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Han X, Jiang X, He J, Zheng G, Xiong Y, Wen Y, Yang Y, He D, Chen Q, Zhao Y, Li Y, Wu W, Cai Z. Clinical outcomes of pomalidomide-based and daratumumab-based therapies in patients with relapsed/refractory multiple myeloma: A real-world cohort study in China. Cancer Med 2024; 13:e7232. [PMID: 38698679 PMCID: PMC11066492 DOI: 10.1002/cam4.7232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Comparative investigations evaluating the efficacy of pomalidomide-based (Pom-based) versus daratumumab-based (Dara-based) therapies in patients with relapsed/refractory multiple myeloma (RRMM) remain scarce, both in randomized controlled trials and real-world studies. METHODS This retrospective cohort study included 140 RRMM patients treated with Pom-based or Dara-based or a combination of pomalidomide and daratumumab (DPd) regimens in a Chinese tertiary hospital between December 2018 and July 2023. RESULTS The overall response rates (ORR) for Pom-based (n = 48), Dara-based (n = 68), and DPd (n = 24) groups were 57.8%, 84.6%, and 75.0%, respectively (p = 0.007). At data cutoff on August 1, 2023, the median progression-free survival (PFS) was 5.7 months (95% CI: 5.0-6.5) for the Pom-based group, 10.5 months (5.2-15.8) for the Dara-based group, and 6.7 months (4.0-9.3) for the DPd group (p = 0.056). Multivariate analysis identified treatment regimens (Dara-based vs. Pom-based, DPd vs. Pom-based) and Eastern Cooperative Oncology Group performance status (ECOG PS) as independent prognostic factors for PFS. In the subgroups of patients aged >65 years, with ECOG PS ≥2, lines of therapy ≥2, extramedullary disease or double-refractory disease (refractory to both lenalidomide and proteasome inhibitors), the superiority of Dara-based regimens over Pom-based regimens was not evident. A higher incidence of infections was observed in patients receiving Dara-based and DPd regimens (Pom-based 39.6% vs. Dara-based 64.7% vs. DPd 70.8%, p = 0.009). CONCLUSIONS In real-world settings, Pom-based, Dara-based, and DPd therapies exhibited favorable efficacy in patients with RRMM. Dara-based therapy yielded superior clinical response and PFS compared to Pom-based therapy.
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Affiliation(s)
- Xiaoyan Han
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Xincheng Jiang
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Jingsong He
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Gaofeng Zheng
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Yaqin Xiong
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Yanling Wen
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Yang Yang
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Donghua He
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Qingxiao Chen
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Yi Zhao
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Yi Li
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Wenjun Wu
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
| | - Zhen Cai
- Department of Hematology and Bone Marrow Transplantation CenterThe First Affiliated Hospital, School of Medicine, Zhejiang UniversityHangzhouZhejiangChina
- Institute of Hematology, Zhejiang UniversityHangzhouZhejiangChina
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Trudel S, McCurdy A, Louzada ML, Parkin S, White D, Chu MP, Kotb R, Mian H, Othman I, Su J, Khan A, Gul E, Reece D. Belantamab mafodotin, pomalidomide and dexamethasone in refractory multiple myeloma: a phase 1/2 trial. Nat Med 2024; 30:543-551. [PMID: 38177852 PMCID: PMC10878971 DOI: 10.1038/s41591-023-02703-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/10/2023] [Indexed: 01/06/2024]
Abstract
Due to evolving treatment standards for newly diagnosed multiple myeloma, many patients will be triple-class exposed after initial relapses and have poor survival. Novel therapies and combinations are therefore required to improve outcomes. B cell maturation antigen (BCMA)-targeted biologics have emerged as an important new area of therapeutics for relapsed multiple myeloma. The two-part ALGONQUIN trial evaluated various doses and schedules of the anti-BCMA antibody-drug conjugate belantamab mafodotin plus pomalidomide and dexamethasone for patients who are lenalidomide refractory and proteosome inhibitor exposed. The primary endpoints, including evaluating dose-limiting toxicities, establishing the recommended Part 2 dose (RP2D) and overall response rate for patients treated at the RP2D, were met. Secondary efficacy endpoints included progression-free survival and overall survival. Patients treated on study (N = 87) had a median of three previous regimens and 55.2% were triple-class refractory. At the RP2D the most common adverse events were decrease in best-corrected visual acuity (71.1%), keratopathy (65.8%), fatigue (57.9%), infection (47.4%; 7.9% grade ≥3), neutropenia (39.5%) and thrombocytopenia (39.5%). For RP2D patients (n = 38), the overall response rate was 85.3%, ≥very good partial response 75.7% and estimated two-year progression-free survival 52.8% (95% confidence interval, 33.9% to 82.4%), at a median follow-up of 13.9 months. The RP2D schedule was associated with manageable antibody-drug conjugate-associated corneal adverse events and improved tolerability without compromising efficacy. Belantamab mafodotin plus pomalidomide and dexamethasone induced durable responses with promising overall survival in relapsed multiple myeloma, the results of which are yet to be confirmed in the phase 3 DREAMM-8 study. ClinicalTrials.gov Identifier: NCT03715478 .
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Affiliation(s)
- Suzanne Trudel
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
| | | | | | - Stephen Parkin
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Darrell White
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Rami Kotb
- CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Hira Mian
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | | | - Jiandong Su
- Canadian Myeloma Research Group (CMRG), Vaughan, Ontario, Canada
| | - Aniba Khan
- Canadian Myeloma Research Group (CMRG), Vaughan, Ontario, Canada
| | - Engin Gul
- Canadian Myeloma Research Group (CMRG), Vaughan, Ontario, Canada
| | - Donna Reece
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Davies FE, Leleu X, Vogel P, Dhanasiri S, Le Nouveau P, Weisel K. A Meta-Analysis of the Efficacy of Pomalidomide-Based Regimens for the Treatment of Relapsed/Refractory Multiple Myeloma After Lenalidomide Exposure. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:829-837.e1. [PMID: 37684184 DOI: 10.1016/j.clml.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 09/10/2023]
Abstract
INTRODUCTION The objective was to assess the benefit of pomalidomide-based combination regimens in patients with relapsed/refractory multiple myeloma (RRMM) previously treated with lenalidomide. A pooled estimate was obtained for efficacy outcomes including overall response rate (ORR), complete response (CR) rate, and progression-free survival (PFS) based on multiple trials conducted in this patient population. PATIENTS AND METHODS A literature search was conducted on March 22, 2022 for relevant trials published between January 1, 2016 and the search date. The search identified 12 eligible trials with publications dated between 2016 and 2021. The meta-analyses were conducted among the intention-to-treat (ITT) population (patients treated in all lines of therapy) and 2 subpopulations: 2L (only patients treated in the second line [2L]) and ≥2L (patients treated in the 2L and beyond). RESULTS From the meta-analyses, ORR was 69.9% for ITT, 74.4% for ≥2L, and 87.2% for 2L. CR rate was 12.1% for ITT, 17.6% for ≥2L, and 29.7% for 2L. One-year PFS rates were 55.1% for ITT, 59.1% for ≥2L, and 74.0% for 2L. Two-year PFS rates were 29.3% for ITT, 36.0% for ≥2L, and 41.9% for 2L. CONCLUSION Pomalidomide-based combination regimens were effective in patients with RRMM previously treated with lenalidomide and tended to be associated with better outcomes when used earlier in the treatment pathway. A drug class switch may not always be necessary when making treatment decisions for patients with RRMM for whom the benefits of lenalidomide have been exhausted, although this must be supported by comparative studies.
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Affiliation(s)
| | - Xavier Leleu
- Service d'Hématologie et Thérapie Cellulaire, Hôpital La Milétrie, CHU, Poitiers, France
| | - Prisca Vogel
- Celgene, a Bristol-Myers Squibb Company, Boudry, Switzerland
| | | | | | - Katja Weisel
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Song GY, Lee JJ, Moon JH, Kim D, Kim MK, Kim HJ, Mun YC, Lee WS, Do YR, Lee JH, Jung SH, Kim JS. Open-labeled, multicenter phase II study of prophylactic administration of pegylated granulocyte colony-stimulating factor in relapsed or refractory multiple myeloma who received pomalidomide-based regimens (KMM170). Front Oncol 2023; 13:1209110. [PMID: 37965454 PMCID: PMC10642200 DOI: 10.3389/fonc.2023.1209110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 10/09/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction Pegylated granulocyte colony-stimulating factor (G-CSF) has been widely used for preventing febrile neutropenia in various types of cancer treatment. In the present study, we prospectively evaluated the safety and efficacy of pegfilgrastim as a primary prophylaxis of febrile neutropenia and infection among patients with relapsed refractory multiple myeloma (RRMM) treated with pomalidomide-based regimens. Methods Thirty-three patients with RRMM who received pomalidomide and dexamethasone (Pd) with or without cyclophosphamide (PCd) were enrolled in this study. Twenty-eight patients were treated with PCd and 5 patients were treated with Pd. All patients were given pegfilgrastim subcutaneously with a single administration performed on the first day of each cycle as primary prophylaxis until the fourth cycle. Results The median age of the patients was 75 (range 56-85), and the median prior line of therapy was 2 (range 2-6). Seventeen patients (51.5%) had any grade of neutropenia and 20 (60.6%) had any grade of thrombocytopenia before starting pomalidomide treatment. During the 4 cycles of treatment, grade 3 or more neutropenia occurred in 17 patients (51.5%), and 4 (12.1%) experienced grade 3 or more febrile neutropenia. Grade 3 or more infections occurred in 5 patients (15.2%). Interestingly, the patients with markedly increased ANC of more than 2 x 109/L compared to baseline ANC after 7 days of pegfilgrastim at 1st cycle of treatment showed a significantly lower incidence of grade 3-4 neutropenia. The most common adverse event of pegfilgrastim was fatigue, and all the adverse events caused by pegfilgrastim were grade 1 or 2. And there was no significant change in the immune cell population and cytokines during the administration of pegfilgrastim. Discussion Considering that this study included elderly patients with baseline neutropenia, pegylated G-CSF could be helpful to prevent severe neutropenia, febrile neutropenia, or infection in patients with RRMM.
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Affiliation(s)
- Ga-Young Song
- Department of Hemotology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Jeollanamdo, Republic of Korea
| | - Je-Jung Lee
- Department of Hemotology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Jeollanamdo, Republic of Korea
| | - Joon Ho Moon
- Department of Hematology-Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Dajung Kim
- Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Republic of Korea
| | - Min Kyoung Kim
- Department of Hematology and Oncology, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Yeung-Chul Mun
- Division of Hematology-Oncology, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Won-Sik Lee
- Busan Paik Hospital, Inje University, Busan, Republic of Korea
| | - Young Rok Do
- Department of Internal Medicine, Keimyung University, School of Medicine, Keimyung University Hospital, Daegu, Republic of Korea
| | - Jae Hoon Lee
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Sung-Hoon Jung
- Department of Hemotology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Jeollanamdo, Republic of Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Wu HY, Zhou X, Chu XX, Deng XZ, Yuan CL, Ran XH, Liu GQ, Fan CB, Hao HY, Zhong YP. [Bendamustine combined with pomalidomide and dexamethasone in relapsed multiple myeloma with extramedullary disease: a multicenter study]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:667-671. [PMID: 37803841 PMCID: PMC10520229 DOI: 10.3760/cma.j.issn.0253-2727.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Indexed: 10/08/2023]
Abstract
Objective: To evaluate the efficacy and safety of bendamustine combined with pomalidomide and dexamethasone (BPD regimen) in the treatment of relapsed multiple myeloma (MM) with extramedullary disease. Methods: This open, single-arm, multicenter prospective cohort study included 30 relapsed MM patients with extramedullary disease diagnosed in seven hospitals including Qingdao Municipal Hospital. The patients were treated with BPD regimen from February 2021 to November 2022. This study analyzed the efficacy and adverse reactions of the BPD regimen. Results: The median age of the 30 patients was 62 (47-72) years, of which 18 (60% ) had first-time recurrence. The overall response rate (ORR) of the 18 patients with first-time recurrence was 100%, of which three (16.7% ) achieved complete remission, 10 (55.5% ) achieved very good partial remission (VGPR), and five (27.8% ) achieved partial remission (PR). The ORR of 12 patients with recurrence after second-line or above treatment was 50%, including zero patients with ≥VGPR and six patients (50% ) with PR. Three cases (25% ) had stable disease, and three cases (25% ) had disease progression. The one-year progression free survival rate of all patients was 65.2% (95% CI 37.2% -83.1% ), and the 1-year overall survival rate was 90.0% (95% CI 76.2% -95.4% ). The common grade 3-4 hematology adverse reactions included two cases (6.7% ) of neutropenia and one case (3.3% ) of thrombocytopenia. The overall adverse reactions are controllable. Conclusions: The BPD regimen has good efficacy and tolerance in relapsed MM patients with extramedullary disease.
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Affiliation(s)
- H Y Wu
- Qingdao Hospital, University of Health and Rehabilitation Sciences, Qingdao Municipal Hospital, Qingdao 266071, China
| | - X Zhou
- Qingdao Hospital, University of Health and Rehabilitation Sciences, Qingdao Municipal Hospital, Qingdao 266071, China
| | - X X Chu
- Yantai Yuhuangding Hospital, Yantai 264099, China
| | - X Z Deng
- Weihai Municipal Hospital, Weihai 264299, China
| | - C L Yuan
- Qilu Hospital of Shandong University, Qingdao 266035, China
| | - X H Ran
- Weifang People's Hospital, Weifang 261044, China
| | - G Q Liu
- Shengli Oilfield Center Hospital, Dongying 257099, China
| | - C B Fan
- Qingdao Haici Medical Group, Qingdao 266033, China
| | - H Y Hao
- Qilu Hospital of Shandong University, Qingdao 266035, China
| | - Y P Zhong
- Qingdao Hospital, University of Health and Rehabilitation Sciences, Qingdao Municipal Hospital, Qingdao 266071, China
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Neri P, Nijhof I. Evidence-based mechanisms of synergy with IMiD agent-based combinations in multiple myeloma. Crit Rev Oncol Hematol 2023:104041. [PMID: 37268176 DOI: 10.1016/j.critrevonc.2023.104041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 05/18/2023] [Accepted: 05/30/2023] [Indexed: 06/04/2023] Open
Abstract
Treatment of multiple myeloma (MM) has seen great advances in recent years, and a key contributor to this change has been the effective use of combination therapies, which have improved both the depth and duration of patient responses. IMiD agents (lenalidomide and pomalidomide) have both tumoricidal and immunostimulatory functions, and due to their multiple mechanisms of action have become the backbone of numerous combination treatments in the newly diagnosed and relapsed/refractory settings. Although IMiD agent-based combination regimens provide improved clinical outcomes for patients with MM, the mechanisms underpinning these combinations are not well understood. In this review we describe the potential mechanisms of synergy leading to the enhanced activity observed when IMiD agents and other drug classes are used in combination through interrogation of the current knowledge surrounding their mechanism of actions.
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Affiliation(s)
- Paola Neri
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, AB, Canada.
| | - Inger Nijhof
- Department of Hematology, Amsterdam University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Department of Internal Medicine and Department of Hematology, St. Antonius Hospital Nieuwegein, Koekoekslaan 1, 3435CM, Nieuwegein, the Netherlands
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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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Dima D, Ullah F, Mazzoni S, Williams L, Faiman B, Kurkowski A, Chaulagain C, Raza S, Samaras C, Valent J, Khouri J, Anwer F. Management of Relapsed-Refractory Multiple Myeloma in the Era of Advanced Therapies: Evidence-Based Recommendations for Routine Clinical Practice. Cancers (Basel) 2023; 15:2160. [PMID: 37046821 PMCID: PMC10093129 DOI: 10.3390/cancers15072160] [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: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023] Open
Abstract
Multiple myeloma (MM) is the second most common hematologic malignancy in adults worldwide. Over the past few years, major therapeutic advances have improved progression-free and overall survival, as well as quality of life. Despite this recent progress, MM remains incurable in the vast majority of cases. Patients eventually relapse and become refractory to multiple drug classes, making long-term management challenging. In this review, we will focus on the treatment paradigm of relapsed/refractory MM (RRMM) in the era of advanced therapies emphasizing the available novel modalities that have recently been incorporated into routine practice, such as chimeric antigen receptor T-cell therapy, bispecific antibodies, and other promising approaches. We will also discuss major factors that influence the selection of appropriate drug combinations or cellular therapies, such as relapse characteristics, and other disease and patient related parameters. Our goal is to provide insight into the currently available and experimental therapies for RRMM in an effort to guide the therapeutic decision-making process.
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Affiliation(s)
- Danai Dima
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Fauzia Ullah
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Sandra Mazzoni
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Louis Williams
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Beth Faiman
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Austin Kurkowski
- Department of Pharmacy, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Chakra Chaulagain
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Maroone Cancer Center, Weston, FL 33331, USA
| | - Shahzad Raza
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Christy Samaras
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Jason Valent
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Jack Khouri
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Faiz Anwer
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
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McCaughan GJ, Gandolfi S, Moore JJ, Richardson PG. Lenalidomide, bortezomib and dexamethasone induction therapy for the treatment of newly diagnosed multiple myeloma: a practical review. Br J Haematol 2022; 199:190-204. [PMID: 35796524 PMCID: PMC9796722 DOI: 10.1111/bjh.18295] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/10/2022] [Accepted: 05/20/2022] [Indexed: 01/07/2023]
Abstract
For patients with newly diagnosed multiple myeloma, survival outcomes continue to improve significantly: however, nearly all patients will relapse following induction treatment. Optimisation of induction therapy is essential to provide longer term disease control and the current standard of care for most patients incorporates an immunomodulatory agent and proteasome inhibitor, most commonly lenalidomide and bortezomib in combination with dexamethasone (RVD), with maintenance until progression. Historically there has been limited access to RVD as an induction strategy outside of the United States; fortunately, there is now increasing access worldwide. This review discusses the rationale for use of RVD as induction therapy and aims to provide guidance in prescribing this regimen in order to optimise efficacy while minimising the toxicities of treatment. We also highlight the increasing evidence for the utility of addition of a monoclonal antibody to the RVD backbone to deepen responses and potentially provide longer disease control.
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Affiliation(s)
- Georgia J. McCaughan
- Department of HaematologySt Vincent's HospitalSydneyAustralia
- University of New South Wales, Medicine and HealthSydneyAustralia
| | - Sara Gandolfi
- Translational Research ProgramUniversity of HelsinkiHelsinkiFinland
- Haematology Research UnitUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - John J. Moore
- Department of HaematologySt Vincent's HospitalSydneyAustralia
- University of New South Wales, Medicine and HealthSydneyAustralia
| | - Paul G. Richardson
- Dana‐Farber Cancer Institute, Jerome Lipper Multiple Myeloma Center, Department of Medical OncologyBostonMassachusettsUSA
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[Expert consensus on the prevention and treatment of multiple myeloma related venous thromboembolism in China (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:726-731. [PMID: 36709165 PMCID: PMC9613487 DOI: 10.3760/cma.j.issn.0253-2727.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Indexed: 12/05/2022]
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Afari J, Spektor TM, Turner C, Cohen A, Bessudo A, Jhangiani H, Gabrail N, Kubba S, Neidhart JD, Eshaghian S, Swift RA, Eades BM, Kim C, Kim S, Vescio R, Berenson JR. Efficacy and safety of replacing lenalidomide with pomalidomide for patients with multiple myeloma refractory to a lenalidomide-containing combination regimen. Exp Hematol 2022; 114:54-60. [DOI: 10.1016/j.exphem.2022.07.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/21/2022] [Accepted: 07/29/2022] [Indexed: 11/04/2022]
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Mian H, Reece D, Masih-Khan E, McCurdy A, Kardjadj M, Jimenez-Zepeda VH, Song K, Louzada M, LeBlanc R, Sebag M, White D, Stakiw J, Reiman A, Kotb R, Aslam M, Gul E, Venner CP. Survival and Outcomes of Newly Diagnosed Multiple Myeloma Patients Stratified by Transplant Status 2007-2018: Retrospective Analysis from the Canadian Myeloma Research Group Database. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:608-617. [PMID: 35379589 DOI: 10.1016/j.clml.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/17/2022] [Accepted: 03/04/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Considerable progress has been made in therapeutic options for multiple myeloma (MM). Understanding the current landscape of MM treatment options and associated outcomes in the real world is important in providing key insights into clinical and knowledge gaps which could be targeted for further optimization. METHODS The Canadian Myeloma Research Group Database (CMRG-DB) is a prospectively maintained disease-specific database with >7000 patients. The objective of this study was to describe the trends in the treatment landscape and outcomes including early mortality, time to next treatment, and overall survival (OS) in each line of treatment stratified by autologous stem cell transplant (ASCT) receipt among newly-diagnosed MM patients in Canada between 2007 and 2018. RESULTS A total of 5154 patients were identified among which 3030 patients (58.8%) received an upfront ASCT and 2124 (41.2%) did not. At diagnosis, the median age was 64 years and 58.6% were males. Bortezomib and lenalidomide were most frequently used (>50%) in first and second-line treatment respectively among both the ASCT and non-ASCT cohort. The median OS was 122.0 months (95% Cl 115.0-135.0 months) and 54.3 months (95% CI 50.8-58.8 months) for the ASCT and non-ASCT cohort respectively with an incremental decrease in OS in each subsequent line of treatment. CONCLUSION We present the largest study to date in the Canadian landscape showing the characteristics, therapy usage, and outcomes among MM patients. This information will be critical in benchmarking current outcomes and provide key insight into areas of unmet needs and gaps for improvement of MM patients nationally.
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Affiliation(s)
- Hira Mian
- Juravinski Cancer Center, Hamilton, Ontario, Canada
| | - Donna Reece
- Canadian Myeloma Research Group, Toronto, Ontario, Canada; Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Esther Masih-Khan
- Canadian Myeloma Research Group, Toronto, Ontario, Canada; Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
| | | | | | | | - Kevin Song
- BC Cancer Agency, Vancouver General Hospital, British Columbia, Canada
| | | | - Richard LeBlanc
- Maisonneuve-Rosemont Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada
| | | | - Darrell White
- Queen Elizabeth II Health Sciences Centre. Dalhousie University, Halifax, Nova Scotia, Canada
| | - Julie Stakiw
- Saskatoon Cancer Centre, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Anthony Reiman
- Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | - Rami Kotb
- Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | | | - Engin Gul
- Canadian Myeloma Research Group, Toronto, Ontario, Canada
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13
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Kumar S, Baizer L, Callander NS, Giralt SA, Hillengass J, Freidlin B, Hoering A, Richardson PG, Schwartz EI, Reiman A, Lentzsch S, McCarthy PL, Jagannath S, Yee AJ, Little RF, Raje NS. Gaps and opportunities in the treatment of relapsed-refractory multiple myeloma: Consensus recommendations of the NCI Multiple Myeloma Steering Committee. Blood Cancer J 2022; 12:98. [PMID: 35768410 PMCID: PMC9243011 DOI: 10.1038/s41408-022-00695-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/29/2022] [Accepted: 06/08/2022] [Indexed: 01/05/2023] Open
Abstract
A wide variety of new therapeutic options for Multiple Myeloma (MM) have recently become available, extending progression-free and overall survival for patients in meaningful ways. However, these treatments are not curative, and patients eventually relapse, necessitating decisions on the appropriate choice of treatment(s) for the next phase of the disease. Additionally, an important subset of MM patients will prove to be refractory to the majority of the available treatments, requiring selection of effective therapies from the remaining options. Immunomodulatory agents (IMiDs), proteasome inhibitors, monoclonal antibodies, and alkylating agents are the major classes of MM therapies, with several options in each class. Patients who are refractory to one agent in a class may be responsive to a related compound or to a drug from a different class. However, rules for selection of alternative treatments in these situations are somewhat empirical and later phase clinical trials to inform those choices are ongoing. To address these issues the NCI Multiple Myeloma Steering Committee formed a relapsed/refractory working group to review optimal treatment choices, timing, and sequencing and provide recommendations. Additional issues considered include the role of salvage autologous stem cell transplantation, risk stratification, targeted approaches for genetic subsets of MM, appropriate clinical trial endpoints, and promising investigational agents. This report summarizes the deliberations of the working group and suggests potential avenues of research to improve the precision, timing, and durability of treatments for Myeloma.
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Affiliation(s)
- Shaji Kumar
- Hematologic Malignancies, Mayo Clinic College of Medicine and Science, Rochester, USA
| | - Lawrence Baizer
- Division of Lung Diseases, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Natalie S Callander
- Myeloma Clinical Program, University of Wisconsin Carbone Cancer Center, Madison, USA
| | - Sergio A Giralt
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, Madison, USA
| | - Jens Hillengass
- Oncology and Internal Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, USA
| | - Boris Freidlin
- Biometric Research Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Antje Hoering
- Cancer Research and Biostatistics and University of Washington School of Public Health, Seattle, USA
| | - Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, USA
| | - Elena I Schwartz
- Coordinating Center for Clinical Trials, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Anthony Reiman
- University of New Brunswick, Department of Medicine, Dalhousie University Department of Oncology, Saint John Regional Hospital, Fredericton, Canada
| | - Suzanne Lentzsch
- Multiple Myeloma and Amyloidosis Service, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Philip L McCarthy
- Department of Medicine, Oncology and Internal Medicine, Transplant & Cellular Therapy Center, Roswell Park Comprehensive Cancer Center, Buffalo, USA
| | - Sundar Jagannath
- Division of Hematology and Medical Oncology, Mount Sinai School of Medicine, Center of Excellence for Multiple Myeloma, New York, USA
| | - Andrew J Yee
- Department of Medicine, Harvard Medical School, Multiple Myeloma Program, Medical Oncology, Massachusetts General Hospital, Boston, USA
| | - Richard F Little
- Clinical Investigations Branch, Cancer Therapy Evaluation Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Noopur S Raje
- Department of Medicine, Harvard Medical School, Multiple Myeloma Program, Medical Oncology, Massachusetts General Hospital, Boston, USA
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14
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Yang P, Qu Y, Wang M, Chu B, Chen W, Zheng Y, Niu T, Qian Z. Pathogenesis and treatment of multiple myeloma. MedComm (Beijing) 2022; 3:e146. [PMID: 35665368 PMCID: PMC9162151 DOI: 10.1002/mco2.146] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/27/2022] [Accepted: 04/27/2022] [Indexed: 02/05/2023] Open
Abstract
Multiple myeloma (MM) is the second‐ranking malignancy in hematological tumors. The pathogenesis of MM is complex with high heterogeneity, and the development of the disease is a multistep process. Chromosomal translocations, aneuploidy, genetic mutations, and epigenetic aberrations are essential in disease initiation and progression. The correlation between MM cells and the bone marrow microenvironment is associated with the survival, progression, migration, and drug resistance of MM cells. In recent decades, there has been a significant change in the paradigm for the management of MM. With the development of proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies, chimeric antigen receptor T‐cell therapies, and novel agents, the survival of MM patients has been significantly improved. In addition, nanotechnology acts as both a nanocarrier and a treatment tool for MM. The properties and responsive conditions of nanomedicine can be tailored to reach different goals. Nanomedicine with a precise targeting property has offered great potential for drug delivery and assisted in tumor immunotherapy. In this review, we summarize the pathogenesis and current treatment options of MM, then overview recent advances in nanomedicine‐based systems, aiming to provide more insights into the treatment of MM.
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Affiliation(s)
- Peipei Yang
- Department of Hematology and Institute of Hematology, State Key Laboratory of Biotherapy and Cancer Center West China Hospital Sichuan University Chengdu Sichuan China
| | - Ying Qu
- Department of Hematology and Institute of Hematology, State Key Laboratory of Biotherapy and Cancer Center West China Hospital Sichuan University Chengdu Sichuan China
| | - Mengyao Wang
- Department of Hematology and Institute of Hematology, State Key Laboratory of Biotherapy and Cancer Center West China Hospital Sichuan University Chengdu Sichuan China
| | - Bingyang Chu
- Department of Hematology and Institute of Hematology, State Key Laboratory of Biotherapy and Cancer Center West China Hospital Sichuan University Chengdu Sichuan China
| | - Wen Chen
- Department of Hematology and Institute of Hematology, State Key Laboratory of Biotherapy and Cancer Center West China Hospital Sichuan University Chengdu Sichuan China
| | - Yuhuan Zheng
- Department of Hematology and Institute of Hematology, State Key Laboratory of Biotherapy and Cancer Center West China Hospital Sichuan University Chengdu Sichuan China
| | - Ting Niu
- Department of Hematology and Institute of Hematology, State Key Laboratory of Biotherapy and Cancer Center West China Hospital Sichuan University Chengdu Sichuan China
| | - Zhiyong Qian
- Department of Hematology and Institute of Hematology, State Key Laboratory of Biotherapy and Cancer Center West China Hospital Sichuan University Chengdu Sichuan China
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15
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Fotiou D, Gavriatopoulou M, Terpos E, Dimopoulos MA. Pomalidomide- and dexamethasone-based regimens in the treatment of refractory/relapsed multiple myeloma. Ther Adv Hematol 2022; 13:20406207221090089. [PMID: 35585966 PMCID: PMC9109494 DOI: 10.1177/20406207221090089] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/09/2022] [Indexed: 11/17/2022] Open
Abstract
Pomalidomide is a potent immunomodulatory agent that is currently a standard of care backbone for the treatment of multiple myeloma (MM) patients in the relapsed/refractory setting after exposure to lenalidomide and a proteasome inhibitor. The present review addresses current knowledge regarding the clinical use of pomalidomide in relapsed myeloma patients. Pomalidomide has direct myeloma cell tumoricidal effects by activating proteasomal degradation of Ikaros and Aiolos transcription factors and also indirect effects by modulation of immune responses, interaction with bone marrow stromal cells, and inhibition of angiogenesis. It is approved by regulatory authorities as doublet combination with dexamethasone but four more triplets are also approved for this setting. Many ongoing trials are evaluating the pomalidomide-dexamethasone backbone with newer anti-myeloma class agents or in quadruplet combinations. Pomalidomide-dexamethasone is currently one of the powerful tools available for use in the relapsed/refractory MM setting. Insights into the synergistic immunomodulatory effects of pomalidomide and other anti-myeloma agents and the mechanisms that overcome clonal resistance will potentially allow targeted use of triplet combinations at each relapse.
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Affiliation(s)
- Despina Fotiou
- Department of Clinical Therapeutics, National
and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National
and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National
and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A. Dimopoulos
- Alexandra Hospital, Department of Clinical
Therapeutics, National and Kapodistrian University of Athens, Vas. Sofias 80
and Lourou 4, 11528, Athens, Greece
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16
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Kumar S, Sharma A, Malik PS, Gogia A, Pathak N, Sahoo RK, Gupta R, Prasad CP, Kumar L. Bendamustine in combination with pomalidomide and dexamethasone in relapsed/refractory multiple myeloma: A phase II trial. Br J Haematol 2022; 198:288-297. [PMID: 35499209 DOI: 10.1111/bjh.18200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/22/2022] [Accepted: 03/25/2022] [Indexed: 11/28/2022]
Abstract
Treatment of patients with resistant/refractory multiple myeloma (MM) is an unmet need. In this phase II study, we evaluated the role of bendamustine, pomalidomide and dexamethasone combination in this setting. Between February 2020 and December 2021, 28 patients were recruited. Patients received bendamustine 120 mg/m2 day 1, pomalidomide 3 mg days 1-21, and dexamethasone 40 mg days 1, 8, 11, 22, regimen given for a maximum of six cycles. The median (range) age of the patients was 54 (30-76) years and 15 (53.6%) were males. Patients had received a median (range) of three (two-six) prior lines and 85.7% were refractory to both lenalidomide and bortezomib. The primary end-point was the overall response rate (ORR) defined as ≥partial response after at least three cycles. Secondary objectives were toxicity, progression-free survival (PFS), time to progression and overall survival (OS). An intent-to-treat analysis was done. An ORR of 57.6% was achieved. Patients with extramedullary myeloma had a better response rate. At a median follow-up of 8.6 months, the median PFS and OS were 6.2 and 9.7 months respectively. Toxicity was manageable; mainly haematological (neutropenia, 46.4%; anaemia, 42.8%; and thrombocytopenia, 7.1%). Bendamustine, pomalidomide and dexamethasone could be a novel combination for the heavily pretreated, lenalidomide-refractory myeloma population.
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Affiliation(s)
- Sudhir Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Prabhat Singh Malik
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Gogia
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Pathak
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ranjit Kumar Sahoo
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ritu Gupta
- Department of Lab Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Chandra Prakash Prasad
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
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17
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Vekemans MC, Doyen C, Caers J, Wu K, Kentos A, Mineur P, Michaux L, Delforge M, Meuleman N. Recommendations on the management of multiple myeloma in 2020. Acta Clin Belg 2022; 77:445-461. [PMID: 33355041 DOI: 10.1080/17843286.2020.1860411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
With the introduction of immunomodulatory drugs, proteasome inhibitors, and anti-CD38 monoclonal antibodies, major improvements have been achieved in the treatment of multiple myeloma (MM), with a significant impact on the outcome of this disease. Different treatment combinations are now in use and other therapies are being developed. Based on an extensive review of the recent literature, we propose practical recommendations on myeloma management, to be used by hematologists as a reference for daily practice.
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Affiliation(s)
| | - Chantal Doyen
- Centre Hospitalier Universitaire de Namur, UCL, Yvoir, Belgium
| | - Jo Caers
- Centre Hospitalier Universitaire de Liège, Ulg, Liège, Belgium
| | - Kalung Wu
- Zienkenhuis Netwerk Antwerpen, Antwerp, Belgium
| | | | | | - Lucienne Michaux
- Universitair Ziekenhuis Leuven Gasthuisberg, KUL, Leuven, Belgium
| | - Michel Delforge
- Universitair Ziekenhuis Leuven Gasthuisberg, KUL, Leuven, Belgium
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18
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Pomalidomide in Patients With Relapsed and/or Refractory Multiple Myeloma: A Prospective Study Within the Nationwide Netherlands Cancer Registry. Hemasphere 2022; 6:e683. [PMID: 35106452 PMCID: PMC8797586 DOI: 10.1097/hs9.0000000000000683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 01/06/2022] [Indexed: 11/26/2022] Open
Abstract
Patients with relapsed and/or refractory multiple myeloma (RRMM) generally have limited treatment options and a poor prognosis. Previous trials demonstrated that pomalidomide combined with low-dose dexamethasone (Pd) is effective in these patients with significant responses and improved progression-free survival (PFS). Pd has been approved in RRMM patients who received ≥2 prior lines of therapy. Here, we present the results of a population-based study of patients with RRMM treated with Pd in The Netherlands from time of pomalidomide approval. Using the nationwide Netherlands Cancer Registry, data from all nontrial patients with RRMM treated with Pd were collected. Data were analyzed of response, PFS, and overall survival (OS). A total of 237 patients were included in this analysis. Previous treatment consisted of a proteasome inhibitor in 227 patients (96%) and/or an immune-modulating agent in 235 patients (99%). One hundred forty patients (59%) were refractory to an immune-modulating agent in their last line of therapy. Median time from diagnosis to treatment with Pd was 4.9 years (interquartile range, 2.7–7.9), and the median number of prior treatments was 4 (interquartile range, 3–5). Median PFS and OS for all patients were 3.6 months (95% confidence interval [CI], 3.1–3.8) and 7.7 months (95% CI, 5.7–9.7), respectively. For patients achieving ≥PR, median PFS and OS were 10.6 months (95% CI, 8.3–12.9) and 16.3 months (95% CI, 13.6–23.2), respectively. This nationwide, population-based registry study confirms data shown in pivotal clinical trials on Pd. PFS in this analysis is comparable to PFS observed in those clinical trials.
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19
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Park H, Byun JM, Yoon SS, Koh Y, Yoon SW, Shin DY, Hong J, Kim I. Cyclophosphamide addition to pomalidomide/dexamethasone is not necessarily associated with universal benefits in RRMM. PLoS One 2022; 17:e0260113. [PMID: 35085238 PMCID: PMC8794080 DOI: 10.1371/journal.pone.0260113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 11/02/2021] [Indexed: 11/18/2022] Open
Abstract
In the backdrop of rapidly changing relapsed/refractory (RR) multiple myeloma (MM) treatment schema that mainly evolves around immunotherapies, it is easy to disregard more traditional drugs. Finding the best partner for pomalidomide, a potent third-generation immunomodulatory drug, is an important agenda we face as a community and cyclophosphamide addition has been used for outcomes augmentation. We carried out this real-world study to identify patients who will show durable response to pomalidomide and those who will benefit from cyclophosphamide addition. A total of 103 patients (57 in pomalidomide-dexamethasone [Pd] group versus 46 in pomalidomide-cyclophosphamide-dexamethasone [PCd]) were studied. They were previously treated with bortezomib (98.1%) or lenalidomide (100%) and previous lines of therapy were median 3 lines. Significantly better overall response rate (ORR) was seen in the PCd (75.6%) than Pd (41.7%) group (p = 0.001), but no differences in survival outcomes. Subgroup analysis revealed that high-risk myeloma features, poor response to lenalidomide or bortezomib had superior ORRs when cyclophosphamide was added. Also, long-term responders for pomalidomide were associated with excellent response to previous IMiD treatments. Pomalidomide-based therapy was discontinued in five patients due to intolerance or adverse events, but there was no mortality during treatment. In conclusion, we showed that pomalidomide-based treatment is still relevant and can ensure durable response in RRMM setting, especially for patients who responded well to previous lenalidomide. Addition of cyclophosphamide to Pd is associated with better ORR, and can be positively considered in fit patients with high-risk MM, extramedullary disease, and less-than-satisfactory response to previous lenalidomide treatment.
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Affiliation(s)
- Hyunkyung Park
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Center for Medical Innovation, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
- * E-mail: (SSY); (YK)
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- * E-mail: (SSY); (YK)
| | - Sock-Won Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong-Yeop Shin
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Center for Medical Innovation, Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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20
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Abstract
Despite recent advances multiple myeloma remains an incurable disease for most of the patients and initial remission will be followed by relapses requiring therapy. For many, there will be several remissions and relapses until resistance develops to all available therapies. With the introduction of several new agents, myeloma treatment has changed drastically and there are new options for the management of relapsed or refractory disease, including new drug classes with distinct mechanisms of action and cellular therapies. However, resistance to major drug classes used in first line remain the most critical factor for the choice of treatment at relapse. Continuous lenalidomide-based therapy is used extensively at first line and resistance to lenalidomide has become the key factor for the choice of salvage therapy. Daratumumab is increasingly used in first line and soon patients that relapse while on daratumumab will become a common challenge. Three-drug regimens are standard approach to manage relapsed disease. Adding drugs with new mechanisms of activity can improves outcomes and overcomes class resistance but, until now, while the biology is important, can offer only limited guidance for the choice of therapy.
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21
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Xia R, Cheng Y, Han X, Wei Y, Wei X. Ikaros Proteins in Tumor: Current Perspectives and New Developments. Front Mol Biosci 2021; 8:788440. [PMID: 34950704 PMCID: PMC8689071 DOI: 10.3389/fmolb.2021.788440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 11/09/2021] [Indexed: 02/05/2023] Open
Abstract
Ikaros is a zinc finger transcription factor (TF) of the Krüppel family member, which significantly regulates normal lymphopoiesis and tumorigenesis. Ikaros can directly initiate or suppress tumor suppressors or oncogenes, consequently regulating the survival and proliferation of cancer cells. Over recent decades, a series of studies have been devoted to exploring and clarifying the relationship between Ikaros and associated tumors. Therapeutic strategies targeting Ikaros have shown promising therapeutic effects in both pre-clinical and clinical trials. Nevertheless, the increasingly prominent problem of drug resistance targeted to Ikaros and its analog is gradually appearing in our field of vision. This article reviews the role of Ikaros in tumorigenesis, the mechanism of drug resistance, the progress of targeting Ikaros in both pre-clinical and clinical trials, and the potential use of associated therapy in cancer therapy.
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Affiliation(s)
- Ruolan Xia
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan Cheng
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Xuejiao Han
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Yuquan Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
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22
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Voorhees PM, Suman VJ, Tuchman SA, Laubach JP, Hassoun H, Efebera YA, Mulkey F, Bova-Solem M, Santo K, Carlisle D, McCarthy PL, Richardson PG. A phase I/II study of ixazomib, pomalidomide, and dexamethasone for lenalidomide and proteasome inhibitor refractory multiple myeloma (Alliance A061202). Am J Hematol 2021; 96:1595-1603. [PMID: 34559902 PMCID: PMC8713771 DOI: 10.1002/ajh.26361] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/10/2021] [Accepted: 09/11/2021] [Indexed: 12/14/2022]
Abstract
Preclinical studies have demonstrated activity of the oral proteasome inhibitor (PI) ixazomib (IXA) in bortezomib-resistant multiple myeloma (MM) and synergy with immunomodulatory drugs. We therefore conducted a phase I/II study to establish the safety and preliminary efficacy of IXA with pomalidomide (POM) and dexamethasone (DEX) in lenalidomide (LEN)/PI-refractory MM. Dose escalation established a 4 mg dose of POM and IXA and 20/40 mg dose of DEX as the maximum tolerated dose. The phase II portion of the trial was redesigned and started anew after six patients had been randomized to IXA-POM-DEX due to a rapidly changing treatment landscape. Among the 29 evaluable LEN/PI-refractory patients treated with IXA-POM-DEX in phase I/II, the overall response rate (partial response or better) was 51.7% with a median duration of response of 16.8 months (range 56 days to 4.1 years), median progression-free survival of 4.4 months (95% confidence interval [CI]: 3.0-18.4), and median overall survival of 34.3 months (95% CI: 19.2 to not reached). Hematologic, gastrointestinal, and constitutional adverse events were common and consistent with the side-effect profiles of the individual agents. Our results support further evaluation of this all-oral regimen in relapsed/refractory MM.
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Affiliation(s)
- Peter M. Voorhees
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Vera J. Suman
- Alliance Statistics and Data Center, Rochester, Minnesota, USA
| | - Sascha A. Tuchman
- Division of Hematology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jacob P. Laubach
- Department of Hematology and Oncology, Dana-Farber/Partners Cancer Care, Harvard Medical School, Boston, Massachusetts, USA
| | - Hani Hassoun
- Myeloma Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan Cancer Center, New York, New York, USA
| | - Yvonne A. Efebera
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Flora Mulkey
- Alliance Statistics and Data Center, Duke University, Durham, North Carolina, USA
| | - Misty Bova-Solem
- Alliance for Clinical Trials in Oncology, Protocol Operations Program, Chicago, Illinois, USA
| | - Katelyn Santo
- Alliance Statistics and Data Center, Rochester, Minnesota, USA
| | - Destin Carlisle
- Alliance for Clinical Trials in Oncology, Protocol Operations Program, Chicago, Illinois, USA
| | - Philip L. McCarthy
- Transplant and Cellular Therapy Program, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Paul G. Richardson
- Division of Hematology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA,Department of Hematology and Oncology, Dana-Farber/Partners Cancer Care, Harvard Medical School, Boston, Massachusetts, USA
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Advances in the Treatment of Relapsed and Refractory Multiple Myeloma in Patients with Renal Insufficiency: Novel Agents, Immunotherapies and Beyond. Cancers (Basel) 2021; 13:cancers13205036. [PMID: 34680184 PMCID: PMC8533858 DOI: 10.3390/cancers13205036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/19/2021] [Accepted: 09/29/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Renal insufficiency is one of the most frequent complications in multiple myeloma. The incidence of renal insufficiency in patients with multiple myeloma ranges from 20% to 50%. Renal impairment in patients with multiple myeloma results primarily from the toxic effects of monoclonal light chains on the kidneys. Dehydration, hypercalcemia, hyperuricemia, the application of nephrotoxic NSARs, antibiotics, contrast agents, etc., all play a major role in the deterioration of renal function in patients with multiple myeloma. The diagnosis and treatment of these patients use an interdisciplinary approach in consultation with hematologist-oncologists, radiologists, nephrologists and intensive care specialists. Using new drugs in the treatment of patients with refractory/relapsed multiple myeloma and renal insufficiency markedly improves progression-free survival and overall survival in these patients. CONCLUSIONS New drugs have helped to widen the treatment options available for patients with renal impairment and refractory/relapsed multiple myeloma, since dose adjustments are unnecessary with carfilzomib as well as with panobinostat, elotuzumab, pomalidomide or daratumumab in patients with renal impairment. Several new substances for the treatment of refractory/relapsed multiple myeloma have been approved in the meantime, including belantamab mafodotin, selinexor, melflufen, venetoclax, CAR T-cell therapy and checkpoint inhibitors. Ongoing studies are investigating their administration in patients with renal impairment.
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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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Gay F, Günther A, Offidani M, Engelhardt M, Salvini M, Montefusco V, Patriarca F, Aquino S, Pönisch W, Spada S, Schub N, Gentili S, Wäsch R, Corradini P, Straka C, Palumbo A, Einsele H, Boccadoro M, Sonneveld P, Gramatzki M. Carfilzomib, bendamustine, and dexamethasone in patients with advanced multiple myeloma: The EMN09 phase 1/2 study of the European Myeloma Network. Cancer 2021; 127:3413-3421. [PMID: 34181755 DOI: 10.1002/cncr.33647] [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: 03/22/2021] [Accepted: 04/16/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Combined therapy with carfilzomib, bendamustine, and dexamethasone was evaluated in this multicenter phase 1/2 trial conducted within the European Myeloma Network (EMN09 trial). METHODS Sixty-three patients with relapsed/refractory multiple myeloma who had received ≥2 lines of prior therapy were included. The phase 1 portion of the study determined the maximum tolerated dose of carfilzomib with bendamustine set at 70 mg/m2 on days 1 and 8. After 8 cycles, responding patients received maintenance therapy with carfilzomib and dexamethasone until progression. RESULTS On the basis of the phase 1 results, the recommended phase 2 dose for carfilzomib was 27 mg/m2 twice weekly in weeks 1, 2, and 3. Fifty-two percent of patients achieved a partial response or better, and 32% reached a very good partial response or better. The clinical benefit rate was 93%. After a median follow-up of 21.9 months, the median progression-free survival was 11.6 months, and the median overall survival was 30.4 months. The reported grade ≥3 hematologic adverse events (AEs) were lymphopenia (29%), neutropenia (25%), and thrombocytopenia (22%). The main nonhematologic grade ≥3 AEs were pneumonia, thromboembolic events (10%), cardiac AEs (8%), and hypertension (2%). CONCLUSIONS In heavily pretreated patients who have relapsed/refractory multiple myeloma, combined carfilzomib, bendamustine, and dexamethasone is an effective treatment option administered in the outpatient setting. Infection prophylaxis and attention to patients with cardiovascular predisposition are required.
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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, Torino, Italy
| | - Andreas Günther
- Division of Stem Cell Transplantation and Immunotherapy, University of Kiel, Kiel, Germany
| | - Massimo Offidani
- Hematology Clinic, AOU Ospedali Riuniti di Ancona, Ancona, Italy
| | - Monika Engelhardt
- Department for Hematology and Oncology, University of Freiburg, Faculty of Freiburg, Freiburg, Germany
| | - Marco Salvini
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Vittorio Montefusco
- Hematology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | - Sara Aquino
- Ematologia e Centro Trapianti, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Wolfram Pönisch
- Department of Hematology, University of Leipzig, Leipzig, Germany
| | - Stefano Spada
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Natalie Schub
- Division of Stem Cell Transplantation and Immunotherapy, University of Kiel, Kiel, Germany
| | | | - Ralph Wäsch
- Department for Hematology and Oncology, University of Freiburg, Faculty of Freiburg, Freiburg, Germany
| | - Paolo Corradini
- Hematology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Christian Straka
- Department of Hematology and Oncology, Munich Clinic Schwabing, Munich, Germany
| | - Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Hermann Einsele
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero Universitaria Città della Salute e della Scienza, Torino, Italy
| | - Pieter Sonneveld
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Martin Gramatzki
- Division of Stem Cell Transplantation and Immunotherapy, University of Kiel, Kiel, Germany
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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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27
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Rodriguez-Otero P, Sirvent M, González-Rodríguez AP, Lavilla E, de Coca AG, Arguiñano JM, Martí JM, Cabañas V, Motlló C, de Cabo E, Encinas C, Murillo I, Hernández-Rivas JÁ, Pérez-Persona E, Casado F, Sampol A, García R, Blanchard MJ, Anguita M, Lafuente AP, Iñigo B, López A, Ribas P, Arnao M, Maldonado R, Bladé J, Mateos MV, Lahuerta JJ, San Miguel JF. Pomalidomide, Cyclophosphamide, and Dexamethasone for the Treatment of Relapsed/Refractory Multiple Myeloma: Real-World Analysis of the Pethema-GEM Experience. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:413-420. [PMID: 33741302 DOI: 10.1016/j.clml.2021.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/02/2021] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Treatment of relapsed/refractory multiple myeloma (RRMM) is highly challenging, especially for patients with disease refractory to initial therapy, and in particular for disease developing refractoriness to lenalidomide. Indeed, with currently approved treatments, median progression-free survival (PFS) in the lenalidomide-refractory setting is less than 10 months, reflecting the difficulty in treating this patient population. Pomalidomide is a second-generation immunomodulatory drug that has shown activity in lenalidomide-refractory disease in the setting of different combinations. PATIENTS AND METHODS A real-world study was conducted by the Spanish Myeloma group in a cohort of patients with RRMM treated with pomalidomide, cyclophosphamide, and dexamethasone (PomCiDex). One hundred patients were treated with a median of 3 prior lines of therapy. RESULTS Overall response rate was 39%, with a clinical benefit rate of 93%. Median PFS was 7.6 months; median overall survival (OS) was 12.6 months. Median PFS and OS survival were consistent across the different subgroups analyzed. Prolonged PFS and OS were found in patients with responsive disease. CONCLUSION Our results compared favorably with those obtained with different pomalidomide-based combinations in a similar patient population. PomCiDex remains a manageable, cost-effective, and all-oral triplet combination for RRMM patients.
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Affiliation(s)
| | - Maialen Sirvent
- Department of Hematology, Hospital Donostia, San Sebastian, Spain
| | | | | | - Alfonso García de Coca
- Department of Hematology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Josep M Martí
- Department of Hematology, Hospital Universitari Mutua Terrassa, Terrassa, Spain
| | - Valentin Cabañas
- Department of Hematology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Cristina Motlló
- Department of Hematology, Hospital de Sant Joan de Déu, Fundació Althaia, Manresa, Spain
| | - Erik de Cabo
- Department of Hematology, Hospital de El Bierzo, León, Spain
| | - Cristina Encinas
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ilda Murillo
- Department of Hematology, Hospital General San Jorge, Huesca, Spain
| | | | | | - Felipe Casado
- Department of Hematology, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Antonia Sampol
- Department of Hematology, Hospital Universitario Son Espases, Mallorca, Spain
| | - Ricarda García
- Department of Hematology, Complejo Hospitalario de Especialidades Virgen de la Victoria, Málaga, Spain
| | | | | | | | - Belén Iñigo
- Department of Hematology, Hospital Clinico San Carlos, Madrid, Spain
| | - Aurelio López
- Department of Hematology, Hospital Arnau de Vilanova, Lleida, Spain
| | - Paz Ribas
- Department of Hematology, Hospital Universitario Dr Peset Aleixandre, Valencia, Spain
| | - Mario Arnao
- Department of Hematology, Hospital Universitario La Fe, Valencia, Spain
| | | | - Joan Bladé
- Department of Hematology, Hospital Clinic de Barcelona, IDIBAPS, Barcelona, Spain
| | | | - Juan José Lahuerta
- Department of Hematology, Hospital Universitario 12 de octubre, Madrid, Spain
| | - Jesús F San Miguel
- Department of Hematology, Clínica Universidad de Navarra, Pamplona, Spain
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Treatment of relapsed and refractory multiple myeloma: recommendations from the International Myeloma Working Group. Lancet Oncol 2021; 22:e105-e118. [PMID: 33662288 DOI: 10.1016/s1470-2045(20)30756-7] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/07/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022]
Abstract
This Policy Review presents the International Myeloma Working Group's clinical practice recommendations for the treatment of relapsed and refractory multiple myeloma. Based on the results of phase 2 and phase 3 trials, these recommendations are proposed for the treatment of patients with relapsed and refractory disease who have received one previous line of therapy, and for patients with relapsed and refractory multiple myeloma who have received two or more previous lines of therapy. These recommendations integrate the issue of drug access in both low-income and middle-income countries and in high-income countries to help guide real-world practice and thus improve patient outcomes.
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Richter J, Anupindi VR, Yeaw J, Kudaravalli S, Zavisic S, Shah D. Real-world treatment patterns in relapsed/refractory multiple myeloma: Clinical and economic outcomes in patients treated with pomalidomide or daratumumab. J Oncol Pharm Pract 2021; 28:395-409. [PMID: 33611973 DOI: 10.1177/1078155221995532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Real-world evidence on later line treatment of relapsed/refractory multiple myeloma (RRMM) is sparse. We evaluated clinical outcomes among RRMM patients in the 1-year following treatment with pomalidomide or daratumumab and compared economic outcomes between RRMM patients and non-MM patients. PATIENT AND METHODS Adult patients with ≥1 claim of pomalidomide or daratumumab were identified between January 2012 and February 2018 using IQVIA PharMetrics® Plus US claims database. Patients were required to have a diagnosis or treatment for MM and a claim of any immunomodulatory drugs and proteasome inhibitors before the index date. Mean time to new therapy, overall survival (OS) using Kaplan-Meier curve and adverse events (AEs) were reported over the 1-year post-index period. RRMM patients were also matched to a non-MM comparator cohort and economic outcomes were compared between the two cohorts. RESULTS 289 RRMM patients were matched to 1,445 patients without MM. Most prevalent hematological AE was anemia (72.0%) and non-hematological AE was infections (75.4%). Mean (SD) time to a new treatment was 4.7 (5.3) months and median OS was 14.6 months. RRMM patients had significantly higher hospitalizations and physician office visits (Both P < .0001) compared to non-MM patients. Adjusting for baseline characteristics, patients with RRMM had 4.9 times (95% CI 3.8-6.4, P < .0001) the total healthcare costs compared with patients without MM. The major driver of total costs among RRMM patients was pharmacy costs (67.3%). CONCLUSION RRMM patients showed a high frequency of AEs, low OS, and a substantial economic burden suggesting need for effective treatment options.
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Affiliation(s)
- Joshua Richter
- Tisch Cancer institute at Mount Sinai Medical Center, New York, NY, USA
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30
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Improving outcomes for patients with relapsed multiple myeloma: Challenges and considerations of current and emerging treatment options. Blood Rev 2021; 49:100808. [PMID: 33863601 DOI: 10.1016/j.blre.2021.100808] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/22/2020] [Accepted: 01/29/2021] [Indexed: 01/23/2023]
Abstract
Despite the recent introduction of new therapies for multiple myeloma (MM), it remains an incurable disease. As MM progresses, patients experience cycles of relapse and remission, with remission periods becoming increasingly shorter as the disease becomes less treatment-sensitive. The treatment of relapsed refractory MM (RRMM) remains a significant clinical challenge. Patients with RRMM are a highly heterogeneous group and choosing the most appropriate treatment requires careful consideration. Furthermore, the number of treatment options for MM is continually growing with no definitive consensus to guide treating clinicians. The emergence of second-generation proteasome inhibitors (e.g., carfilzomib and ixazomib), immunomodulatory drugs (e.g., pomalidomide) and monoclonal antibodies (e.g., isatuximab) has expanded an already complex treatment landscape. This review provides a clear summary of the available treatments for MM and discusses how to tailor treatments to individual patients' needs. Novel treatments currently under clinical development, including venetoclax, melflufen and CAR T-cell therapies, are also discussed.
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31
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Branagan A, Lei M, Lou U, Raje N. Current Treatment Strategies for Multiple Myeloma. JCO Oncol Pract 2021; 16:5-14. [PMID: 32039665 DOI: 10.1200/jop.19.00244] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The treatment of multiple myeloma (MM) continues to evolve with the approval of numerous agents over the past decade. Advances in treatment have led to the incorporation of these newer therapies into the treatment paradigm, with improvements in overall survival and the possibility of deep responses including a minimal residual disease-negative state. The strategy of triplet therapies for patients with newly diagnosed MM, followed by high-dose chemotherapy and autologous stem-cell transplantation for eligible patients, and subsequently consolidation and maintenance therapy, is the current treatment roadmap for patients. However, patients with MM will ultimately develop refractoriness to antimyeloma therapies. In this article, we summarize our current practice of managing patients with MM. We highlight our approach to patients with newly diagnosed MM who are transplantation eligible and ineligible and highlight risk-adapted strategies for these patients. In addition, we discuss our approach to the management of patients with relapsed or refractory MM. Last, we review standard therapies and emerging strategies such as targeted approaches, immune-based therapies, and drugs with novel mechanisms of action. Trials evaluating chimeric antigen receptor T cells targeting B-cell maturation antigen are ongoing and are only one of several novel approaches targeting cell maturation antigen, which include the use of bispecific T-cell engager antibodies and antibody drug conjugates. Emerging therapies offer the promise of more individualized approaches in the management of patients with MM and ultimately may result in the possibility of being one step closer to curing patients with MM.
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Affiliation(s)
| | - Matthew Lei
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Uvette Lou
- Massachusetts General Hospital Cancer Center, Boston, MA
| | - Noopur Raje
- Massachusetts General Hospital Cancer Center, Boston, MA
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Abstract
Multiple myeloma is the second most common haematological malignancy in high-income countries, and typically starts as asymptomatic precursor conditions-either monoclonal gammopathy of undetermined significance or smouldering multiple myeloma-in which initiating genetic abnormalities, such as hyperdiploidy and translocations involving the immunoglobulin heavy chain, are already present. The introduction of immunomodulatory drugs, proteasome inhibitors, and CD38-targeting antibodies has extended survival, but ultimately the majority of patients will die from their disease, and some from treatment-related complications. Disease progression and subsequent relapses are characterised by subclonal evolution and increasingly resistant disease. Patients with multiple myeloma usually have hypercalcaemia, renal failure, anaemia, or osteolytic bone lesions-and a detailed diagnostic investigation is needed to differentiate between symptomatic multiple myeloma that requires treatment, and precursor states. Risk stratification using both patient-specific (eg, performance status) and disease-specific (eg, presence of high-risk cytogenetic abnormalities) is important for prognosis and to define the best treatment strategy. Current research strategies include the use of minimal residual disease assays to guide therapy, refining immunotherapeutic approaches, and intercepting disease early in smouldering multiple myeloma.
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Affiliation(s)
- Niels W C J van de Donk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Hematology, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Charlotte Pawlyn
- The Institute of Cancer Research, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Kwee L Yong
- University College London Cancer Institute, London, UK.
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33
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van de Donk NWCJ. Sequencing multiple myeloma therapies with and after antibody therapies. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:248-258. [PMID: 33275724 PMCID: PMC7727523 DOI: 10.1182/hematology.2020000109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In multiple myeloma (MM), treatment selection and sequencing become increasingly complex with the increasing number of therapeutic options, including antibodies. Choice of treatment is dependent on various factors including patient- and tumor-related features. In addition, treatment-related factors, such as type and response to prior therapy, are also critical in terms of the selection of a new treatment regimen. Furthermore, approval status and reimbursement policies influence treatment choice. At the time of first relapse, patients who received a bortezomib-based regimen can switch to lenalidomide-based treatment, whereas patients who received lenalidomide until progression can switch to a proteasome inhibitor-based therapy. Alternatively, there is increasing evidence that pomalidomide-based triplets are also effective following the development of lenalidomide-refractory disease both in early and later relapse settings. Patients who become refractory to immunomodulatory drugs, proteasome inhibitors, and CD38 antibodies have a poor prognosis. These triple-class refractory patients may benefit from novel, recently approved agents such as XPO1 inhibitors or from participation in a clinical trial. Furthermore, retreatment with agents that were received in previous lines of therapy can also be considered in heavily pretreated patients, for example, in combination with classic cytotoxic drugs. Importantly, with the increasing use of CD38 antibodies in newly diagnosed and early relapsed/refractory MM, more information is needed on the potential value of retreatment with CD38 antibodies. With the introduction of new immunotherapies with novel modes of action, we also need a better understanding of sequencing of immunotherapeutic agents by taking into account the effect of prior therapy on immune function.
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Affiliation(s)
- Niels W C J van de Donk
- Department of Hematology, Cancer Center Amsterdam, Vrije Universiteit Amsterdam, Amsterdam University Medical Centers (UMC), Amsterdam, The Netherlands
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34
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Yang Y, Li Y, Gu H, Dong M, Cai Z. Emerging agents and regimens for multiple myeloma. J Hematol Oncol 2020; 13:150. [PMID: 33168044 PMCID: PMC7654052 DOI: 10.1186/s13045-020-00980-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/19/2020] [Indexed: 02/08/2023] Open
Abstract
The outcomes of multiple myeloma (MM) have been improved significantly with the therapies incorporating proteasome inhibitors (PI), immunomodulatory drugs, monoclonal antibodies (MoAb) and stem cell transplantation. However, relapsed and refractory MM (RRMM) remains a major challenge. Novel agents and regimens are under active clinical development. These include new PIs such as ixazomib, marizomib, and oprozomib; new MoAbs such as isatuximab and MOR202; novel epigenetic agent ricolinostat and novel cytokines such as siltuximab. Recently, the first XPO-1 inhibitor, selinexor, was approved for RRMM. BCMA-targeted BiTE, antibody-drug conjugates and CAR-T cells have the potential to revolutionize the therapy for RRMM. In this review, we summarized the latest clinical development of these novel agents and regimens.
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Affiliation(s)
- Yang Yang
- Bone Marrow Transplantation Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yi Li
- Bone Marrow Transplantation Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huiyao Gu
- Bone Marrow Transplantation Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Mengmeng Dong
- Bone Marrow Transplantation Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zhen Cai
- Bone Marrow Transplantation Center, Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
- Institute of Hematology, Zhejiang University, Hangzhou, Zhejiang, China.
- Zhejiang Laboratory for Systems and Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang, China.
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35
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Bonello F, Boccadoro M, Larocca A. Diagnostic and Therapeutic Challenges in the Management of Intermediate and Frail Elderly Multiple Myeloma Patients. Cancers (Basel) 2020; 12:E3106. [PMID: 33114320 PMCID: PMC7690866 DOI: 10.3390/cancers12113106] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022] Open
Abstract
Multiple myeloma (MM) mostly affects elderly patients, which represent a highly heterogeneous population. Indeed, comorbidities, frailty status and functional reserve may vary considerably among patients with similar chronological age. For this reason, the choice of treatment goals and intensity is particularly challenging in elderly patients, and it requires a multidimensional evaluation of the patients and the disease. In recent years, different tools to detect patient frailty have been developed, and the International Myeloma Working Group frailty score currently represents the gold standard. It identifies intermediate-fit and frail patients requiring gentler treatment approaches compared to fit patients, aiming to preserve quality of life and prevent toxicities. This subset of patients is underrepresented in clinical trials, and studies exploring frailty-adapted approaches are scarce, making the choice of therapy extremely challenging. Treatment options for intermediate-fit and frail patients might include dose-adapted combinations, doublets, and less toxic combinations based on novel agents. This review analyzes the available tools for the assessment of frailty and possible strategies to improve the discriminative power of the scores and expand their use in real-life and clinical trial settings. Moreover, it addresses the main therapeutic challenges in the management of intermediate-fit and frail MM patients at diagnosis and at relapse.
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Affiliation(s)
| | | | - Alessandra Larocca
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy; (F.B.); (M.B.)
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Impact of last lenalidomide dose, duration, and IMiD-free interval in patients with myeloma treated with pomalidomide/dexamethasone. Blood Adv 2020; 3:4095-4103. [PMID: 31821457 DOI: 10.1182/bloodadvances.2019000539] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/04/2019] [Indexed: 12/11/2022] Open
Abstract
To gain insights into the characteristics of clinical resistance to lenalidomide, we evaluated the outcomes of 147 consecutive patients with multiple myeloma (MM) homogeneously treated with immunomodulatory imide drugs (IMiDs) pomalidomide and dexamethasone (Pd) for relapsed and/or refractory MM (median, 3 prior lines of treatment). We focused our analysis on the effect of the lenalidomide dose at which resistance was developed, the duration of lenalidomide exposure, and lenalidomide-free interval. On intent to treat, 33% of patients achieved ≥partial remission (PR) with Pd. When Pd was given immediately after lenalidomide, ≥PR was 32% (vs 37% after bortezomib). The response rates were similar for patients that received 5 to 15 mg vs 25 mg of lenalidomide (38.5% vs 30.5%, P = .329). Response rates were higher for patients that had received at least 12 months of lenalidomide (44% vs 27%) and for those with ≥18 months from last lenalidomide dose to pomalidomide dose (65% vs 23%). Median progression-free survival (PFS) and overall survival (OS) were 5 and 12.1 months, respectively, which was similar for patients who received lenalidomide, bortezomib or other regimens just before Pd and similar for patients who were receiving different doses of lenalidomide. IMiD-free interval ≥18 months was associated with longer PFS (10.3 vs 3.9 months, P = .003) and OS (27.1 vs 9.3, P = .008) as well as duration of last lenalidomide therapy ≥12 months (PFS: 7.8 vs 3.2, P = .023; OS: 16.5 vs 7.9, P = .005) even after adjustment for the number of prior therapies, duration of disease, and last lenalidomide dose.
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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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Sanchez L, Barley K, Richter J, Franz J, Cho HJ, Jagannath S, Madduri D, Parekh S, Richard S, Chari A. Immunomodulatory drug- and proteasome inhibitor-backbone regimens in the treatment of relapsed multiple myeloma: an evidence-based review. Expert Rev Hematol 2020; 13:943-958. [DOI: 10.1080/17474086.2020.1804356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Larysa Sanchez
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kevin Barley
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua Richter
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joseph Franz
- Department of Internal Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hearn Jay Cho
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sundar Jagannath
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepu Madduri
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samir Parekh
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shambavi Richard
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajai Chari
- Multiple Myeloma Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Van Oekelen O, Parekh S, Cho HJ, Vishnuvardhan N, Madduri D, Richter J, Ip C, Lau K, Florendo E, Mancia IS, Thomas J, Verina D, Chan E, Zarychta K, La L, Strumolo G, Melnekoff DT, Leshchenko VV, Kim-Schulze S, Couto S, Wang M, Pierceall WE, Thakurta A, Laganà A, Jagannath S, Chari A. A phase II study of pomalidomide, daily oral cyclophosphamide, and dexamethasone in relapsed/refractory multiple myeloma. Leuk Lymphoma 2020; 61:2208-2215. [DOI: 10.1080/10428194.2020.1805111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | - Samir Parekh
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hearn J. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Deepu Madduri
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua Richter
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chun Ip
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kenneth Lau
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Erika Florendo
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ines S. Mancia
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joanne Thomas
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel Verina
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elaine Chan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Lisa La
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gina Strumolo
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Suzana Couto
- Celgene Corporation, Translational Development and Diagnostics, Summit, NJ, USA
| | - Maria Wang
- Celgene Corporation, Translational Development and Diagnostics, Summit, NJ, USA
| | | | - Anjan Thakurta
- Celgene Corporation, Translational Development and Diagnostics, Summit, NJ, USA
| | | | | | - Ajai Chari
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Lee JH, Kim SH. Treatment of relapsed and refractory multiple myeloma. Blood Res 2020; 55:S43-S53. [PMID: 32719176 PMCID: PMC7386890 DOI: 10.5045/br.2020.s008] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 01/23/2023] Open
Abstract
The therapeutic strategy for relapsed and refractory multiple myeloma (RRMM) integrates a holistic approach regarding patient, disease, and drug-related factors. Patient-related factors include age, frailty status, and underlying comorbidities, especially cardiovascular and renal diseases and peripheral neuropathies that affect tolerability to multiple drug combinations or transplantations. Disease-related factors encompass these multiple patient-related factors, particularly the aggressiveness of the disease and cytogenetics. Regarding drug-related factors, the approval of novel proteasome inhibitors (such as carfilzomib and ixazomib), immunomodulatory agents (such as pomalidomide), monoclonal antibodies (such as daratumumab and elotuzumab), and new classes of drugs increasingly makes the choice treatment more complex and necessitates a comprehensive summary and an update of the efficacy and toxicities of each antimyeloma drug and its combinations. Further, careful monitoring of the side effects and supportive care throughout the course of treatment are important to achieve better outcomes for patients with RRMM.
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Affiliation(s)
- Ji Hyun Lee
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
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CyBorD-DARA is potent initial induction for MM and enhances ADCP: initial results of the 16-BCNI-001/CTRIAL-IE 16-02 study. Blood Adv 2020; 3:1815-1825. [PMID: 31201169 DOI: 10.1182/bloodadvances.2019000010] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/09/2019] [Indexed: 12/12/2022] Open
Abstract
Daratumumab (DARA) has shown impressive activity in combination with other agents for the treatment of multiple myeloma (MM). We conducted a phase 1b study to assess the safety and preliminary efficacy, as well as potential mechanisms of action, of DARA (16 mg/kg) in combination with a weekly schedule of subcutaneous bortezomib (1.3-1.5 mg/m2), cyclophosphamide (150-300 mg/m2), and dexamethasone (40 mg) (CyBorD DARA) as initial induction before autologous stem cell transplantation (ASCT). Eligible patients were ≤70 years of age with untreated MM requiring treatment and who lacked significant comorbidities. A total of 18 patients were enrolled. Their median age was 56 years (range, 32-66 years), and all patients had Eastern Cooperative Oncology Group performance status ≤1. The International Staging System stages were I, II, and III in 78%, 17%, and 6% of patients, respectively; 28% of patients had high-risk genetic features. There was no dose-limiting toxicity, and the incidence of grade 3 or 4 infection or neutropenia was <10%. On an intention-to-treat basis, 94% achieved ≥very good partial response with ≥complete response in 44% of patients. Among 14 of 15 patients who underwent ASCT and were evaluable for response, all 14 achieved at least very good partial response, with 8 (57%) of 14 achieving complete response. After ASCT, 10 (83%) of 12 patients in whom minimal residual disease analysis was possible were negative at a sensitivity of 10-5 (56% on intention-to-treat/whole study population) according to next-generation sequencing. Flow cytometry analysis of patient samples indicated CyBorD DARA induced activation of macrophage-mediated antibody-dependent cellular phagocytosis. This trial was registered at www.clinicaltrials.gov as #NCT02955810.
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Ria R, Melaccio A, Racanelli V, Vacca A. Anti-VEGF Drugs in the Treatment of Multiple Myeloma Patients. J Clin Med 2020; 9:E1765. [PMID: 32517267 PMCID: PMC7355441 DOI: 10.3390/jcm9061765] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 02/07/2023] Open
Abstract
The interaction between the bone marrow microenvironment and plasma cells plays an essential role in multiple myeloma progression and drug resistance. The vascular endothelial growth factor (VEGF)/VEGF receptor (VEGFR) pathway in vascular endothelial cells activates and promotes angiogenesis. Moreover, VEGF activates and promotes vasculogenesis and vasculogenic mimicry when it interacts with VEGF receptors expressed in precursor cells and inflammatory cells, respectively. In myeloma bone marrow, VEGF and VEGF receptor expression are upregulated and hyperactive in the stromal and tumor cells. It has been demonstrated that several antiangiogenic agents can effectively target VEGF-related pathways in the preclinical phase. However, they are not successful in treating multiple myeloma, probably due to the vicarious action of other cytokines and signaling pathways. Thus, the simultaneous blocking of multiple cytokine pathways, including the VEGF/VEGFR pathway, may represent a valid strategy to treat multiple myeloma. This review aims to summarize recent advances in understanding the role of the VEGF/VEGFR pathway in multiple myeloma, and mainly focuses on the transcription pathway and on strategies that target this pathway.
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Affiliation(s)
- Roberto Ria
- Department of Biomedical Sciences and Human Oncology, Section of Internal Medicine and Clinical Oncology, University of Bari “Aldo Moro” Medical School, 70124 Bari, Italy; (A.M.); (V.R.); (A.V.)
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Ocio EM, Motlló C, Rodríguez-Otero P, Martínez-López J, Cejalvo MJ, Martín-Sánchez J, Bladé J, García-Malo MD, Dourdil MV, García-Mateo A, de Arriba F, García-Sanz R, de la Rubia J, Oriol A, Lahuerta JJ, San-Miguel JF, Mateos MV. Filanesib in combination with pomalidomide and dexamethasone in refractory MM patients: safety and efficacy, and association with alpha 1-acid glycoprotein (AAG) levels. Phase Ib/II Pomdefil clinical trial conducted by the Spanish MM group. Br J Haematol 2020; 192:522-530. [PMID: 32501528 DOI: 10.1111/bjh.16788] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/03/2020] [Accepted: 05/04/2020] [Indexed: 01/01/2023]
Abstract
This phase I/II trial evaluated the combination of the kinesin spindle protein inhibitor filanesib with pomalidomide and dexamethasone in relapsed or refractory multiple myeloma (RRMM) patients. Forty-seven RRMM patients with a median of three prior lines (2-8) and 94% refractory to lenalidomide were included: 14 in phase I and 33 in phase II. The recommended dose was 1·25 mg/m2 of filanesib on days 1, 2, 15, 16, with pomalidomide 4 mg on days 1-21 and dexamethasone 40 mg weekly. The defined threshold for success was achieved, with 18 out of 31 patients obtaining at least minor response (MR) in the phase II. In the global population, 51% of patients achieved at least partial response (PR) and 60% ≥MR, resulting in a median progression-free survival (mPFS) of seven months and overall survival (OS) of 19 months. The main toxicity was haematological. Importantly, patients with low serum levels of alpha 1-acid glycoprotein (AAG) at baseline (<800 mg/l) had a superior response (overall response rate of 62% vs. 17%; P = 0·04), which also translated into a longer mPFS (9 vs. 2 months; P = 0·014). In summary, filanesib with pomalidomide and dexamethasone is active in RRMM although with significant haematological toxicity. Most importantly, high levels of AAG can identify patients unlikely to respond to this strategy. Trial registration: clinicaltrials.gov identifier: NCT02384083.
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Affiliation(s)
- Enrique M Ocio
- Hospital Universitario Marqués de Valdecilla (IDIVAL), Universidad de Cantabria, Santander, Spain
| | - Cristina Motlló
- ICO Badalona, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | | | - Mª José Cejalvo
- Hospital Universitario Doctor Peset. Departamento de Medicina Interna y Odontología, Universidad Católica de Valencia, Valencia, Spain
| | | | - Joan Bladé
- Hospital Clinic de Barcelona, Barcelona, Spain
| | | | | | | | | | - Ramón García-Sanz
- Complejo Asistencial Universitario de Salamanca (IBSAL) y Centro de Investigación del Cáncer (IBMCC-CSIC), Universidad de Salamanca, Salamanca, Spain
| | - Javier de la Rubia
- Hospital Universitario Doctor Peset. Departamento de Medicina Interna y Odontología, Universidad Católica de Valencia, Valencia, Spain
| | - Albert Oriol
- ICO Badalona, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | | | - María-Victoria Mateos
- Complejo Asistencial Universitario de Salamanca (IBSAL) y Centro de Investigación del Cáncer (IBMCC-CSIC), Universidad de Salamanca, Salamanca, Spain
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Ciftciler R, Goker H, Buyukasik Y, Sayınalp N, Haznedaroglu IC, Aksu S, Ozcebe O, Demiroglu H. Comparison of bortezomibcyclophosphamide- dexamethasone versus bortezomib-dexamethasone based regimens in newly diagnosed multiple myeloma patients. Hematol Rep 2020; 12:8267. [PMID: 32399162 PMCID: PMC7212206 DOI: 10.4081/hr.2020.8267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 11/18/2019] [Indexed: 11/30/2022] Open
Abstract
The treatment landscape and clinical outcome of multiple myeloma (MM) patients have changed in the last decades, with an improved median survival of 8-10 years. This study aimed to evaluate the bortezomib, cyclophosphamide and dexamethasone (VCD) regimen versus bortezomib and dexamethasone (VD) regimen in patients with newly diagnosed MM. This study has been performed in a retrospective manner. One hundred and three patients with newly diagnosed MM who received chemotherapy at our tertiary care center between the years of 2009 and 2018 were evaluated. A total of 103 patients were included. The 5-year overall survival (OS) for patients who received VD regimen and patients who received VCD regimen were 75% and 83%, respectively. The OS for VD patients was 113.1±12.5 versus 122.2±9.5 months for VCD patients with no statistically significant difference (P=0.47). The 5- year PFS (progression free survival) for patients who received VD regimen and patients who received VCD regimen were 66% and 75%, respectively. The PFS for VCD patients was higher than the PFS for VD patients (67.1±7.4 versus 97.7±13.4 months), but no statistically significant difference was observed (P=0.59). Relapse rate (P=0.002) and mortality rate (P=0.01) were higher in VD group than VCD group and they were statistically significant. The OS and PFS were clinically longer in patients receiving VCD regimen than in patients receiving VD regimen, although not statistically significant. Cyclophosphamide should be given to patients at physician discretion and depending on patient’s frailty function.
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Affiliation(s)
- Rafiye Ciftciler
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Hakan Goker
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Yahya Buyukasik
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Nilgun Sayınalp
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | | | - Salih Aksu
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Osman Ozcebe
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Haluk Demiroglu
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Beyond DNA Damage: Exploring the Immunomodulatory Effects of Cyclophosphamide in Multiple Myeloma. Hemasphere 2020; 4:e350. [PMID: 32309787 PMCID: PMC7162079 DOI: 10.1097/hs9.0000000000000350] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/30/2020] [Accepted: 02/07/2020] [Indexed: 12/22/2022] Open
Abstract
The alkylating agent cyclophosphamide has been used in the treatment of multiple myeloma for over 60 years. At low doses, cyclophosphamide also has significant immunomodulatory activity, which can be used to modify the immunosuppressive tumor microenvironment in order to augment responses to existing therapies. Immune-mediated therapies are becoming more widespread in modern approaches to myeloma treatment. In this review, we discuss the effects cyclophosphamide has on the immune system, and how it can be used synergistically with other treatment modalities including the immunomodulatory agents, monoclonal antibodies and cellular therapies.
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Lee HS, Kim K, Kim SJ, Lee J, Kim I, Kim JS, Eom H, Yoon DH, Suh C, Shin H, Mun Y, Kim MK, Lim S, Choi CW, Kang HJ, Yoon S, Min C. Pomalidomide, cyclophosphamide, and dexamethasone for elderly patients with relapsed and refractory multiple myeloma: A study of the Korean Multiple Myeloma Working Party (KMMWP-164 study). Am J Hematol 2020; 95:413-421. [PMID: 31919872 PMCID: PMC7983889 DOI: 10.1002/ajh.25726] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/21/2019] [Accepted: 01/03/2020] [Indexed: 01/17/2023]
Abstract
Patients with transplant‐ineligible relapsed and refractory multiple myeloma (RRMM) have a short life expectancy, especially when they have failed both the proteasome inhibitor and immunomodulator therapies. This study aimed to assess the efficacy and safety of pomalidomide, cyclophosphamide, and dexamethasone (PCd) in elderly patients with RRMM. This phase 2 clinical trial recruited 55 elderly patients with RRMM. The patients underwent a 28‐day treatment cycle: pomalidomide (4 mg/day on days 1‐21, administered orally) and cyclophosphamide (400 mg/day on days 1, 8, and 15; administered orally) plus dexamethasone. The median (range) age of the patients was 73.3 (64‐86) years, and 8 (14.5%) patients who were ≥ 80 years old. Eight (14.5%) and 31 (56.4%) patients exhibited stage III (revised international staging system) and frail status (simplified frailty scale), respectively. The overall response rate (ORR) and clinical benefit rate (CBR) of PCd therapy were 58.2% and 72.7%, respectively. The median PFS and median overall survival (OS) were 6.90 months (95% CI, 4.7‐9.0) and 18.48 months (95% CI, 9.4‐27.6), respectively. The incidence rate of grade ≥ 3 non‐hematological toxicities was 70.8%. In particular, the incidence rate of primary infection was 45.4%, including 21.8% for pneumonia, 9.0% for sepsis, and 14.6% for febrile neutropenia. In conclusion, PCd is an effective regimen for elderly patients with RRMM who had failed both bortezomib and lenalidomide treatments, but in whom the treatment‐associated infection is the main cause of morbidity and mortality.
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Affiliation(s)
- Ho Sup Lee
- Department of Internal Medicine Kosin University College of Medicine Busan South Korea
| | - Kihyun Kim
- Department of Medicine, Samsung Medical Center Sunkyunkwan University School of Medicine Seoul South Korea
| | - Seok Jin Kim
- Department of Medicine, Samsung Medical Center Sunkyunkwan University School of Medicine Seoul South Korea
| | - Je‐Jung Lee
- Department of Hematology‐Oncology Chonnam National University Hwasun Hospital Hwasun Jeollanam‐do South Korea
| | - Inho Kim
- Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital Yonsei University College of Medicine Seoul South Korea
| | - Hyeon‐Seok Eom
- Department of Internal Medicine National Cancer Center of Korea Goyang South Korea
| | - Dok Hyun Yoon
- Department of Oncology, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Cheolwon Suh
- Department of Oncology, Asan Medical Center University of Ulsan College of Medicine Seoul South Korea
| | - Ho‐Jin Shin
- Department of Internal Medicine Pusan National University Hospital Busan South Korea
| | - Yeung‐Chul Mun
- Department of Internal Medicine Ewha Womans University School of Medicine Seoul South Korea
| | - Min Kyoung Kim
- Department of Medicine Yeungnam University College of Medicine Daegu South Korea
| | - Sung‐Nam Lim
- Department of Internal Medicine Haeundae Baek Hospital Busan South Korea
| | - Chul Won Choi
- Division of Hematology‐oncology, Department of Internal Medicine Korea University Guro Hospital Seoul South Korea
| | - Hye Jin Kang
- Department of Hemato‐Oncology Korea Institute of Radiological and Medical Sciences Seoul South Korea
| | - Sung‐Soo Yoon
- Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Chang‐Ki Min
- Department of Internal Medicine, Seoul St. Maryʼs Hospital Catholic University of Korea Seoul South Korea
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Cope S, Toor K, Popoff E, Fonseca R, Landgren O, Mateos MV, Weisel K, Jansen JP. Critical Appraisal of Published Indirect Comparisons and Network Meta-Analyses of Competing Interventions for Multiple Myeloma. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:441-450. [PMID: 32327161 PMCID: PMC7480667 DOI: 10.1016/j.jval.2019.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 09/11/2019] [Accepted: 11/16/2019] [Indexed: 05/08/2023]
Abstract
OBJECTIVES In the field of relapsed or refractory multiple myeloma (RRMM), between-trial or indirect comparisons are required to estimate relative treatment effects between competing interventions based on the available evidence. Two approaches are frequently used in RRMM: network meta-analysis (NMA) and unanchored matching-adjusted indirect comparison (MAIC). The objective of the current study was to evaluate the relevance and credibility of published NMA and unanchored MAIC studies aiming to estimate the comparative efficacy of treatment options for RRMM. METHODS Twelve relevant studies were identified in the published literature (n = 7) and from health technology assessment agencies (n = 5). Data from trials were extracted to identify between-trial differences that may have biased results. Credibility of the performed analyses and relevance of the research questions were critically appraised using the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) checklist and feedback based on consultations with clinical experts. RESULTS The identified studies concerned NMAs of randomized controlled trials (RCTs; n = 7), unanchored MAICs (n = 4), or both types of analyses (n = 1). According to clinical expert consultation, the majority of the identified NMAs did not consider differences in prior therapies or treatment duration across the RCTs included in the analyses, thereby compromising the relevance. CONCLUSION Based on the results and feedback from clinicians, the majority of NMAs did not consider prior treatment history or treatment duration, which resulted in nonrelevant comparisons. Furthermore, it may have compromised the credibility of the estimates owing to differences in effect-modifiers between the different trials. Pairwise comparisons by means of unanchored MAICs require clear justification given the reliance on non-randomized comparisons.
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Affiliation(s)
- Shannon Cope
- Precision Health Economics and Outcomes Research, Vancouver, BC, Canada
| | - Kabirraaj Toor
- Precision Health Economics and Outcomes Research, Vancouver, BC, Canada.
| | - Evan Popoff
- Precision Health Economics and Outcomes Research, Vancouver, BC, Canada
| | - Rafael Fonseca
- Division of Hematology and Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - María-Victoria Mateos
- University Hospital of Salamanca-Instituto de Investigacion Biomedica de Salamanca, Salamanca, Spain
| | - Katja Weisel
- Department of Hematology and Oncology, University Hospital of Tuebingen, Tuebingen, Germany
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Mechanism of Action and Novel IMiD-Based Compounds and Combinations in Multiple Myeloma. ACTA ACUST UNITED AC 2020; 25:19-31. [PMID: 30694856 DOI: 10.1097/ppo.0000000000000354] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Over the last 2 decades, thalidomide analogs have induced significant antimyeloma effects via immune-modulation, antiangiogenesis and antiproliferative effects. While the exact molecular mechanism of the targets or the mediators of thalidomide activity were not known, a seminal discovery of cereblon as a thalidomide-binding protein led to explaining the mechanistic basis of antimyeloma activity for this class of agents. Identification of the mechanisms of resistance for immunomodulatory agents (IMiDs), which will have significant clinical implications, remains poorly understood. Newer cereblon modulators with differential effects and improved increased efficacy in cell lines resistant to the current IMiDs are in development with encouraging preclinical data. In this review, we have summarized the mechanisms of action of IMiDs, clinical development, and potential mechanisms of resistance. We also describe novel IMiD-based combinations and the newer cereblon modulators as well.
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Soekojo CY, Ooi M, de Mel S, Chng WJ. Immunotherapy in Multiple Myeloma. Cells 2020; 9:E601. [PMID: 32138182 PMCID: PMC7140529 DOI: 10.3390/cells9030601] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/27/2020] [Accepted: 02/27/2020] [Indexed: 12/15/2022] Open
Abstract
Multiple myeloma is a complex disease and immune dysfunction has been known to play an important role in the disease pathogenesis, progression, and drug resistance. Recent efforts in drug development have been focused on immunotherapies to modify the MM disease process. Here, we summarize the emerging immunotherapies in the MM treatment landscape.
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Affiliation(s)
| | | | | | - Wee Joo Chng
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, National University Health System, 1E Kent Ridge Road, Singapore 119228, Singapore; (C.Y.S.); (M.O.); (S.d.M.)
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Phase 2 study of clarithromycin, pomalidomide, and dexamethasone in relapsed or refractory multiple myeloma. Blood Adv 2020; 3:603-611. [PMID: 30792190 DOI: 10.1182/bloodadvances.2018028027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/15/2019] [Indexed: 01/17/2023] Open
Abstract
The addition of clarithromycin enhances the efficacy of lenalidomide plus dexamethasone in treatment-naive multiple myeloma (MM). We conducted a phase 2 trial to evaluate the safety and efficacy of clarithromycin, pomalidomide, and dexamethasone (ClaPd) in relapsed or refractory multiple myeloma (RRMM) with prior lenalidomide exposure. One hundred twenty patients with a median of 5 prior lines of therapy received clarithromycin 500 mg orally twice daily, pomalidomide 4 mg orally on days 1 to 21, and dexamethasone 40 mg orally on days 1, 8, 15, and 22 of a 28-day cycle. The overall response rate (ORR) was 60% with 23% achieving at least a very good partial response. There was no statistical difference in response rates for patients who were refractory to lenalidomide (ORR, 58%), bortezomib (ORR, 55%), or both lenalidomide and bortezomib (ORR, 54%). Median progression-free survival (PFS) for the cohort was 7.7 months and median overall survival (OS) was 19.2 months. A history of dual-refractoriness to lenalidomide and bortezomib did not significantly impact either PFS or OS. The most common toxicities were neutropenia (83%), lymphopenia (74%), and thrombocytopenia (71%). The most common grade ≥3 toxicities included neutropenia (58%), thrombocytopenia (31%), and anemia (28%). ClaPd is an effective combination in RRMM with response and survival outcomes that are independent of lenalidomide- or bortezomib-refractory status. Toxicities are manageable with low rates of nonhematologic or high-grade events. ClaPd is a convenient, all-oral option in RRMM with comparable efficacy to other highly active, 3-drug, pomalidomide-based combinations. This trial was registered at www.clinicaltrials.gov as #NCT01159574.
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