbourne, Parkville, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, East Melbourne, Australia; Department of Medicine, University of Melbourne, Parkville, Australia; Victorian Infectious Diseases Service, Doherty Institute for Infection and Immunity, Australia
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Lee HS, Min CK. Optimal maintenance and consolidation therapy for multiple myeloma in actual clinical practice. Korean J Intern Med 2016; 31:809-19. [PMID: 27604793 PMCID: PMC5016292 DOI: 10.3904/kjim.2016.110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 08/23/2016] [Indexed: 12/22/2022] Open
Abstract
Multiple myeloma is an incurable malignant plasma cell-originating cancer. Although its treatment outcomes have improved with the use of glucocorticoids, alkylating drugs, and novel agents, including proteasome inhibitors (bortezomib and carfilzomib) and immunomodulatory drugs (thalidomide, lenalidomide, and pomalidomide), relapse remains a serious problem. Strategies to improve outcomes following autologous stem cell transplantation and frontline treatments in non-transplant patients include consolidation to intensify therapy and improve the depth of response and maintenance therapy to achieve long-term disease control. Many clinical trials have reported increased progression-free and overall survival rates after consolidation and maintenance therapy. The role of consolidation/maintenance therapy has been assessed in patients eligible and ineligible for transplantation and is a valuable option in clinical trial settings. However, the decision to use consolidation and/or maintenance therapy needs to be guided by the individual patient situation in actual clinical practice. This review analyzes the currently available evidence from several reported clinical trials to determine the optimal consolidation and maintenance therapy in clinical practice.
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Affiliation(s)
- Ho Sup Lee
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Chang-Ki Min
- Division of Hematology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
- Correspondence to Chang-Ki Min, M.D. Division of Hematology, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea Tel: +82-2-2258-6053 Fax: +82-2-599-3589 E-mail:
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Rajkumar SV. Multiple myeloma: 2016 update on diagnosis, risk-stratification, and management. Am J Hematol 2016; 91:719-34. [PMID: 27291302 PMCID: PMC5291298 DOI: 10.1002/ajh.24402] [Citation(s) in RCA: 311] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 02/07/2023]
Abstract
Multiple myeloma accounts for approximately 10% of hematologic malignancies.The diagnosis requires ≥10% clonal bone marrow plasma cells or a biopsy proven plasmacytoma plus evidence of one or more multiple myeloma defining events (MDE): CRAB (hypercalcemia, renal failure, anemia, or lytic bone lesions) features felt related to the plasma cell disorder, bone marrow clonal plasmacytosis ≥60%, serum involved/uninvolved free light chain (FLC) ratio ≥100 (provided involved FLC is ≥100 mg/L), or >1 focal lesion on magnetic resonance imaging. Patients with del(17p), t(14;16), and t(14;20) have high-risk multiple myeloma. Patients with t(4;14) translocation and gain(1q) have intermediate-risk. All others are considered standard-risk. Initial treatment consists of bortezomib, lenalidomide, dexamethasone (VRD). In high-risk patients, carfilzomib, lenalidomide, dexamethasone (KRD) is an alternative to VRD. In eligible patients, initial therapy is given for approximately 3-4 months followed by autologous stem cell transplantation (ASCT). Standard risk patients can opt for delayed ASCT at first relapse. Patients not candidates for transplant are treated with Rd until progression, or alternatively, a triplet regimen such as VRD for approximately 12-18 months. After ASCT, lenalidomide maintenance is considered for standard risk patients especially in those who are not in very good partial response or better, while maintenance with a bortezomib-based regimen is needed for patients with intermediate or high-risk disease. Patients with indolent relapse can be treated with 2-drug or 3-drug combinations. Patients with more aggressive relapse require a triplet regimen or a combination of multiple active agents. Am. J. Hematol. 91:720-734, 2016. © 2016 Wiley Periodicals, Inc.
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The Value of Patient Reported Outcomes and Other Patient-Generated Health Data in Clinical Hematology. Curr Hematol Malig Rep 2016; 10:213-24. [PMID: 26040262 DOI: 10.1007/s11899-015-0261-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
With cures and long-term survival rates increasing in hematologic malignancies, increased focus has been placed on gaining a better understanding of the patient experience from disease and treatment effects. This has been the basis for the utilization of patient reported outcomes (PRO) and other patient-generated health data (PGHD) in efforts to improve long-term health-related quality of life (HRQOL). This review will summarize the impact PROs have had on the evolving standard of care for patients with hematologic malignant conditions and will conclude with a template for the integration of PRO and PGHD to enhance the patient experience, using stem cell transplantation as an example.
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Weisel K, Doyen C, Dimopoulos M, Yee A, Lahuerta JJ, Martin A, Travers K, Druyts E, Toor K, Abildgaard N, Lu J, Van Droogenbroeck J, Geraldes C, Petrini M, Voillat L, Voog E, Facon T. A systematic literature review and network meta-analysis of treatments for patients with untreated multiple myeloma not eligible for stem cell transplantation. Leuk Lymphoma 2016; 58:153-161. [PMID: 27124703 DOI: 10.1080/10428194.2016.1177772] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In newly diagnosed multiple myeloma (MM), patients ineligible for front-line autologous stem cell transplantation (ASCT), melphalan and prednisone (MP) with thalidomide (MPT) or bortezomib (VMP) are standard first-line therapeutic options. Despite new treatment regimens incorporating bortezomib or lenalidomide, MM remains incurable. The FIRST study demonstrated significant improvement in progression-free survival (PFS) and overall survival (OS) for the combination of lenalidomide and low-dose dexamethasone (Rd) until progression vs. MPT in transplant-ineligible ndMM patients. However, to date no head-to-head randomized controlled trials (RCTs) have compared Rd or MPT versus VMP. We conducted a network meta-analysis using RCTs identified through a systematic literature review to evaluate the relative efficacy of Rd versus other regimens on survival endpoints in previously untreated MM patients ineligible for ASCT. In this analysis, Rd was associated with a significant PFS and survival advantage versus other first-line treatments (VMP, MPT, MP), challenging the role of alkylators in this setting.
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Affiliation(s)
- Katja Weisel
- a Division of Haematology/Oncology, University Hospital Tubingen, University of Tübingen , Tübingen , Germany
| | | | | | - Adrian Yee
- d BC Cancer Agency , British Columbia , Canada
| | | | | | | | | | | | | | - Jin Lu
- i Peking University Institute of Hematology, People's Hospital , Beijing , China
| | | | | | - Mario Petrini
- l Chiara Dip. Oncologia , A.O. Universitaria Ospedale S , Pisa , Italy
| | | | - Eric Voog
- n Centre Jean Bernard , Le Mans , France
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Wildes TM, Campagnaro E. Management of multiple myeloma in older adults: Gaining ground with geriatric assessment. J Geriatr Oncol 2016; 8:1-7. [PMID: 27118356 DOI: 10.1016/j.jgo.2016.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/28/2015] [Accepted: 04/05/2016] [Indexed: 01/22/2023]
Abstract
Multiple myeloma increases in incidence with age. With the aging of the population, the number of cases of multiple myeloma diagnosed in older adults each year will nearly double in the next 20years. The novel therapeutic agents have significantly improved survival in older adults, but their outcomes remain poorer than in younger patients. Older adults may be more vulnerable to toxicity of therapy, resulting in decreased dose intensity and contributing to poorer outcomes. Data are beginning to emerge to aid in identifying which individuals are at greater risk for toxicity of therapy; comorbidities, functional limitations, and age over 80years are among the factors associated with greater risk. Geriatric assessment holds promise in the care of older adults with multiple myeloma, both to allow modification of treatment to prevent toxicity, and to identify vulnerabilities that may require intervention. Emerging treatments with low toxicity and attention to individualizing therapy based on geriatric assessment may aid in further improving outcomes in older adults with multiple myeloma.
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Affiliation(s)
- Tanya M Wildes
- Washington University School of Medicine, St. Louis, MO, USA.
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Melphalan, prednisone, and lenalidomide versus melphalan, prednisone, and thalidomide in untreated multiple myeloma. Blood 2016; 127:1109-16. [DOI: 10.1182/blood-2015-11-679415] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/22/2015] [Indexed: 12/21/2022] Open
Abstract
Key Points
In a multicenter, randomized phase 3 trial, MPR-R was not superior over MPT-T with respect to response rate, PFS, and OS. Grade 3/4 hematologic toxicity requiring growth factor support occurred with MPR-R vs clinically significant neuropathy with MPT-T.
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Gao M, Kong Y, Wang H, Xie B, Yang G, Gao L, Zhang Y, Zhan F, Dai B, Tao Y, Shi J. Thalidomide treatment for patients with previously untreated multiple myeloma: a meta-analysis of randomized controlled trials. Tumour Biol 2016; 37:11081-98. [PMID: 26906553 DOI: 10.1007/s13277-016-4963-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 02/02/2016] [Indexed: 12/23/2022] Open
Abstract
The efficacy and safety of thalidomide as an initial treatment in myeloma patients who were unsuitable for autologous stem cell transplantation (ASCT), as induction treatment prior to ASCT, or as a maintenance treatment was unclear. The purpose of this study was to assess the benefits and risks of thalidomide for previously untreated myeloma patients. MEDLINE, EMBASE, and Cochrane Library were searched for randomized controlled trials (RCTs) of thalidomide used in either induction or maintenance therapy for previously untreated myeloma patients. Twenty-two RCTs enrolling 9098 patients were identified, including 15 RCTs of induction thalidomide, 6 RCTs of maintenance thalidomide, and 1 RCT of induction and maintenance thalidomide. Induction thalidomide improved overall response rate (ORR) (risk ratio (RR) 1.54, 95 % confidence interval (CI) 1.30-1.83), complete response rate (CRR) (RR 3.03, 95 % CI 1.91-4.80), progression-free survival (PFS) (hazard ratio (HR) 0.65, 95 % CI 0.56-0.76), and overall survival (OS) (HR 0.78, 95 % CI 0.67-0.91) in patients who were not allowed to receive ASCT. Induction thalidomide improved pre-ASCT ORR (RR 1.20, 95 % CI 1.11-1.30), pre-ASCT and post-ASCT CRR (RR 1.47, 95 % CI 1.12-1.93 and RR 1.23, 95 % CI 1.00-1.50, respectively), and PFS (HR 0.73, 95 % CI 0.59-0.91) in patients who were allowed to receive ASCT, but it did not improve post-ASCT ORR (RR 1.04, 95 % CI 0.99-1.09) and OS (HR 0.91, 95 % CI 0.79-1.05). Improved PFS and prolonged OS were observed (HR 0.61, 95 % CI 0.53-0.70 and HR 0.77, 95 % CI 0.62-0.95, respectively) when thalidomide was added to maintenance therapy. More patients experienced venous thromboembolism (VTE) of grade 3/4 when thalidomide was added to induction or maintenance therapy (HR 2.15, 95 % CI 1.58-2.92 and RR 1.96, 95 % CI 1.13-3.40, respectively). Induction thalidomide still increased the risk of VTE (RR 1.53, 95 % CI 1.12-2.08) after VTE prophylaxis was used. Induction thalidomide effectively improved CRR, ORR, and PFS (except post-ASCT ORR). Notably, induction thalidomide improved OS in patients who were not allowed to receive ASCT but not in patients who were allowed to receive ASCT. The addition of thalidomide to maintenance therapy improved both PFS and OS. However, thalidomide led to a greater risk of VTE with grade 3/4. This risk did not disappear after VTE prophylaxis was used in induction therapy with thalidomide.
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Affiliation(s)
- Minjie Gao
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China, 200072
| | - Yuanyuan Kong
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China, 200072
| | - Houcai Wang
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China, 200072
| | - Bingqian Xie
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China, 200072
| | - Guang Yang
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China, 200072
| | - Lu Gao
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China, 200072
| | - Yiwen Zhang
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China, 200072
| | - Fenghuang Zhan
- Department of Internal Medicine, University of Iowa, Carver College of Medicine, Iowa, IA, USA
| | - Bojie Dai
- College of life science and technology, Tongji University, Shanghai, China
| | - Yi Tao
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China, 200072.
| | - Jumei Shi
- Department of Hematology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China, 200072.
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Efficacy and Safety of Novel Agent-Based Therapies for Multiple Myeloma: A Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6848902. [PMID: 26949704 PMCID: PMC4753325 DOI: 10.1155/2016/6848902] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 12/15/2015] [Accepted: 12/22/2015] [Indexed: 12/26/2022]
Abstract
This study aimed at comparing bortezomib, thalidomide, and lenalidomide in patients with multiple myeloma (MM) for safety and efficacy using meta-analysis. This meta-analysis identified 17 randomized controlled trials (RCTs) including 6742 patients. These RCTs were separated according to the different agent-based regimens and to autologous stem-cell transplantation (ASCT). Complete response (CR), progression-free survival (PFS), overall survival (OS), and adverse events (AE) were combined. The total weighted risk ratio (RR) of CR was 3.29 [95% confidence interval (95% CI): 2.22–4.88] (P < 0.0001) for the novel agent-based regimens. These novel agent-based regimens showed greater benefit in terms of PFS of all subgroups irrespective of whether the patient received ASCT or not. The hazard ratio (HR) for PFS was 0.64 [95% CI: 0.60–0.69] (P < 0.00001). Improvements of OS could be found only in the bortezomib- and thalidomide-based regimens without ASCT. The pooled HRs were 0.74 [95% CI: 0.65–0.86] (P < 0.0001) and 0.80 [95% CI: 0.70–0.90] (P = 0.0004), respectively. Several AEs were shown more frequently in the novel agent-based regimens compared with controls such as hematologic events (neutropenia, anemia, and thrombocytopenia), gastrointestinal infection, peripheral neuropathy, thrombosis, and embolism events. In conclusion, in spite of the AEs, novel agent-based regimens are safe and effective for the treatment of MM.
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Bonomo L, Lue J, Jagannath S, Chari A. The outcomes of newly diagnosed elderly multiple myeloma patients treated at a single U.S. institution. Cancer Med 2016; 5:500-5. [PMID: 26799254 PMCID: PMC4799960 DOI: 10.1002/cam4.620] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 10/19/2015] [Accepted: 11/24/2015] [Indexed: 01/26/2023] Open
Abstract
Improvements in the outcomes of elderly multiple myeloma (MM) patients have lagged behind those of transplant-eligible patients, likely due in part to the use of less efficacious melphalan-containing regimens. To date, there are very limited data for the outcomes of elderly MM patients in the United States (US), particularly for novel agent-containing triplet regimens. In this retrospective study at a single U.S. institution, the outcomes of 117 consecutive newly diagnosed, symptomatic MM patients over the age of 70 were evaluated. The median age was 75 years (range 70-95) with significant baseline comorbidities including 36% cardiac and 20% renal (CrCl < 30 mL/min). The median follow-up was 43 months and the median number of lines of therapy during the study period was 2 (1-7). Eighty-six patients (83%) received non-melphalan doublet, triplet, or quadruplet initial therapy, most with significant planned dose attenuations. For those treated with dose-attenuated RVD (n = 34), the outcomes were particularly impressive with overall response rate (ORR), complete remission and very good partial remission (CR + VGPR), and progression-free survival (PFS) of 94%, 65%, and 36 months, respectively, and overall survival (OS) not reached. The PFS with RVD was significantly greater than that of all other regimens (P = 0.030), including RD.
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Affiliation(s)
- Lauren Bonomo
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York City, New York, 10029
| | - Jerry Lue
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York City, New York, 10029
| | - Sundar Jagannath
- Division of Hematology Oncology, Icahn School of Medicine at Mount Sinai, Gustave Levy Place, Box 1185, New York City, New York, 10029
| | - Ajai Chari
- Division of Hematology Oncology, Icahn School of Medicine at Mount Sinai, Gustave Levy Place, Box 1185, New York City, New York, 10029
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