Outcomes of Patients with Heavily Pretreated Relapsed/Refractory Multiple Myeloma Receiving Salvage Cytotoxic Therapy with Supportive Stem Cell Boost

BACKGROUND

Multiple myeloma (MM) is an incurable hematologic malignancy characterized by the neoplastic proliferation of plasma cells, which produce monoclonal immunoglobulin that can cause vital organ damage, subsequently leading to significant morbidity and mortality. Autologous hematopoietic stem cell transplant (ASCT) is the standard-of-care management of eligible patients with newly diagnosed MM. Experts recommend collecting enough stem cells upfront to support a possible tandem transplant, salvage ASCT, or a stem cell "boost" to allow for the administration of multiagent cytotoxic chemotherapy in patients with relapsed/refractory disease.

OBJECTIVE

There is currently a paucity of data on the response rates and outcomes of patients with relapsed MM who undergo cytotoxic chemotherapy followed by a stem cell boost; this study examines the outcomes of patients treated with this approach.

METHODS

We conducted a retrospective chart review from two oncologic treatment centers in the United States of adult patients who underwent a first ASCT between 1999 and 2021 and subsequently received cytotoxic chemotherapy followed by stem cell boost further on in their disease course. Survival analysis was carried out using the Kaplan-Meier method, and the log-rank test was used to compare survival curves.

RESULTS

We found that the majority (56.6%) of these patients responded to therapy and that 60.6% of these patients were able to receive at least one subsequent line of therapy post-boost. Furthermore, patients who responded to therapy had significantly longer median overall survival compared to those who did not respond (323 days vs 93 days, p=0.0045), and age did not affect response to therapy.

CONCLUSION

This data allow clinicians to appropriately implement and inform patients of the therapeutic uses and clinical outcomes of stem cell boost in patients with multiply relapsed/refractory MM.

Interaction between age and gender on survival outcomes in extramedullary multiple myeloma over the past two decades

BACKGROUND

Extramedullary multiple myeloma (MM) (EMM) is a rare and aggressive subentity of MM that can be present at diagnosis or develop anytime during the disease course. There is a paucity of data on the clinical characteristics and overall epidemiology of EMM. Furthermore, there is a scarcity of data on how the interaction of age and gender influences the survival of EMM.

AIM

To evaluate the clinical characteristics of patients with EMM over the past 2 decades and to identify epidemiologic characteristics that may impact overall prognosis.

METHODS

A total of 858 patients diagnosed with EMM, between 2000 and 2017, were ultimately enrolled in our study by retrieving the Surveillance, Epidemiology, and End Results database. We analyzed demographics, clinical characteristics, and overall mortality (OM) as well as cancer-specific mortality (CSM) of EMM. Variables with a P value < 0.1 in the univariate Cox regression were incorporated into the multivariate Cox model to determine the independent prognostic factors, with a hazard ratio (HR) of greater than 1 representing adverse prognostic factors.

RESULTS

From a sample of 858 EMM, the male gender (63.25%), age range 60-79 years (51.05%), and non-Hispanic whites (66.78%) were the most represented. Central Nervous System and the vertebral column was the most affected site (33.10%). Crude analysis revealed higher OM in the age group 80+ [HR = 6.951, 95% confidence interval (95%CI): 3.299-14.647, P = 0], Non-Hispanic Black population (HR = 1.339, 95%CI: 1.02-1.759, P = 0.036), Bones not otherwise specified (NOS) (HR = 1.74, 95%CI: 1.043-2.902, P = 0.034), and widowed individuals (HR = 2.107, 95%CI: 1.511-2.938, P = 0). Skin involvement (HR = 0.241, 95%CI: 0.06-0.974, P = 0.046) and a yearly income of $75000+ (HR = 0.259, 95%CI: 0.125-0.538, P = 0) had the lowest OM in the crude analysis. Crude analysis revealed higher CSM in the age group 80+, Non-Hispanic Black, Bones NOS, and widowed. Multivariate cox proportional hazard regression analyses only revealed higher OM in the age group 80+ (HR = 9.792, 95%CI: 4.403-21.774, P = 0) and widowed individuals (HR = 1.609, 95%CI: 1.101-2.35, P = 0.014). Multivariate cox proportional hazard regression analyses of CSM also revealed higher mortality of the same groups. Eyes, mouth, and ENT involvement had the lowest CSM in the multivariate analysis. There was no interaction between age and gender in the adjusted analysis for OM and CSM.

CONCLUSION

EMM is a rare entity. To our knowledge, there is a scarcity of data on the clinical characteristics and prognosis factors of patients with extramedullary multiple myeloma. In this retrospective cohort, using a United States-based population, we found that age, marital status, and tumor site were independent prognostic factors. Furthermore, we found that age and gender did not interact to influence the mortality of patients with EMM.

Impact of the COVID-19 Pandemic on Treatment Patterns for Patients With Metastatic Solid Cancer in the United States

BACKGROUND

The COVID-19 pandemic has led to delays in patients seeking care for life-threatening conditions; however, its impact on treatment patterns for patients with metastatic cancer is unknown. We assessed the COVID-19 pandemic's impact on time to treatment initiation (TTI) and treatment selection for patients newly diagnosed with metastatic solid cancer.

METHODS

We used an electronic health record-derived longitudinal database curated via technology-enabled abstraction to identify 14 136 US patients newly diagnosed with de novo or recurrent metastatic solid cancer between January 1 and July 31 in 2019 or 2020. Patients received care at approximately 280 predominantly community-based oncology practices. Controlled interrupted time series analyses assessed the impact of the COVID-19 pandemic period (April-July 2020) on TTI, defined as the number of days from metastatic diagnosis to receipt of first-line systemic therapy, and use of myelosuppressive therapy.

RESULTS

The adjusted probability of treatment within 30 days of diagnosis was similar across periods (January-March 2019 = 41.7%, 95% confidence interval [CI] = 32.2% to 51.1%; April-July 2019 = 42.6%, 95% CI = 32.4% to 52.7%; January-March 2020 = 44.5%, 95% CI = 30.4% to 58.6%; April-July 2020 = 46.8%, 95% CI= 34.6% to 59.0%; adjusted percentage-point difference-in-differences = 1.4%, 95% CI = -2.7% to 5.5%). Among 5962 patients who received first-line systemic therapy, there was no association between the pandemic period and use of myelosuppressive therapy (adjusted percentage-point difference-in-differences = 1.6%, 95% CI = -2.6% to 5.8%). There was no meaningful effect modification by cancer type, race, or age.

CONCLUSIONS

Despite known pandemic-related delays in surveillance and diagnosis, the COVID-19 pandemic did not affect TTI or treatment selection for patients with metastatic solid cancers.

Optimal Management of Patients with Advanced or Metastatic Cholangiocarcinoma: An Evidence-Based Review

Cholangiocarcinomas are rare tumors originating at any point along the biliary tree. These tumors often pose significant challenges for diagnosis and treatment, and often carry a poor prognosis. However, in recent years, studies have identified significant molecular heterogeneity with up to 50% of tumors having detectable mutations, leading to the guideline recommendations for molecular testing as part of the diagnostic workup for these tumors. In addition, better classification of these tumors and understanding of their biology has led to new drugs being approved for treatment of this resistant tumor. This manuscript will provide a comprehensive review of the epidemiology, risk factors, diagnostic approach, molecular classification, and treatment options for patients with advanced cholangiocarcinomas.

Impact of the COVID-19 pandemic on treatment patterns for US patients with metastatic solid cancer

BACKGROUND

The COVID-19 pandemic has led to delays in patients seeking care for life-threatening conditions; however, its impact on treatment patterns for patients with metastatic cancer is unknown. We assessed the COVID-19 pandemic's impact on time to treatment initiation (TTI) and treatment selection for patients newly diagnosed with metastatic solid cancer.

METHODS

We used an electronic health record-derived longitudinal database curated via technology-enabled abstraction to identify 14,136 US patients newly diagnosed with de novo or recurrent metastatic solid cancer between January 1 and July 31 in 2019 or 2020. Patients received care at ∼280 predominantly community-based oncology practices. Controlled interrupted time series analyses assessed the impact of the COVID-19 pandemic period (April-July 2020) on TTI, defined as the number of days from metastatic diagnosis to receipt of first-line systemic therapy, and use of myelosuppressive therapy.

RESULTS

The adjusted probability of treatment within 30 days of diagnosis [95% confidence interval] was similar across periods: January-March 2019 41.7% [32.2%, 51.1%]; April-July 2019 42.6% [32.4%, 52.7%]; January-March 2020 44.5% [30.4%, 58.6%]; April-July 2020 46.8% [34.6%, 59.0%]; adjusted percentage-point difference-in-differences 1.4% [-2.7%, 5.5%]. Among 5,962 patients who received first-line systemic therapy, there was no association between the pandemic period and use of myelosuppressive therapy (adjusted percentage-point difference-in-differences 1.6% [-2.6%, 5.8%]). There was no meaningful effect modification by cancer type, race, or age.

CONCLUSIONS

Despite known pandemic-related delays in surveillance and diagnosis, the COVID-19 pandemic did not impact time to treatment initiation or treatment selection for patients with metastatic solid cancers.

Impact of COVID-19 pandemic on time to treatment initiation for patients with advanced cancer

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Background: The COVID-19 pandemic has disrupted US healthcare delivery and led to delays in life-prolonging therapy for some conditions. Its impact on diagnosis and timely care delivery for patients (pts) with cancer is unknown. We assessed the pandemic’s impact on time from advanced diagnosis to systemic treatment initiation (TTI) for pts with newly diagnosed advanced solid cancers. Methods: We performed a controlled interrupted time series analysis using the nationwide Flatiron Health electronic health record-derived de-identified database, which originated from ̃280 US cancer clinics. The study sample included pts ≥ 18 years diagnosed with advanced solid cancers from Jan 1-Jul 31 in 2019 or in 2020, excluding a 30-day period (Mar 8-Apr 7) encompassing the start of most state stay-at-home orders. We used Cox proportional hazards models to estimate standardized predicted probabilities of TTI within 30 days of advanced diagnosis before (Jan-Mar) and during (Apr-Jul) the pandemic in 2020, compared to historical controls in 2019, adjusted for age, sex, race, insurance, performance status, and cancer type. Interactions by cancer type and race examined heterogeneity of effects. Results: The study included 12,977 pts (median age 69 yrs [IQR 61-77]; 47.4% female; 59.4% non-Hispanic white). At the time of analysis, fewer advanced cancer diagnoses were recorded in 2020 (Jan-Mar 2,409; Apr-Jul 3,027) than in 2019 (Jan-Mar 2,910; Apr-Jul 4,631). Compared to Apr-Jul 2019, pts diagnosed with advanced cancer during the COVID-19 period were more likely to have de novo (vs recurrent) disease (67.3% vs 56.8%). In adjusted models, the COVID-19 period was associated with an increased probability of treatment within 30 days (adjusted difference-in-differences +5.2 percentage points [ppts]). TTI improvements were not observed for pts with advanced breast cancer or Black pts, but effect differences across subgroups were not statistically significant (Table). Conclusions: Among pts diagnosed with advanced cancer, the COVID-19 pandemic was associated with shorter time to systemic therapy initiation. These treatment patterns may reflect the fewer advanced cancer diagnoses and higher proportion of de novo cancers observed during this period. Longer follow-up and data maturity are needed to understand the impact of the pandemic on clinical outcomes.[Table: see text]

Checkpoint inhibitor therapy, with and without radiation, in diffuse large B cell lymphoma: A single-center analysis

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Background: Single agent checkpoint inhibitors (CPI) in NHLs have resulted in modest successes. Exceptions include RT, PCNS and testicular lymphomas, where higher activity is seen. As a single agent, CPI response rates range from 10-40% in relapsed refractory (RR) DLBCL, with few CRs and short response durations. In a cohort of RR DLBCL patients at our institution, we sought to identify clinical features that defined responders and non-responders. Methods: Between 9/2016 and 7/2018, 13 pts with DLBCL/RT, treated with a CPI, either on trial or as off-label therapy, with at minimum 1 infusion/cycle were included. Pathology specimens confirming DLBCL/RT were reviewed at FCCC. All pts had measurable disease by CT or PET/CT prior to CPI and had an evaluable response. Cell of origin was determined by Hans IHC. Results: Almost half (6/13) of pts achieved a response to CPI. Notably all responders had either concurrent or pre-treatment XRT. All 3 RT patients responded to CPI and continued to allo transplant. P3 and P6 both developed GVHD post allo, resulting in a demise in P3. No GC subtype pts responded nor had prior/ concurrent XRT with CPI. In 2 pts responses are ongoing, > 1 yr, and 1 RT pt remains in CR. Conclusions: XRT, prior or concurrent with CPI , was associated with durable responses in RR DLBCL. Patients with bulky ( > 7cm), rapidly progressive disease (8/13 cases) may require a 'debulking' strategy for CPI efficacy. An abscopal effect achieved with XRT/CPI combinations, may be impactful RR NHL. Analysis of PDL1/2 and MHC I/II, with other biomarkers, are underway. These clinical results warrant validation in a larger cohort, therefore a prospectively designed study is planned for 2019 in RR DLBCL/RT. [Table: see text]

Monoclonal gammopathy of undetermined significance in systemic transthyretin amyloidosis (ATTR)

OBJECTIVE

To identify the prevalence of monoclonal gammopathy of undetermined significance (MGUS) in patients with transthyretin (ATTR) amyloidosis.

PATIENTS AND METHODS

We performed a retrospective analysis of patients with biopsy-proven ATTRwt (wild-type transthyretin amyloid protein) and genopositive ATTR V122I (valine-to-isoleucine substitution at position 122 of the TTR gene) amyloidosis evaluated at the Amyloidosis Center at Boston University and Boston Medical Center between 1 January 2003 and 31 December 2016.

RESULTS

There were a total of 226 patients with ATTRwt and ATTR V122I amyloidosis evaluated during the specified time frame with 155 and 71 patients in each cohort, respectively. Those with complete medical records, 140 patients with ATTRwt and 57 V1221 ATTRm subjects, were included in the analyses. Fifty-five patients (39%) in the ATTRwt cohort and 28 patients (49%) in the ATTR V122I cohort had an MGUS, as indicated by an abnormality in the serum-free light-chain ratio and/or serum immunofixation electrophoresis.

CONCLUSION

These data confirm the high prevalence of coexistent MGUS with ATTR amyloidosis in this patient population, with an MGUS rate that is higher than the general population. These findings also highlight the importance of a thorough diagnostic evaluation in patients with amyloidosis to determine the precursor protein, as the clinical course and treatment of AL (light-chain amyloid protein) and ATTR amyloidosis are distinct.

Systematic review and meta-analysis of the evidence for flexible sigmoidoscopy as a screening method for the prevention of colorectal cancer

BACKGROUND

Colorectal cancer is a significant cause of death. Removal of precancerous adenomas, and early detection and treatment of cancer, has been shown to reduce the risk of death. The aim of this review and meta-analysis was to determine whether flexible sigmoidoscopy (FS) is an effective population screening method for reducing mortality from colorectal cancer.

METHODS

MEDLINE (1946 to December 2012) and Embase (1980-2012, week 15) were searched for randomized clinical trials in which FS was used to screen non-symptomatic adults from a general population, and FS was compared with either no screening or any other alternative screening methods. Meta-analysis was carried out using a random-effects Mantel-Haenzsel model.

RESULTS

Twenty-four papers met the inclusion criteria, reporting results from 14 trials. Uptake of FS was usually lower than that for stool-based tests, although FS was more effective at detecting advanced adenoma and carcinoma. FS reduced the incidence of colorectal cancer after screening, and long-term mortality from colorectal cancer, compared with no screening in a selected population. Compared with stool-based tests in a general population, FS was associated with fewer interval cancers.

CONCLUSION

FS is efficacious at reducing colorectal cancer mortality compared with no screening. It is more effective at detecting advanced adenoma and carcinoma than stool-based tests. FS may be compromised by poorer uptake. Introduction of FS as a screening method should be done on a pilot basis in populations in which it is not currently used, and close attention should be paid to maximizing uptake. The relative risk of adverse events with FS compared with stool-based tests should be quantified, and its real-world effectiveness evaluated against the most effective stool-based tests.

MR colonography without bowel cleansing or water enema: a pilot study

OBJECTIVES

The value of screening for colorectal cancer has been well demonstrated, and national programmes are being implemented. At present the primary imaging modality is colonoscopy, which has an associated morbidity and mortality. CT colonography (CTC) has been proposed as an alternative, but this is associated with radiation exposure and generally requires bowel preparation. The aim of this pilot study was to assess the feasibility of MR colonography (MRC) without bowel preparation or water enema for the detection of colorectal neoplasia.

METHODS

Patients scheduled for colonoscopy were invited to participate in the study; informed consent was obtained. MRC (with oral barium faecal tagging and colonic air distension) was performed 1-2 weeks before the colonoscopy. Axial T(2) weighted single-shot fast spin-echo (prone and supine) and axial T(1) weighted fast spoiled gradient-recalled (pre- and post-iv gadolinium) supine MRI sequences were performed. The examinations were reported by two gastrointestinal radiologists by consensus. Colonoscopy following standard bowel preparation was performed by a single endoscopist blinded to the MRC results. Significant lesions were defined as polyps or masses >10 mm in diameter.

RESULTS

29 patients were studied. Colonoscopy revealed 25 mass lesions in 13 patients. MRC correctly identified four of the nine lesions >10 mm in diameter (sensitivity 44%; specificity 100%). Although specificity remained high for smaller lesions, sensitivity was poor.

CONCLUSION

This pilot study has demonstrated the feasibility of performing MRC without bowel preparation or water enema. This would seem to be a promising modality for colorectal cancer screening. Larger studies are required to determine the accuracy of this modality for the detection of colorectal neoplasia.

Audit of bowel preparation with Picolax (sodium picosulfate plus magnesium citrate) for colonoscopy

The aim of this study was to assess the quality of bowel preparation for colonoscopy with standard dose Picolax (two sachets administered on the day prior to the procedure, as per the manufacturer's instructions) in a large cohort of patients. A retrospective audit was performed of colonoscopies performed at our institution over a 1-year period. Patients were excluded if standard dose Picolax was not used, if the quality of the bowel preparation was not recorded or if completion of the procedure was not recorded. Of the 619 fully evaluable cases, the quality of the bowel preparation was assessed by the colonoscopist performing the procedure as good in 263 (42.5%), satisfactory in 242 (39.1%) and poor in 114 (18.4%) of the cases. In only 28 (4.5%) cases, poor bowel preparation was the reason cited for an incomplete colonoscopy. There was no difference in the quality of bowel preparation between inpatients and outpatients. In clinical practice, Picolax is an effective bowel preparation for colonoscopy in the vast majority of cases.