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Engelhardt M, Kortüm KM, Goldschmidt H, Merz M. Functional cure and long-term survival in multiple myeloma: how to challenge the previously impossible. Haematologica 2024; 109:2420-2435. [PMID: 38356448 PMCID: PMC11290544 DOI: 10.3324/haematol.2023.283058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 02/06/2024] [Indexed: 02/16/2024] Open
Abstract
Multiple myeloma (MM) is a heterogeneous disease with survival ranging from months to decades. The goal of 'cure' remains elusive for most patients, but has been shown to be possible, with durable remission and a transition to a plateau phase (analogous to monoclonal gammopathy of uncertain significance/smoldering myeloma). In this review, two representative cases set the stage to illustrate how this might be possible and what still needs to be determined to achieve functional disease control over a prolonged period. Several developments have emerged, such as improved diagnostics including the definitions and use of SLiM-CRAB criteria and measurable residual disease (MRD) with whole-genome/single-cell sequencing as well as other correlates to better understand disease biology. These advances enable earlier detection, more accurate risk stratification and improved personalized treatment strategies by facilitating analysis of genetic alterations and clonal heterogeneity. Whole-genome sequencing may also identify driver mutations and modes of resistance to immunotherapies as well as other targeted therapies. Today, induction with a CD38 antibody, proteasome inhibitor, immunomodulatory drug, and dexamethasone, potentially followed by autologous stem cell transplantation and lenalidomide maintenance, can be considered standard of care for transplant-eligible (TE) patients with newly diagnosed MM (NDMM). That prolonged disease control and functional cure can be achieved in non-transplant-eligible (NTE) patients is currently emerging as a distinct possibility: data from phase III trials that incorporate a CD38 antibody into the treatment of NTE NDMM patients demonstrate impressive MRD negativity rates that appear sustained over several years. While the long-term durability of chimeric antigen receptor T cells, bi-specific antibodies and other immunotherapies are being evaluated, several clinical trials are now investigating their role in frontline treatment for TE and NTE patients. These trials will address whether chimeric antigen receptor T-cell therapy will replace autologous stem cell transplantation and whether such immunotherapies will represent a truly curative option. We conclude that while cure remains elusive, the concept of operational or functional cure provides a new benchmark to strive for and is an emerging area of active and potentially achievable clinical research for MM.
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Affiliation(s)
- Monika Engelhardt
- Department of Medicine I Hematology and Oncology, Medical Center University of Freiburg, Faculty of Medicine, Comprehensive Cancer Center Freiburg (CCCF).
| | - K Martin Kortüm
- Department of Medicine II, University Hospital of Würzburg, Würzburg
| | - Hartmut Goldschmidt
- University Hospital Heidelberg and the National Center for Tumor Diseases, Heidelberg
| | - Maximilian Merz
- Department of Hematology, Cell therapy and Hemostaseology, University Hospital Leipzig, Leipzig.
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2
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Seehaus CM, Schutz N, Brulc E, Ferini G, Arbelbide J, Fantl D, Basquiera AL. Autologous stem cell transplantation in patients older than 65 years with multiple myeloma: a real-world study. Hematol Transfus Cell Ther 2023:S2531-1379(23)00169-4. [PMID: 37739860 DOI: 10.1016/j.htct.2023.07.012] [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: 03/20/2022] [Revised: 06/20/2023] [Accepted: 07/24/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION The treatment of elderly multiple myeloma (MM) patients with autologous stem cell transplantation (ASCT) is a controversial procedure. Most clinical trials evaluating the safety and efficacy of ASCT have primarily included patients younger than 65 years. DESIGN AND METHODS This was a retrospective analysis of patients with MM who underwent ASCT between 2008 and 2018. Patients at or over 65 years were compared with patients under 65 years. We analyzed treatment-related mortality (TRM), response rate, progression-free survival (PFS) and overall survival (OS). RESULTS Two hundred and twenty-one patients were included: 50 patients at or over 65 years, (median age 68 years), including 7 patients over 70 years and 151 patients under 65 years, (median age 57 years). No differences were found in the neutrophil and platelet engraftment, median days of hospitalization and life support requirement during the hospitalization period for the ASCT. No statistically significant differences were found in the incidence of TRM between both groups at 100 days post-transplant (2% vs. 2.9%, p = 0.322). The ASCT improved complete response and stringent complete response rates (44% vs. 37%, p < 0.001). Survival was not modified by age: after a median follow-up of 53 months, the estimated PFS rates at three years were 63% and 60% (p = 0.88) and the OS rates at five years were 75% and 74% (p = 0.72), respectively. CONCLUSIONS Our data suggest that the ASCT is feasible in selected elderly patients with MM over 65 years of age, achieving response and survival rates similar to those of younger patients.
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Affiliation(s)
| | - Natalia Schutz
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Erika Brulc
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gonzalo Ferini
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Dorotea Fantl
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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3
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Revannasiddaiah S, Nagaraju PRVMA, Palassery R, Jagadish A, Maka VV, Kilara N, Rondelli D, Devadas SK. The limited use of autologous hematopoietic stem cell transplant for fit older patients with multiple myeloma in India: a retrospective analysis. J Egypt Natl Canc Inst 2022; 34:21. [DOI: 10.1186/s43046-022-00123-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/19/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Multiple myeloma (MM) predominantly affects older patients; many of whom do not undergo autologous hematopoietic stem cell transplant (AHSCT) despite the associated survival benefits. This study was conceived to investigate the patterns of AHSCT among MM patients with due regard to their age and standardized fitness assessments.
Methods
Fitness scores as per the hematopoietic stem cell transplant-comorbidity index (HSCT-CI) and risk scores as per the revised-myeloma comorbidity index (R-MCI) of MM patients treated between January 2017 and December 2019 were analyzed to assess fitness for AHSCT. Proportions of patients who underwent AHSCT were calculated with regard to age and fitness for AHSCT.
Results
Of the 81 eligible patient records with a median age of 62 years, the HSCT-CI classified 79.6% and 77.8% of patients aged ≤65 years and >65 years as AHSCT eligible (p 1). Using the R-MCI, 96.3% and 81.5% of patients aged ≤65 years and >65 years, respectively, were classified as eligible for AHSCT (p 0.0381). Overall, patients aged ≤65 years underwent AHSCT with a greater frequency compared to those aged >65years (38.9 vs. 14.8%, p 0.0402). Irrespective of the age group, there was a statistically significant difference (p 0.0167) in terms of survival which favored those who underwent AHSCT.
Conclusions
Both the HSCT-CI and the R-MCI revealed that nearly 80% of patients aged >65 years were fit enough to receive AHSCT. However, far fewer patients of this age group underwent AHSCT. We propose that the routine inclusion of objective fitness assessment could ensure that fit older patients undergo AHSCT and thus do not miss out on the benefits of the same.
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4
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Oganesyan A, Ghahramanyan N, Mekinian A, Bejanyan N, Kazandjian D, Hakobyan Y. Managing multiple myeloma in a resource-limited region: Diagnosis and treatment in Armenia. Semin Oncol 2021; 48:269-278. [PMID: 34895914 DOI: 10.1053/j.seminoncol.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/05/2021] [Accepted: 11/05/2021] [Indexed: 11/11/2022]
Abstract
Multiple myeloma (MM) is the second most common blood cancer in adults leading to 117,000 deaths every year. Major breakthroughs in clinical research of the past decades transformed the diagnosis and treatment of MM improving the survival rates and overall quality of life of patients. Unfortunately, scientific advancements are not distributed equally around the globe leading to disparities in the treatment outcomes between different regions of the world. Management of MM in low- and middle-income countries represents a big challenge for healthcare providers considering the economic, technological, and infrastructural restraints in comparison to developed countries. Many standards of practice, including diagnostic tools and therapeutic regimens, are not available in developing regions of the world. As an example of an upper-middle-income country, Armenia has been witnessing considerable progress in the diagnosis and treatment of MM, including but not limited to the establishment of autologous stem cell transplant (ASCT), accessibility to modern anti-myeloma medications, and improved diagnostic and monitoring workup. Despite significant improvements, there is still a need for refinement in the management of MM. The aim of this review article is to discuss the latest developments and the current diagnosis and treatment of MM in Armenia as an example of a resource-limited region.
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Affiliation(s)
- Artem Oganesyan
- Myeloma Research Group, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Nerses Ghahramanyan
- Myeloma Research Group, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Arsene Mekinian
- French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia; AP-HP, Hôpital Saint Antoine, Service de Médecine Interne et Inflammation-Immunopathology-Biotherapy Department (DMU i3), Sorbonne Université, Paris, France
| | - Nelli Bejanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL
| | - Dickran Kazandjian
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Yervand Hakobyan
- Myeloma Research Group, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia; French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia; Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia.
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5
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Straka C, Salwender H, Knop S, Vogel M, Müller J, Metzner B, Langer C, Sayer H, Jung W, Dürk HA, Bassermann F, Gramatzki M, Rösler W, Wolf HH, Brugger W, Engelhardt M, Fischer T, Liebisch P, Einsele H. Full or intensity-reduced high-dose melphalan and single or double autologous stem cell transplant with or without bortezomib consolidation in patients with newly diagnosed multiple myeloma. Eur J Haematol 2021; 107:529-542. [PMID: 34270825 DOI: 10.1111/ejh.13690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE A post hoc subgroup analysis of two phase III trials (NCT00416273, NCT00416208) was carried out to investigate the influence of 100/140 and 200 mg/m² melphalan as well as single/double autologous stem cell transplantation (ASCT) on progression-free survival (PFS). Additionally, the effect of bortezomib consolidation on PFS was analyzed. METHODS Following induction therapy and high-dose melphalan with subsequent ASCT, patients with newly diagnosed multiple myeloma (NDMM) were randomized 1:1 to either four 35-day cycles of bortezomib consolidation (1.6 mg/m² IV on days 1, 8, 15, 22) or observation. RESULTS Of the 340 patients included in this analysis, 13.5% received 1 × MEL100/140, 22.9% 2 × MEL100/140, 31.2% 1 × MEL200, and 32.4% 2 × MEL200. With higher cumulative melphalan dose, PFS improved (P = .0085). PFS curves of patients treated with 2 × MEL100/140 and 1 × MEL200 were very similar. The superior dose effect of MEL200 over MEL100/140 was non-existent in the bortezomib consolidation arm but pronounced in the observation arm (P = .0015). Similarly, double ASCT was only beneficial in patients without bortezomib consolidation (P = .0569). CONCLUSIONS Full dose melphalan and double transplantation seem advantageous only as long as patients are not receiving bortezomib consolidation afterwards.
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Affiliation(s)
| | - Hans Salwender
- Asklepios Tumorzentrum, AK Altona und AK St. Georg, Hamburg, Germany
| | - Stefan Knop
- Universitätsklinikum Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany
| | | | | | - Bernd Metzner
- Universitätsklinik für Innere Medizin II, Oldenburg, Germany
| | - Christian Langer
- Universitätsklinikum Ulm, Klinik für Innere Medizin II, Ulm, Germany
| | - Herbert Sayer
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Jena, Germany
| | - Wolfram Jung
- Universitätsmedizin Göttingen, Göttingen, Germany
| | | | - Florian Bassermann
- Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | | | - Wolf Rösler
- Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | | | | | - Peter Liebisch
- Universitätsklinikum Ulm, Klinik für Innere Medizin II, Ulm, Germany
| | - Hermann Einsele
- Universitätsklinikum Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany
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6
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Decisional involvement and information preferences of patients with hematologic malignancies. Blood Adv 2020; 4:5492-5500. [PMID: 33166406 DOI: 10.1182/bloodadvances.2020003044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/13/2020] [Indexed: 11/20/2022] Open
Abstract
Understanding decisional involvement and information preferences in patients with hematologic malignancies may help to optimize physician-patient communication about treatment decisions and align the decision-making processes with patients' preferences. We described and examined factors associated with preferences of patients with hematologic malignancies for decisional involvement, information sources, and presentation of information. In a multicenter observational study, we recruited 216 patients with hematologic malignancies of any stage from September 2003 to June 2007. Patients were asked about their decisional involvement preferences (Control Preferences Scale), information sources (including most useful source of information), and preferences for their oncologists' presentation of treatment success information. We used multivariate logistic regressions to identify factors associated with decisional involvement preferences and usefulness of information sources (physicians vs nonphysicians). Patient-directed, shared, and physician-directed approaches were preferred in 34%, 38%, and 28% of patients, respectively. Physicians and computer/Internet were the most common information sources; 42% perceived physicians as the most useful source. On multivariate analysis, patients with less than a college education (vs postgraduate education) were less likely to perceive their physician as the most useful source (adjusted odds ratio [AOR], 0.46; 95% confidence interval (CI), 0.21-1.00), whereas patients with acute leukemia (vs other blood cancers) were more likely to perceive their physician as the most useful source (AOR, 2.49; 95% CI, 1.07-5.80). In terms of communicating treatment success rates, 70% preferred ≥1 method(s), and 88% preferred presentation in percentages. Our study suggests that decisional involvement and information preferences vary and should be assessed explicitly as part of each decision-making encounter.
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7
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Mai EK, Miah K, Bertsch U, Dürig J, Scheid C, Weisel KC, Kunz C, Munder M, Lindemann HW, Merz M, Hose D, Jauch A, Seckinger A, Luntz S, Sauer S, Fuhrmann S, Brossart P, Elmaagacli A, Goerner M, Bernhard H, Hoffmann M, Raab MS, Blau IW, Hänel M, Benner A, Salwender HJ, Goldschmidt H. Bortezomib-based induction, high-dose melphalan and lenalidomide maintenance in myeloma up to 70 years of age. Leukemia 2020; 35:809-822. [PMID: 32684633 PMCID: PMC8318883 DOI: 10.1038/s41375-020-0976-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/29/2020] [Accepted: 07/06/2020] [Indexed: 01/03/2023]
Abstract
Intensive upfront therapy in newly-diagnosed multiple myeloma (MM) including induction therapy (IT), high-dose melphalan (MEL200), and autologous blood stem cell transplantation (ASCT) followed by consolidation and/or maintenance is mostly restricted to patients up to 65 years of age. Prospective phase III trial data in the era of novel agents for patients up to 70 years of age are not available. The GMMG-MM5 trial included 601 patients between 18 and 70 years of age, divided in three groups for the present analysis: ≤60 years (S1, n = 353), 61–65 years (S2, n = 107) and 66–70 years (S3, n = 141). Treatment consisted of a bortezomib-containing IT, MEL200/ASCT, consolidation, and maintenance with lenalidomide. Adherence to treatment was similar among patients of the three age groups. Overall toxicity during all treatment phases was increased in S2 and S3 compared to S1 (any adverse event/any serious adverse event: S1:81.7/41.8% vs. S2:90.7/56.5% vs. S3:87.2/68.1%, p = 0.05/<0.001). With respect to progression-free survival (log-rank p = 0.73), overall survival (log-rank p = 0.54) as well as time-to-progression (Gray’s p = 0.83) and non-relapse mortality (Gray’s p = 0.25), no differences were found between the three age groups. Our results imply that an intensive upfront therapy with a bortezomib-containing IT, MEL200/ASCT, lenalidomide consolidation, and maintenance should be applied to transplant-eligible MM patients up to 70 years of age.
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Affiliation(s)
- Elias K Mai
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.,National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - Kaya Miah
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Uta Bertsch
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.,National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - Jan Dürig
- Department of Hematology, University Clinic Essen, Essen, Germany
| | - Christof Scheid
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - Katja C Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Hematology, Oncology and Immunology, University Hospital Tübingen, Tübingen, Germany
| | - Christina Kunz
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Institute of Child Nutrition, Max Rubner Institute, Federal Research Institute of Nutrition and Food, Karlsruhe, Germany
| | - Markus Munder
- Department of Internal Medicine III, University Medical Center Mainz, Mainz, Germany
| | - Hans-Walter Lindemann
- Department of Hematology and Oncology, Katholisches Krankenhaus Hagen, Hagen, Germany
| | - Maximilian Merz
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Dirk Hose
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna Jauch
- Institute of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Anja Seckinger
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Steffen Luntz
- Coordination Centre for Clinical Trials, University Hospital Heidelberg, Heidelberg, Germany
| | - Sandra Sauer
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Stephan Fuhrmann
- Department of Hematology and Oncology, Helios Hospital Berlin Buch, Berlin, Germany
| | | | - Ahmet Elmaagacli
- Department of Hematology and Oncology, Asklepios Hospital Hamburg St. Georg, Hamburg, Germany
| | - Martin Goerner
- Department of Hematology, Oncology and Palliative Care, Klinikum Bielefeld, Bielefeld, Germany
| | - Helga Bernhard
- Department of Internal Medicine V, Klinikum Darmstadt, Darmstadt, Germany
| | - Martin Hoffmann
- Medical Clinic A, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Marc S Raab
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Igor W Blau
- Medical Clinic, Charité University Medicine Berlin, Berlin, Germany
| | - Mathias Hänel
- Department of Internal Medicine III, Klinikum Chemnitz, Chemnitz, Germany
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hans J Salwender
- Department of Hematology and Oncology, Asklepios Hospital Hamburg Altona, Hamburg, Germany
| | - Hartmut Goldschmidt
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany. .,National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany.
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Ntanasis-Stathopoulos I, Gavriatopoulou M, Kastritis E, Terpos E, Dimopoulos MA. Multiple myeloma: Role of autologous transplantation. Cancer Treat Rev 2019; 82:101929. [PMID: 31770695 DOI: 10.1016/j.ctrv.2019.101929] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/31/2019] [Accepted: 11/05/2019] [Indexed: 01/07/2023]
Abstract
Autologous stem cell transplantation (ASCT) has been the mainstay of multiple myeloma (MM) treatment for approximately 30 years. Although the continuous introduction of novel agents in the armamentarium against MM has questioned its value, ASCT remains a backbone treatment for fit MM patients. However, there is no unanimous approach for several aspects including the positioning of ASCT in the therapeutic algorithm either upfront or following the first relapse, the need for single or tandem ASCT, as well as the role of ASCT as salvage therapy. Furthermore, the anti-CD38 monoclonal antibodies along with the next generation proteasome inhibitors and immunomodulatory drugs provide a platform for optimizing the induction and consolidation/maintenance regimens. In this review, we present current data pertaining to all aspects of ASCT in MM, whereas we highlight the open issues that should be addressed in the design of future clinical trials in the field.
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Affiliation(s)
- Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
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9
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Straka C, Knop S, Vogel M, Müller J, Kropff M, Metzner B, Langer C, Sayer H, Jung W, Dürk HA, Salwender H, Wandt H, Bassermann F, Gramatzki M, Rösler W, Wolf H, Brugger W, Fischer T, Liebisch P, Engelhardt M, Einsele H. Bortezomib consolidation following autologous transplant in younger and older patients with newly diagnosed multiple myeloma in two phase III trials. Eur J Haematol 2019; 103:255-267. [DOI: 10.1111/ejh.13281] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 01/10/2023]
Affiliation(s)
| | - Stefan Knop
- Medizinische Klinik und Poliklinik II Julius Maximilians Universität Würzburg Würzburg Germany
| | | | | | | | - Bernd Metzner
- Universitätsklinik für Innere Medizin – Onkologie und Hämatologie Klinikum Oldenburg Oldenburg Germany
| | | | - Herbert Sayer
- Klinik für Innere Medizin II [Hämatologie/Onkologie] Universitätsklinikum Jena Jena Germany
| | - Wolfram Jung
- Onkologie Universitätsmedizin Göttingen Göttingen Germany
| | | | | | - Hannes Wandt
- Medizinische Klinik 5 Paracelsus Medizinische Privatuniversität Nürnberg Nürnberg Germany
| | - Florian Bassermann
- Klinikum rechts der Isar, III. Medizinische Klinik Technische Universität München München Germany
| | | | - Wolf Rösler
- Universitätsklinkum Erlangen Erlangen Germany
| | | | | | | | - Peter Liebisch
- Zentrum für Innere Medizin Universitätsklinikum Ulm Ulm Germany
| | | | - Hermann Einsele
- Medizinische Klinik und Poliklinik II Julius Maximilians Universität Würzburg Würzburg Germany
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10
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11
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Fraz MA, Warraich FH, Warraich SU, Tariq MJ, Warraich Z, Khan AY, Usman M, Ijaz A, Tenneti P, Mushtaq A, Akbar F, Shahid Z, Ali Z, Fazeel HM, Rodriguez C, Nasar A, McBride A, Anwer F. Special considerations for the treatment of multiple myeloma according to advanced age, comorbidities, frailty and organ dysfunction. Crit Rev Oncol Hematol 2019; 137:18-26. [PMID: 31014512 PMCID: PMC6508081 DOI: 10.1016/j.critrevonc.2019.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 02/24/2019] [Indexed: 12/30/2022] Open
Abstract
Multiple Myeloma (MM) is primarily a disease of old age with a median age of sixty-nine years at diagnosis. The development of novel therapies for induction and use of autologous stem cell transplantation has resulted in improved clinical outcomes and better quality of life for MM patients. Elderly patients, comprising the majority of MM population, have a higher incidence of age-related comorbidities, frailty and organ dysfunction which complicates the coordination of treatment and limits the selection of therapies. Even in the era of multiple chemotherapeutic options, the clinical heterogeneity of the myeloma patients' demands personalized treatments which often require dose-adjustments or dose delays. The use of reduced-dose regimens and various comorbidity indices has improved clinical outcome and regimen tolerability in MM patients with renal, neurological and bone abnormalities. We focus on advancements in the treatment of multiple myeloma with the goal to guide clinicians towards patient-specific management.
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Affiliation(s)
- Muhammad Asad Fraz
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Faiza Hassan Warraich
- Department of Internal Medicine, McLaren-Flint Medical Center, Flint, MI, 48532, United States
| | - Sami Ullah Warraich
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Muhammad Junaid Tariq
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Zabih Warraich
- Department of Internal Medicine, United Health Services Wilson Memorial Regional Medical Center, Johnson City, NY, 13790, United States
| | - Ali Younas Khan
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Muhammad Usman
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Awais Ijaz
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Pavan Tenneti
- Department of Medicine, Banner University Medical Center, Tucson, AZ, 85724, United States
| | - Adeela Mushtaq
- Department of Medicine, University of Pittsburgh Medical Center, McKeesport, PA, 15132, United States
| | - Faisal Akbar
- Department of Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, 27157, United States
| | - Zaina Shahid
- Department of Medicine, Wilkes Medical Center- Wake Forest Baptist Health, Wilkesboro, NC, 28659, United States
| | - Zeeshan Ali
- Department of Medicine, Southern Arizona Veterans Affairs Health Care System, Tucson, AZ, 85723, United States
| | - Hafiz Muhammad Fazeel
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States
| | - Cesar Rodriguez
- Department of Hematology Oncology, Wake Forest Baptist Medical Comprehensive Cancer Center, Winston Salem, NC, 27157, United States
| | - Aboo Nasar
- Department of Geriatrics, Tri-City Medical Center, 4002 Vista Way, Oceanside, CA 92056, United States
| | - Ali McBride
- Department of Pharmacy, The University of Arizona Cancer Center, Tucson, AZ, 85737, United States
| | - Faiz Anwer
- Department of Medicine, Division of Hematology Oncology, Blood and Marrow Transplantation, University of Arizona, Tucson, AZ, 85721, United States; Taussig Cancer Center, Department of Hematology, Medical Oncology, Cleveland Clinic, Cleveland, OH, 44195, United States.
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12
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Mina R, Lonial S. Is there still a role for stem cell transplantation in multiple myeloma? Cancer 2019; 125:2534-2543. [PMID: 30985927 DOI: 10.1002/cncr.32060] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/16/2018] [Accepted: 07/23/2018] [Indexed: 12/16/2022]
Abstract
High-dose chemotherapy and autologous stem cell transplantation (ASCT) are a standard of care for transplant-eligible patients with newly diagnosed multiple myeloma (MM). The introduction of novel agents, which range from immunomodulatory drugs and proteasome inhibitors to monoclonal antibodies and have now been integrated into both induction and salvage regimens, has dramatically revolutionized the treatment landscape of MM and challenged the role of high-dose chemotherapy and ASCT in treating MM. These advances have led to a number of provocative questions. First, what is the current role of stem cell transplantation (SCT) in comparison with standard-dose therapy incorporating novel agents? Second, should ASCT be performed upfront ("early") or later ("delayed") in the course of the disease? Third, should single or double ASCT be performed? Fourth, is allogeneic SCT still an option for patients with MM? This article provides an overview of available data and evidence-based responses regarding the role of SCT in MM.
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Affiliation(s)
- Roberto Mina
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sagar Lonial
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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13
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Al Hamed R, Bazarbachi AH, Malard F, Harousseau JL, Mohty M. Current status of autologous stem cell transplantation for multiple myeloma. Blood Cancer J 2019; 9:44. [PMID: 30962422 PMCID: PMC6453900 DOI: 10.1038/s41408-019-0205-9] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 03/05/2019] [Accepted: 03/12/2019] [Indexed: 12/22/2022] Open
Abstract
More than 30 years after its introduction, autologous stem cell transplantation (ASCT) remains the standard of care for young patients with newly diagnosed multiple myeloma. Not only did the arrival of novel agents such as immunomodulatory drugs (IMiDs), proteasome inhibitors (PI) and monoclonal antibodies not replace ASCT, instead they solidified its central role as standard of care. Novel agent use is now inarguably essential in induction, maintenance, and possibly consolidation. In light of these new advancements, new challenges arise in deciding on optimal practice. Who is most suited to undergo ASCT? Is there an age threshold that should not be surpassed? Should transplantation be embarked on early or is it reasonable to delay it? What are the optimal induction, consolidation, and maintenance therapies? What is the role of tandem transplantation in the era of novel agents and where do patient-specific cytogenetics come into the equation when deciding on treatment? These are some of the questions addressed in this review which we will attempt to answer with the latest currently available data.
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Affiliation(s)
- Rama Al Hamed
- Service d'hématologie clinique et thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938 and université Sorbonne, Paris, France
| | - Abdul Hamid Bazarbachi
- Service d'hématologie clinique et thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938 and université Sorbonne, Paris, France
| | - Florent Malard
- Service d'hématologie clinique et thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938 and université Sorbonne, Paris, France
| | - Jean-Luc Harousseau
- Institut de Cancerologie de l'Ouest, Centre René Gauducheau, Nantes-St Herblain, France
| | - Mohamad Mohty
- Service d'hématologie clinique et thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938 and université Sorbonne, Paris, France.
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14
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Mikhael J, Ismaila N, Cheung MC, Costello C, Dhodapkar MV, Kumar S, Lacy M, Lipe B, Little RF, Nikonova A, Omel J, Peswani N, Prica A, Raje N, Seth R, Vesole DH, Walker I, Whitley A, Wildes TM, Wong SW, Martin T. Treatment of Multiple Myeloma: ASCO and CCO Joint Clinical Practice Guideline. J Clin Oncol 2019; 37:1228-1263. [PMID: 30932732 DOI: 10.1200/jco.18.02096] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To provide evidence-based recommendations on the treatment of multiple myeloma to practicing physicians and others. METHODS ASCO and Cancer Care Ontario convened an Expert Panel of medical oncology, surgery, radiation oncology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and some phase II studies published from 2005 through 2018. Outcomes of interest included survival, progression-free survival, response rate, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 124 relevant studies to inform the evidence base for this guideline. RECOMMENDATIONS Evidence-based recommendations were developed for patients with multiple myeloma who are transplantation eligible and those who are ineligible and for patients with relapsed or refractory disease.
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Affiliation(s)
- Joseph Mikhael
- 1 City of Hope Cancer Center, Phoenix, AZ.,2 International Myeloma Foundation, North Hollywood, CA
| | | | | | | | | | | | | | - Brea Lipe
- 8 University of Rochester Medical Center, Rochester, NY
| | | | - Anna Nikonova
- 10 Juravinski Cancer Center, Hamilton, Ontario, Canada
| | - James Omel
- 11 Education and Advocacy, Grand Island, NE
| | | | - Anca Prica
- 13 Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Noopur Raje
- 14 Massachusetts General Hospital, Boston, MA
| | - Rahul Seth
- 15 Upstate Medical University, Syracuse, NY
| | - David H Vesole
- 16 Hackensack University Medical Center, Hackensack, NJ.,17 Georgetown University, Washington, DC
| | - Irwin Walker
- 18 McMaster University, Hamilton, Ontario, Canada
| | | | | | - Sandy W Wong
- 21 University of California San Francisco, San Francisco, CA
| | - Tom Martin
- 21 University of California San Francisco, San Francisco, CA
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15
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Mina R, Bringhen S, Wildes TM, Zweegman S, Rosko AE. Approach to the Older Adult With Multiple Myeloma. Am Soc Clin Oncol Educ Book 2019; 39:500-518. [PMID: 31099676 PMCID: PMC7363047 DOI: 10.1200/edbk_239067] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Multiple myeloma (MM) is a disease of aging adults, and numerous therapeutic options are available for this growing demographic. MM treatment of older adults continues to evolve and includes novel combinations, new generations of targeted agents, immunotherapy, and increasing use of autologous stem cell transplantation (ASCT). Understanding age-related factors, independent of chronologic age itself, is an increasingly recognized factor in MM survivorship, especially in understudied populations, such as octogenarians. Octogenarians have inferior survival that cannot be explained by cytogenetic profiles alone. Incorporating assessments of geriatric factors can provide guidance on how to intensify or de-escalate therapeutic options. Functional status, using objective testing, is superior to traditional metrics of performance status and should be implemented to optimize the risk-benefit ratio of ASCT. ASCT is feasible and cost-effective, and chronologic age should not exclude ASCT eligibility. Upfront ASCT remains the standard of care, in the context of a sequential approach that includes pre-transplantation induction and post-transplantation maintenance. High-risk MM is classically defined by disease characteristics, yet shifting frameworks suggest that the high-risk designation could refer to any patient subgroup who is at risk for poorer outcomes-beyond disease-focused outcomes to patient-focused outcomes. Defining the optimal treatment of subgroups of older patients with high-risk disease on the basis of chromosomal abnormalities is unexplored. Here, we review tools to assess individual health status, explore vulnerability in octogenarians with MM, address ASCT decision-making, and examine high-risk MM to understand factors that contribute to survival disparities for older adults with MM.
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Affiliation(s)
- Roberto Mina
- 1 Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Sara Bringhen
- 1 Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Tanya M Wildes
- 2 Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO
| | - Sonja Zweegman
- 3 Department of Hematology, Amsterdam UMC, VU University Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Ashley E Rosko
- 4 Division of Hematology, The Ohio State University, Columbus, OH
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16
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Gavriatopoulou M, Fotiou D, Ntanasis-Stathopoulos I, Kastritis E, Terpos E, Dimopoulos MA. How I treat elderly patients with plasma cell dyscrasias. Aging (Albany NY) 2018; 10:4248-4268. [PMID: 30568029 PMCID: PMC6326666 DOI: 10.18632/aging.101707] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 12/04/2018] [Indexed: 01/01/2023]
Abstract
Plasma cell dyscrasias are a rare heterogeneous group of hematological disorders which are more prevalent in the older part of the population. The introduction of novel agents, improved understanding of disease biology and better supportive management have improved outcomes considerably and in the era of the aging population the question of how to best manage older patients with plasma cell dyscrasias has never been more relevant. Data on how to treat these patients comes mostly from subgroup analysis as they are underrepresented in clinical trials. This review will cover issues, available evidence and recommendations relevant to diagnosis and management of the older patients with Multiple Myeloma (MM), Waldenstrom Macroglobulinemia (WM) and systemic AL Amyloidosis. What will become increasingly evident is the need to develop and establish the use of disease-specific geriatric assessment (GA) tools. Frailty status assessment using GA tools and moving away from making decisions based merely on chronological age will allow setting clear treatment goals and consequently achieving an optimum balance between effectiveness and toxicity for this complex and heterogeneous group of patients.
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Affiliation(s)
- Maria Gavriatopoulou
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
- Equal contribution
| | - Despoina Fotiou
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
- Equal contribution
| | - Ioannis Ntanasis-Stathopoulos
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Efstathios Kastritis
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Evangelos Terpos
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Meletios Athanasios Dimopoulos
- Alexandra Hospital, Oncology Department, Department of Therapeutics, National and Kapodistrian University of Athens, 11528 Athens, Greece
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17
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Marini C, Maia T, Bergantim R, Pires J, Aguiar E, Guimarães JE, Trigo F. Real-life data on safety and efficacy of autologous stem cell transplantation in elderly patients with multiple myeloma. Ann Hematol 2018; 98:369-379. [PMID: 30368589 PMCID: PMC6342895 DOI: 10.1007/s00277-018-3528-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 10/17/2018] [Indexed: 12/22/2022]
Abstract
Autologous stem cell transplantation (ASCT) is still debatable in treatment of patients over 65 years with multiple myeloma (MM). We performed a retrospective analysis of newly diagnosed MM patients who underwent ASCT between January 2010 and July 2016. A non-transplanted group with similar clinical characteristics, aged 65-70 years old, diagnosed and treated in the same timeline was used for comparison. We analyzed a total of 155 patients, 132 of which underwent ASCT (≤ 65 years, n = 103, median 56 years; > 65 years, n = 29, median 67 years) and 23 non-transplanted (median 68 years). Conditioning consisted of melphalan 200 mg/m2 (MEL200) in younger patients and melphalan 140 mg/m2 (MEL140) in half of elderly patients. Stratifying by age, there were no statistically significant differences concerning transplant-related myelotoxicity and non-hematopoietic toxicity; however, elderly patients conditioned with MEL200 had higher needs of transfusional support and more days of intravenous antibiotics. Those patients also had higher needs of transfusional support, higher grade of mucositis (p = 0.028), and more days of intravenous antibiotics (p = 0.019) than the elderly transplanted with MEL140. Global transplant-related mortality was 3.8%. Survival was not influenced by age. Non-transplanted elderly patients had comparable disease features, and induction response was similar in both groups (before ASCT in the transplanted cohort). Survival of transplanted elderly patients was superior to non-transplanted (OS, 59 months vs 30 months, p = 0.037; EFS, 45 months vs 27 months, p = 0.014). Selected elderly patients when transplanted have similar disease response and survival as younger patients. A higher dose of melphalan has more toxicity, but it is globally a well-tolerated procedure.
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Affiliation(s)
| | - Tânia Maia
- Centro Hospitalar de São João, Porto, Portugal
| | - Rui Bergantim
- Centro Hospitalar de São João, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Jorge Pires
- Centro Hospitalar de São João, Porto, Portugal
| | | | - José Eduardo Guimarães
- Centro Hospitalar de São João, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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18
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Sekine L, Ziegelmann PK, Manica D, da Fonte Pithan C, Sosnoski M, Morais VD, Falcetta FS, Ribeiro MR, Salazar AP, Ribeiro RA. Frontline treatment for transplant-eligible multiple myeloma: A 6474 patients network meta-analysis. Hematol Oncol 2018; 37:62-74. [PMID: 30129104 DOI: 10.1002/hon.2552] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/03/2018] [Accepted: 08/11/2018] [Indexed: 12/18/2022]
Abstract
Autologous transplantation continues to be the cornerstone of younger and fit multiple myeloma patients. It is known that frontline induction therapy before transplantation can influence post-transplant results. Therefore, best frontline treatment for transplant-eligible patients should be based on best available evidence to guide therapy. Furthermore, until now due to data scarcity, it was not possible to thoroughly compare lenalidomide to other regimens in this setting. We performed a systematic review and network (mixed treatment comparison) meta-analysis of 21 clinical trial publications, enrolling 6474 patients and comparing 11 different treatment frontline setting regimens regarding survival, response, and safety outcomes. OS analysis showed superiority of CRD (cyclophosphamide-lenalidomide-dexamethasone) over TD-based (thalidomide-dexamethasone, HR = 0.76,0.62-0.90), VAD-based (HR = 0.71,0.52-0.90), and Z-Dex (idarubicin-dexamethasone, HR = 0.37,0.17-0.76) regimens. Concerning PFS, VTD (bortezomib-thalidomide-dexametasone) showed superior results when compared with TD-based (HR = 0.66,0.51-0.84), VAD-based (HR = 0.61,0.46-0.82), Z-Dex (HR = 0.42,0.22-0.78), and high dose dexamethasone (Dex, HR = 0.62,0.41-0.90) regimens. Bortezomib/thalidomide regimens were not superior to lenalidomide, considering these outcomes. Also, concerning complete and overall response, VTD ranked first among other regimens, showing clear superiority over thalidomide-only containing protocols. Safety outcome evaluated infectious, cardiac, gastrointestinal, neurological, thrombotic, and hematological grade 3 to 4 adverse events. Risk of thrombotic events was higher with TAD (thalidomide-doxorubicin-dexamethasone), neurological with PAD (bortezomib-doxorubicin-dexamethasone), infectious with Dex, hematological with Z-Dex, gastrointestinal with VTD, and cardiac with PAD regimens. Our study endorses current recommendations on combined immunomodulatory drugs and proteasome inhibitors frontline regimens (in triplets) in transplant-eligible multiple myeloma patients, but also formally demonstrates the favorable performance of lenalidomide in overall and progression-free survival, when compared with bortezomib/thalidomide protocols.
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Affiliation(s)
- Leo Sekine
- Post-graduation Program in Epidemiology-Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Denise Manica
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | | | | | | | - Ana Paula Salazar
- Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, Brazil
| | - Rodrigo Antonini Ribeiro
- Post-graduation Program in Epidemiology-Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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19
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Abstract
Multiple myeloma is a malignant plasma cell disease, which typically affects older patients, with a median age at diagnosis of 70 years. The recent introduction of novel drugs and ongoing improvements in supportive care have significantly contributed to overall better management and outcomes for patients with multiple myeloma. Autologous stem-cell transplantation has been a standard part of therapy for myeloma patients for many years, first in younger patients and increasingly in older, and may still be considered in selected older patients with myeloma. In addition, in both newly diagnosed patients and in the relapsed/refractory setting, a number of novel agents tested in large phase III trials have yielded improvements in overall outcomes. As clinical trials under-enrol older patients and have stringent exclusion criteria, the data and results from them may not be generalizable to all older adults. In this review, we examine the treatment options for older adults with myeloma with a specific focus on the currently available data on novel agents in this cohort. The clinical efficacy and unique toxicity profile of each novel agent must be considered prior to the treatment plan in older adults.
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20
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Patient-centered practice in elderly myeloma patients: an overview and consensus from the European Myeloma Network (EMN). Leukemia 2018; 32:1697-1712. [DOI: 10.1038/s41375-018-0142-9] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/03/2018] [Accepted: 04/09/2018] [Indexed: 12/27/2022]
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21
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Engelhardt M, Ihorst G, Caers J, Günther A, Wäsch R. Autotransplants in older multiple myeloma patients: hype or hope in the era of novel agents? Haematologica 2018; 101:1276-1278. [PMID: 27799344 DOI: 10.3324/haematol.2016.154807] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Monika Engelhardt
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Medical Center - University of Freiburg, Faculty of Medicine, Germany
| | - Jo Caers
- Department of Hematology, University Hospital of Liège, Belgium
| | - Andreas Günther
- Division of Stem Cell Transplantation and Immunotherapy, Medical Department 2, University of Kiel, Germany
| | - Ralph Wäsch
- Department of Medicine I, Hematology, Oncology & Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, Germany
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22
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Gay F, Engelhardt M, Terpos E, Wäsch R, Giaccone L, Auner HW, Caers J, Gramatzki M, van de Donk N, Oliva S, Zamagni E, Garderet L, Straka C, Hajek R, Ludwig H, Einsele H, Dimopoulos M, Boccadoro M, Kröger N, Cavo M, Goldschmidt H, Bruno B, Sonneveld P. From transplant to novel cellular therapies in multiple myeloma: European Myeloma Network guidelines and future perspectives. Haematologica 2018; 103:197-211. [PMID: 29217780 PMCID: PMC5792264 DOI: 10.3324/haematol.2017.174573] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 12/05/2017] [Indexed: 12/20/2022] Open
Abstract
Survival of myeloma patients has greatly improved with the use of autologous stem cell transplantation and novel agents, such as proteasome inhibitors, immunomodulatory drugs and monoclonal antibodies. Compared to bortezomib- and lenalidomide-based regimens alone, the addition of high-dose melphalan followed by autologous transplantation significantly improves progression-free survival, although an overall survival benefit was not observed in all trials. Moreover, follow up of recent trials is still too short to show any difference in survival. In the light of these findings, novel agent-based induction followed by autologous transplantation is considered the standard upfront treatment for eligible patients (level of evidence: 1A). Post-transplant consolidation and maintenance treatment can further improve patient outcome (1A). The availability of several novel agents has led to the development of multiple combination regimens such as salvage treatment options. In this context, the role of salvage autologous transplantation and allotransplant has not been extensively evaluated. In the case of prolonged remission after upfront autologous transplantation, another autologous transplantation at relapse can be considered (2B). Patients who experience early relapse and/or have high-risk features have a poor prognosis and may be considered as candidates for clinical trials that, in young and fit patients, may also include an allograft in combination with novel agents (2B). Ongoing studies are evaluating the role of novel cellular therapies, such as inclusion of antibody-based triplets and quadruplets, and chimeric antigen receptor-T cells. Despite encouraging preliminary results, longer follow up and larger patient numbers are needed before the clinical use of these novel therapies can be widely recommended.
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Affiliation(s)
- Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda-Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Monika Engelhardt
- Universitätsklinikum Freiburg, Medical Department, Hematology, Oncology & Stem Cell Transplantation, Freiburg, Germany
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | - Ralph Wäsch
- Universitätsklinikum Freiburg, Medical Department, Hematology, Oncology & Stem Cell Transplantation, Freiburg, Germany
| | - Luisa Giaccone
- Department of Oncology, A.O.U Città della Salute e della Scienza di Torino, and Department of Molecular Biotechnology and Health Sciences, University of Torino, Italy
| | - Holger W Auner
- Centre for Haematology, Department of Medicine, Imperial College London, UK
| | - Jo Caers
- Department of Clinical Hematology, Centre Hospitalier Universitaire de Liège, Domaine Universitaire du Sart Tilman, Liège, Belgium
| | - Martin Gramatzki
- Division of Stem Cell Transplantation and Immunotherapy, 2 Medical Department, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Niels van de Donk
- Department of Hematology, VU University Medical Center, Amsterdam, the Netherlands
| | - Stefania Oliva
- Myeloma Unit, Division of Hematology, University of Torino, Azienda-Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Elena Zamagni
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Italy
| | - Laurent Garderet
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, Paris, AP-HP, Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire; Sorbonne Universités, UPMC Univ Paris 06, France
| | | | - Roman Hajek
- Department of Hematooncology, University Hospital Ostrava, Czech Republic and Faculty of Medicine University of Ostrava, Czech Republic
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, c/o Department of Medicine I, Center of Oncology, Hematology and Palliative Care, Vienna, Austria
| | - Herman Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Germany
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda-Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Nicolaus Kröger
- Department of Stem cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany
| | - Michele Cavo
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Italy
| | - Hartmut Goldschmidt
- Medizinische Klinik, Abteilung Innere Medizin V, Universitätsklinikum Heidelberg und National Centrum für Tumorerkrankungen (NCT), Heidelberg, Germany
| | - Benedetto Bruno
- Department of Oncology, A.O.U Città della Salute e della Scienza di Torino, and Department of Molecular Biotechnology and Health Sciences, University of Torino, Italy
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
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23
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Auner HW, Iacobelli S, Sbianchi G, Knol-Bout C, Blaise D, Russell NH, Apperley JF, Pohlreich D, Browne PV, Kobbe G, Isaksson C, Lenhoff S, Scheid C, Touzeau C, Jantunen E, Anagnostopoulos A, Yakoub-Agha I, Tanase A, Schaap N, Wiktor-Jedrzejczak W, Krejci M, Schönland SO, Morris C, Garderet L, Kröger N. Melphalan 140 mg/m 2 or 200 mg/m 2 for autologous transplantation in myeloma: results from the Collaboration to Collect Autologous Transplant Outcomes in Lymphoma and Myeloma (CALM) study. A report by the EBMT Chronic Malignancies Working Party. Haematologica 2017; 103:514-521. [PMID: 29217776 PMCID: PMC5830386 DOI: 10.3324/haematol.2017.181339] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 12/01/2017] [Indexed: 12/22/2022] Open
Abstract
Melphalan at a dose of 200 mg/m2 is standard conditioning prior to autologous hematopoietic stem cell transplantation for multiple myeloma, but a dose of 140 mg/m2 is often used in clinical practice in patients perceived to be at risk of excess toxicity. To determine whether melphalan 200 mg/m2 and melphalan 140 mg/m2 are equally effective and tolerable in clinically relevant patient subgroups we analyzed 1964 first single autologous transplantation episodes using a series of Cox proportional-hazards models. Overall survival, progression-free survival, cumulative incidence of relapse, non-relapse mortality, hematopoietic recovery and second primary malignancy rates were not significantly different between the melphalan 140 mg/m2 (n=245) and melphalan 200 mg/m2 (n=1719) groups. Multivariable subgroup analysis showed that disease status at transplantation interacted with overall survival, progression-free survival, and cumulative incidence of relapse, with a significant advantage associated with melphalan 200 mg/m2 in patients transplanted in less than partial response (adjusted hazard ratios for melphalan 200 mg/m2versus melphalan 140 mg/m2: 0.5, 0.54, and 0.56). In contrast, transplantation in very good partial or complete response significantly favored melphalan 140 mg/m2 for overall survival (adjusted hazard ratio: 2.02). Age, renal function, prior proteasome inhibitor treatment, gender, or Karnofsky score did not interact with overall/progression-free survival or relapse rate in the melphalan dose groups. There were no significant survival or relapse rate differences between melphalan 200 mg/m2 and melphalan 140 mg/m2 patients with high-risk or standard-risk chromosomal abnormalities. In conclusion, remission status at the time of transplantation may favor the use of melphalan 200 mg/m2 or melphalan 140 mg/m2 for key transplant outcomes (NCT01362972).
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Affiliation(s)
| | | | - Giulia Sbianchi
- Department of Biology, Tor Vergata University of Rome, Italy
| | | | | | | | | | | | - Paul V Browne
- St. James's Hospital, Trinity College Dublin, Ireland
| | - Guido Kobbe
- Heinrich Heine Universität, Düsseldorf, Germany
| | | | | | | | | | | | | | | | | | - Nicolaas Schaap
- Radboud University Medical Centre, Nijmegen, the Netherlands
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Sahin U, Demirer T. Current strategies for the management of autologous peripheral blood stem cell mobilization failures in patients with multiple myeloma. J Clin Apher 2017; 33:357-370. [DOI: 10.1002/jca.21591] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 09/09/2017] [Accepted: 09/11/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Ugur Sahin
- Department of Hematology; Ankara University Medical School; Ankara Turkey
| | - Taner Demirer
- Department of Hematology; Ankara University Medical School; Ankara Turkey
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Naegele M, Kirsch M, Ihorst G, Fierz K, Engelhardt M, De Geest S. Symptom experience of multiple myeloma (syMMex) patients treated with autologous stem cell transplantation following high-dose melphalan: a descriptive longitudinal study. Support Care Cancer 2017; 26:833-841. [DOI: 10.1007/s00520-017-3897-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/11/2017] [Indexed: 12/13/2022]
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