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Lipof JJ, Abdallah N, Lipe B. Personalized Treatment of Multiple Myeloma in Frail Patients. Curr Oncol Rep 2024:10.1007/s11912-024-01545-2. [PMID: 38761302 DOI: 10.1007/s11912-024-01545-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE OF REVIEW As the treatment landscape for multiple myeloma (MM) continues to expand at a rapid pace, management of older adults and frail patients becomes increasingly challenging. As these patients have traditionally been underrepresented on clinical trials, there is limited guidance on the optimal approach to frail patients with newly diagnosed multiple myeloma (NDMM) or relapsed and refractory multiple myeloma (RRMM). RECENT FINDINGS Frailty is an independent predictor of tolerability and response to antineoplastic treatment. Stringent eligibility criteria have often excluded these patients, but recently some large trials have included frailty sub-analyses to help guide management. In general, triplet regimens are preferred to doublet regimens in this population and enrollment on a clinical trial should be prioritized when possible. In this review, we summarize the MM frailty scoring tools that have been developed to identify and assess this vulnerable population. We present the clinical trials over the past decade that have enrolled frail patients and/or have included subgroup analyses to help elucidate the response and tolerability of different regimens in this underrepresented group. We provide practical advice regarding assessment and management of frail patients NDMM and RRMM.
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Affiliation(s)
- Jodi J Lipof
- Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, NY, USA
| | - Nadine Abdallah
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brea Lipe
- Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, NY, USA.
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Neuendorff NR, Khan A, Ullrich F, Yates S, Devarakonda S, Lin RJ, von Tresckow B, Cordoba R, Artz A, Rosko AE. Cellular therapies in older adults with hematological malignancies: A case-based, state-of-the-art review. J Geriatr Oncol 2024; 15:101734. [PMID: 38430810 DOI: 10.1016/j.jgo.2024.101734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 11/05/2023] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
Cellular therapies, including autologous stem cell transplant (ASCT), allogeneic hematopoietic cell transplantation (alloHCT), and chimeric antigen receptor- (CAR-) T cell therapies are essential treatment modalities for many hematological malignancies. Although their use in older adults has substantially increased within the past decades, cellular therapies represent intensive treatment approaches that exclude a large percentage of older adults due to comorbidities and frailty. Under- and overtreatment in older adults with hematologic malignancy is a challenge and many treatment decisions are influenced by chronologic age. The advent of efficient and well-tolerated newer treatment approaches for multiple myeloma has challenged the role of ASCT. In the modern era, there are no randomized clinical trials of transplant versus non-transplant strategies for patients ≥65 years. Nonetheless, ASCT is feasible for selected older patients and does not result in long-term compromise in quality of life. AlloHCT is the only curative approach for acute myeloid leukemia of intermediate and unfavourable risk but carries a significant risk for non-relapse mortality depending on comorbidities, general fitness, and transplant-specific characteristics, such as intensity of conditioning and donor choice. However, alloHCT is feasible in appropriately-selected older adults. Early referral for evaluation is strongly encouraged as this is the most obvious barrier. CAR-T cell therapies have shown unprecedented clinical efficacy and durability in relapsed and refractory diffuse large B cell lymphoma. Its use is well tolerated in older adults, although evidence comes from limited case numbers. Whether patients who are deemed unfit for ASCT qualify for CAR-T cell therapy remains elusive, but the tolerability and efficacy of CAR-T cell therapy appears promising, especially for older patients. The evidence from randomized trials is strong in favor of using a comprehensive geriatric assessment (CGA) to reduce treatment-related toxicities and guide treatment intensity in the care for solid tumors; its use for evaluation of cellular therapies is less evidence-based. However, CGA can provide useful information on patients' fitness, resilient mechanisms, and reveal potential optimization strategies for compensating for vulnerabilities. In this narrative review, we will discuss key questions on cellular therapies in older adults based on illustrative patient cases.
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Affiliation(s)
- Nina Rosa Neuendorff
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany.
| | - Abdullah Khan
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
| | - Fabian Ullrich
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany
| | - Samuel Yates
- Department of Internal Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, United States of America
| | - Srinivas Devarakonda
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
| | - Richard J Lin
- Adult Bone Marrow Transplantation (BMT) Service, Cellular Therapy Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Bastian von Tresckow
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany
| | - Raul Cordoba
- Lymphoma Unit, Department of Hematology, Health Research Institute IIS-FJD, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
| | - Andrew Artz
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Ashley E Rosko
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
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Hsu TL, Tsai CK, Liu CY, Yeh CM, Lin FL, Hsiao LT, Liu YC, Chien SH, Wang HY, Ko PS, Lin TA, Chen WC, Chen PM, Liu JH, Gau JP, Liu CJ. Risk factors of early disease progression and decreased survival for multiple myeloma patients after upfront autologous stem cell transplantation. Ann Hematol 2024:10.1007/s00277-024-05641-y. [PMID: 38472362 DOI: 10.1007/s00277-024-05641-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/19/2024] [Indexed: 03/14/2024]
Abstract
Multiple myeloma (MM) stands as the second most prevalent hematological malignancy, constituting approximately 10% of all hematological malignancies. Current guidelines recommend upfront autologous stem cell transplantation (ASCT) for transplant-eligible MM patients. This study seeks to delineate factors influencing post-ASCT outcomes in MM patients. Our cohort comprised 150 MM patients from Taipei Veterans General Hospital, with progression-free survival (PFS) as the primary endpoint and overall survival (OS) as the secondary endpoint. A Cox proportional hazards model was employed to discern potential predictive factors for survival. ASCT age ≥ 65 (hazard ratio [HR] 1.94, 95% confidence interval [CI] 1.08-3.47) and the presence of extramedullary disease (HR 2.53, 95% CI 1.53-4.19) negatively impacted PFS. Conversely, treatment response ≥ VGPR before ASCT (HR 0.52, 95% CI 0.31-0.87) and total CD34+ cells collected ≥ 4 × 106 cells/kg on the first stem cell harvesting (HR 0.52, 95% CI 0.32-0.87) were positively associated with PFS. For OS, patients with ISS stage III (HR 2.06, 95% CI 1.05-4.04), the presence of extramedullary disease (HR 3.92, 95% CI 2.03-7.58), light chain ratio ≥ 100 before ASCT (HR 7.08, 95% CI 1.45-34.59), post-ASCT cytomegalovirus infection (HR 9.43, 95% CI 3.09-28.84), and a lower conditioning melphalan dose (< 140 mg/m2; HR 2.75, 95% CI 1.23-6.17) experienced shorter OS. In contrast, post-ASCT day + 15 absolute monocyte counts (D15 AMC) > 500/µl (HR 0.36, 95% CI 0.17-0.79) and post-ASCT day + 15 platelet counts (D15 PLT) > 80,000/µl (HR 0.48, 95% CI 0.24-0.94) were correlated with improved OS. Significantly, early PLT and AMC recovery on day + 15 predicting longer OS represents a novel finding not previously reported. Other factors also align with previous studies. Our study provides real-world insights for post-ASCT outcome prediction beyond clinical trials.
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Affiliation(s)
- Te-Lin Hsu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- Division of Holistic and Multidisciplinary Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chun-Kuang Tsai
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Yu Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chiu-Mei Yeh
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fen-Lan Lin
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Liang-Tsai Hsiao
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yao-Chung Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Sheng-Hsuan Chien
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hao-Yuan Wang
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Shen Ko
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ting-An Lin
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Chun Chen
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Min Chen
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jin-Hwang Liu
- Section of Hematology and Oncology, Department of Internal Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
- Institute of Biopharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Chong Hin Loon Memorial Cancer and Biotherapy Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jyh-Pyng Gau
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Jen Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201 Shipai Road, Sec. 2, Taipei, 11217, Taiwan.
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
- Institute of Emergency and Critical Care Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Davis JA, Dima D, Ahmed N, DeJarnette S, McGuirk J, Jia X, Raza S, Khouri J, Valent J, Anwer F, Abdallah AO, Hashmi H. Impact of Frailty on Outcomes after Chimeric Antigen Receptor T Cell Therapy for Patients with Relapsed/Refractory Multiple Myeloma. Transplant Cell Ther 2024; 30:298-305. [PMID: 38142943 DOI: 10.1016/j.jtct.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/29/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
The literature is limited regarding outcomes in older adults and frail patients receiving BCMA-directed chimeric antigen receptor T cell therapy (CAR-T) for relapsed or refractory multiple myeloma. Here we describe the safety and efficacy of CAR-T in these clinically important subgroups treated in a real-world setting. Frailty was defined as a frail score ≥2 using the simplified frailty index (score based on age + Eastern Cooperative Oncology Group [ECOG] Performance Status + Hematopoietic Cell Transplantation Comorbidity Index [HCT-CI]). Of the 136 patients analyzed (age range, 41 to 81 years), 83 (61%) were considered frail at the time of CAR-T infusion. Compared to the nonfrail group, the frail group had higher proportions of patients with renal insufficiency (18% versus 6%), high-risk cytogenetics (45% versus 35%), extramedullary disease (51% versus 43%), and ECOG Performance Status ≥2 (18% versus 2%), and worse HCT-CI (3 versus 1). Although patients in the frail group had a higher incidence of immune effector cell-associated neurotoxicity syndrome (ICANS) (39% versus 17%), the incidences of all- grade cytokine release syndrome (CRS), as well as high-grade CRS and ICANS, were similar in the 2 groups. With a median follow-up of 7 months, the median progression-free survival was 6.9 months in the frail group versus 11.1 months in the nonfrail group (P = .028). The median overall survival was 14 months in the frail group and was not reached in the nonfrail group (P = .025). This study highlights the tolerable safety and reasonable efficacy of CAR-T for frail myeloma patients in a real-world practice. Although the frail patients did not experience any excessive high-grade toxicities, they did have inferior efficacy outcomes.
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Affiliation(s)
- James A Davis
- US Myeloma Innovations Research Collaborative, Kansas City, Kansas; Department of Hematology-Oncology, Medical University of South Carolina, Charleston, South Carolina
| | - Danai Dima
- US Myeloma Innovations Research Collaborative, Kansas City, Kansas; Department of Hematology-Oncology, Cleveland Clinic, Taussig Cancer Center, Cleveland, Ohio
| | - Nausheen Ahmed
- US Myeloma Innovations Research Collaborative, Kansas City, Kansas; Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, Kansas
| | - Shaun DeJarnette
- Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, Kansas
| | - Joseph McGuirk
- US Myeloma Innovations Research Collaborative, Kansas City, Kansas; Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, Kansas
| | - Xuefei Jia
- Department of Biostatistics and Quantitative Health Science, Cleveland Clinic, Cleveland, Ohio
| | - Shahzad Raza
- Department of Hematology-Oncology, Cleveland Clinic, Taussig Cancer Center, Cleveland, Ohio
| | - Jack Khouri
- Department of Hematology-Oncology, Cleveland Clinic, Taussig Cancer Center, Cleveland, Ohio
| | - Jason Valent
- Department of Hematology-Oncology, Cleveland Clinic, Taussig Cancer Center, Cleveland, Ohio
| | - Faiz Anwer
- US Myeloma Innovations Research Collaborative, Kansas City, Kansas; Department of Hematology-Oncology, Cleveland Clinic, Taussig Cancer Center, Cleveland, Ohio
| | - Al-Ola Abdallah
- US Myeloma Innovations Research Collaborative, Kansas City, Kansas; Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, Kansas
| | - Hamza Hashmi
- US Myeloma Innovations Research Collaborative, Kansas City, Kansas; Department of Hematology-Oncology, Medical University of South Carolina, Charleston, South Carolina.
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Friend R, Atrash S. Fragile Warriors: Navigating the Delicate Dance of Frailty and CAR-T cell Therapy for Relapsed/Refractory Multiple Myeloma. Transplant Cell Ther 2024; 30:253-254. [PMID: 38485337 DOI: 10.1016/j.jtct.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- Reed Friend
- Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute, Department of Internal Medicine, Wake Forest University School of Medicine, Charlotte, NC.
| | - Shebli Atrash
- Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute, Department of Internal Medicine, Wake Forest University School of Medicine, Charlotte, NC
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Jurgens E, Usmani SZ. SOHO State of the Art Updates and Next Questions: Will CAR-T Replace ASCT in NDMM. Clin Lymphoma Myeloma Leuk 2024:S2152-2650(24)00018-1. [PMID: 38331676 DOI: 10.1016/j.clml.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/04/2024] [Indexed: 02/10/2024]
Abstract
The treatment landscape for multiple myeloma (MM) has rapidly evolved over the last 2 decades. The development of triplet and quadruplet regimens including proteasome inhibitors (PI), immunomodulatory agents (IMiDs), and anti-CD38 monoclonal antibodies has dramatically extended overall survival. In addition to effective multidrug regimens, autologous stem cell transplant (ASCT) is a cornerstone of management in newly diagnosed multiple myeloma (NDMM). However, despite these combined treatment modalities, curative therapy for MM remains elusive. Recent, novel immunotherapies including chimeric antigen T-cell (CAR-T) therapy have demonstrated deep and durable responses in relapsed and refractory multiple myeloma (RRMM). Currently 2 CAR-T products, ciltacabtagene autoleucel (cilta-cel) and idecabtagene vicleucel (ide-cel), are approved by the FDA for the treatment of RRMM. The success of CAR-T therapy revolutionized the management of RRMM prompting clinical trials studying CAR-T therapy in the first line setting. The ongoing KarMMa-4, CARTITUDE-5, and CARTITUDE-6 clinical trials may establish CAR-T therapy as a first line option potentially supplanting ASCT in the initial treatment of NDMM. In this review, we discuss the current standard of care management of NDMM, trace the evolution of CAR-T clinical trials in RRMM, and survey ongoing clinical trials studying CAR-T therapy in NDMM.
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Affiliation(s)
- Eric Jurgens
- Department of Medicine, Hematology Oncology Fellowship Program, MSKCC, New York, NY
| | - Saad Z Usmani
- Department of Medicine, Myeloma Service, MSKCC, New York, NY.
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Gaffney KJ, Bakos JK, Velayati A, Davis JA, Thurlapati A, Weeda E, Maldonado A, Granger K, Butcher C, Herrington T, Smith D, Green K, Hess BT, Hashmi H. Impact of age, obesity, and renal impairment on outcomes after autologous stem cell transplantation for patients with newly diagnosed multiple myeloma. J Oncol Pharm Pract 2024:10781552231224361. [PMID: 38166529 DOI: 10.1177/10781552231224361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
INTRODUCTION There remains a need to determine whether certain subgroups of newly diagnosed multiple myeloma (NDMM) derive the same benefit from high-dose chemotherapy-autologous stem cell transplant (HDT-ASCT). We describe our institutional experience highlighting the impact of age, obesity, and renal impairment on outcomes after HDT-ASCT for patients with NDMM in a real-world setting. METHODS A total of 449 consecutive patients were included in this retrospective analysis. RESULTS No difference in median progression free survival or overall survival was seen for patients with age > 65, body mass index (BMI) > 30 kg/m2, or estimated glomerular filtration rate < 60 mL/min/1.73 m2 when compared to those without these characteristics. From a safety standpoint, there were no differences in the incidence of transplant-related mortality or secondary malignancy among subgroups. CONCLUSION For patients with NDMM undergoing HDT-ASCT, there is no difference in outcomes based on age, BMI, or renal function, and the presence of one or more of these factors should not preclude patients from HDT-ASCT.
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Affiliation(s)
- Kelly J Gaffney
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Jonathan K Bakos
- Department of Hematology and Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Arash Velayati
- Department of Hematology and Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - James A Davis
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Aswani Thurlapati
- Department of Hematology and Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Erin Weeda
- College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Andy Maldonado
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Katelynn Granger
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Coleen Butcher
- Department of Hematology and Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Taylor Herrington
- College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Deidra Smith
- Department of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Kimberly Green
- Department of Hematology and Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Brian T Hess
- Department of Hematology and Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Hamza Hashmi
- Department of Hematology and Oncology, Medical University of South Carolina, Charleston, SC, USA
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Strouse C, Mott SL, Smith BJ, Magalhaes-Silverman M, Farooq U, Zhan F, Jethava Y, Tricot G. Transplant conditioning with bortezomib, thalidomide, and melphalan and intensive 2 year post-transplant therapy for multiple myeloma in older patients. Bone Marrow Transplant 2024; 59:128-130. [PMID: 37816907 PMCID: PMC10781621 DOI: 10.1038/s41409-023-02119-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/14/2023] [Accepted: 09/26/2023] [Indexed: 10/12/2023]
Affiliation(s)
- Christopher Strouse
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA, USA.
| | - Sarah L Mott
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | - Brian J Smith
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
| | | | - Umar Farooq
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA, USA
| | - Fenghuang Zhan
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas Medical Center, Little Rock, AK, USA
| | - Yogesh Jethava
- Indiana Blood & Marrow Transplant, Indianapolis, IN, USA
| | - Guido Tricot
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas Medical Center, Little Rock, AK, USA
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Gibson S, Thornton J, Sunderland K, Pham K, DeStefano C. Multiple Myeloma in Adolescent and Young Adults: An ASCO CancerLinQ and SEER Analysis. Clin Lymphoma Myeloma Leuk 2023; 23:e335-e340. [PMID: 37541820 DOI: 10.1016/j.clml.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Multiple myeloma (MM) is exceedingly rare in adolescents and young adults (AYAs) < 45 years of age. METHODS Real-world data from ASCO's CancerLinQ DiscoveryⓇ (CLQD) MM dataset and SEER were utilized to characterize demographics and outcomes of AYA MM patients in the United States in the modern treatment era. Frequencies of SPMs, VTEs, and infections were assessed, as were OS and cause of death. RESULTS A total of 1946 AYA MM patients from SEER and 1334 from CancerLinQ were included. In terms of SPMs, AYAs were more likely to develop ALL (RR 2.6, P = .003) and AML (RR 1.7, P = .034), and less likely to develop nonmelanoma skin cancer (RR 0.2, P = .001) and prostate cancer (RR 0.1, P = .013) than MM patients ≥ 45. AYAs were at lower risk of VTE (RR 0.75, P = .002) and slightly higher risk of infections (RR 1.11, P = .002). Median OS among AYA MM patients was significantly longer than MM patients ≥ 45 in both datasets. In the SEER cohort, female sex (HR 0.74, P = .003), non-Hispanic ethnicity (HR 0.73, P = .005), and annual household income ≥ $65,000 per year (HR 0.67, P = .001) were associated with lower hazards of mortality. In the CLQD cohort, OS was significantly influenced by female sex (HR 0.6, P = .048). Race did not have a statistically significant impact OS in either cohort. Most AYAs died of MM (68.3%), other primary malignancy (7.5%, mostly leukemia), and cardiovascular events (5.2%). Infections accounted for 3.2% of deaths. CONCLUSION This analysis highlights some unique characteristics of AYA MM patients in the United States in the modern era.
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Affiliation(s)
- Steven Gibson
- Department of Hematology/Oncology, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jennifer Thornton
- Clinical Investigation Facility, David Grant USAF Medical Center, Fairfield, CA; Ripple Effect, Rockville, MD
| | - Kevin Sunderland
- Clinical Investigation Facility, David Grant USAF Medical Center, Fairfield, CA; Ripple Effect, Rockville, MD
| | - Kevin Pham
- Clinical Investigation Facility, David Grant USAF Medical Center, Fairfield, CA
| | - Christin DeStefano
- Department of Hematology/Oncology, Walter Reed National Military Medical Center, Bethesda, MD.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Cerchione C, Grant SJ, Ailawadhi S. Partnering With All Patients: Ensuring Shared Decision Making and Evidence-Based Management for Underrepresented Groups With Multiple Myeloma. Am Soc Clin Oncol Educ Book 2023; 43:e390202. [PMID: 37167570 PMCID: PMC10798363 DOI: 10.1200/edbk_390202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Several landmark therapeutic advances in multiple myeloma (MM) have led to an unprecedented number of options available to patients and their physicians as shared decision making is attempted. A myriad of factors need to be considered to ensure that patient-, disease-, and treatment-related factors are addressed to arrive at the most appropriate choice for patients at that time in their journey with myeloma. Some of these factors have traditionally remained underaddressed but have a clear association with patient outcomes, leading to underrepresented groups of patients with MM, including the elderly patients, racial-ethnic minorities, and those with specific advanced comorbidities, for example, renal insufficiency. Some of these factors may not be modifiable, but data suggest that they may give rise to implicit or explicit bias and affect treatment decisions. A growing body of literature is bringing these factors to light. However, their incorporation in day-to-day decision making for patients needs to be universal. It is imperative that prospective data are generated for all these and other underrepresented groups such that evidence-based medicine is applicable universally to all patients with MM, irrespective of clinical and sociodemographic factors.
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Affiliation(s)
- Claudio Cerchione
- Hematology Unit, Istituto Romagnolo per lo Studio dei
Tumori, Meldola, Italy
| | - Shakira J. Grant
- Department of Medicine, Division of Hematology, University
of North Carolina, Chapel Hill, NC
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12
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Jazowski SA, Samuel-Ryals CA, Wood WA, Zullig LL, Trogdon JG, Dusetzina SB. Association between low-income subsidies and inequities in orally administered antimyeloma therapy use. Am J Manag Care 2023; 29:246-254. [PMID: 37229783 PMCID: PMC10268034 DOI: 10.37765/ajmc.2023.89357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES The Medicare Part D low-income subsidy program drastically reduces patient cost sharing and may improve access to and equitable use of high-cost antimyeloma therapy. We compared initiation of and adherence to orally administered antimyeloma therapy between full-subsidy and nonsubsidy enrollees and assessed the association between full subsidies and racial/ethnic inequities in orally administered antimyeloma treatment use. STUDY DESIGN Retrospective cohort study. METHODS We used Surveillance, Epidemiology, and End Results-Medicare data to identify beneficiaries diagnosed with multiple myeloma between 2007 and 2015. Separate Cox proportional hazards models assessed time from diagnosis to treatment initiation and time from therapy initiation to discontinuation. Modified Poisson regression examined therapy initiation in the 30, 60, and 90 days following diagnosis and adherence to and discontinuation of treatment in the 180 days following initiation. RESULTS Receipt of full subsidies was not associated with earlier initiation of or improved adherence to orally administered antimyeloma therapy. Full-subsidy enrollees were 22% (adjusted HR [aHR], 1.22; 95% CI, 1.08-1.38) more likely to experience earlier treatment discontinuation than nonsubsidy enrollees. Receipt of full subsidies did not appear to reduce racial/ethnic inequities in orally administered antimyeloma therapy use. Black full-subsidy and nonsubsidy enrollees were 14% less likely than their White counterparts to ever initiate treatment (full subsidy: aHR, 0.86; 95% CI, 0.73-1.02; nonsubsidy: aHR, 0.86; 95% CI, 0.74-0.99). CONCLUSIONS Full subsidies alone are insufficient to increase uptake or equitable use of orally administered antimyeloma therapy. Addressing known barriers to care (eg, social determinants of health, implicit bias) could improve access to and use of high-cost antimyeloma therapy.
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Affiliation(s)
- Shelley A Jazowski
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave, Ste 1200, Nashville, TN 37203.
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Chakraborty R, Yi J, Rybicki L, Preussler J, Deol A, Loren A, Savani B, Jim HSL, Cerny J, Reynolds J, Whitten J, Wingard JR, McGuirk JP, Uberti J, Khera N, Stiff P, Jaglowski SM, Hashmi S, Holtan SG, Devine S, Hahn T, Whalen VL, Saber W, Wood W, Baker KS, Syrjala K, Majhail NS. Patient-Reported Outcomes in Long-Term Survivors of Autologous Hematopoietic Cell Transplantation in Multiple Myeloma. Transplant Cell Ther 2023:S2666-6367(23)01102-8. [PMID: 36870388 DOI: 10.1016/j.jtct.2023.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/02/2023] [Accepted: 02/09/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND The overall survival in patients with transplant-eligible multiple myeloma has tripled in the past two decades, leading to a growing population of myeloma survivors. However, there is a paucity of data on health-related quality of life (HRQoL), distress, and health behaviors in long-term myeloma survivors who are in stable remission after autologous hematopoietic cell transplantation (AHCT). METHODS This is a cross-sectional study using data from two randomized controlled trials of survivorship care plans and internet based self-management intervention in transplant survivors. The primary objective of this study was to measure HRQoL (SF12v2), distress, and health behaviors of myeloma survivors in stable remission after AHCT. Distress were measured by Cancer and Treatment Related Distress (CTXD) instrument. FINDINGS A total of 345 patients at a median of 4 years (range, 1.4-11) post-AHCT were included. The mean Physical Component Summary (PCS) and Mental Component Summary (MCS) score was 45.5 (±10.5) and 51.3 (±10.1) respectively, compared to US population norm of 50 (±10) (p<0.001 and p=0.021 for PCS and MCS comparisons, respectively), with neither reaching the threshold for minimal clinically important difference (5) Approximately one-third of patients had clinically significant distress based on CTXD total score, with the following proportion of patients reporting distress at each domain: Health Burden (53%), Uncertainty (46%), Finances (33%), Family Strain (31%), Identity (21%), and Medical Demands (15%). Preventative care guidelines were met by 81% of myeloma survivors. However, adherence to exercise and diet guideline were relatively low at 33% and 13% respectively. INTERPRETATION Myeloma AHCT survivors in stable remission have no clinically meaningful worsening in physical functioning compared to general population.. Survivorship programs should address ongoing distress due to health burden, uncertainty, and finances in myeloma survivors, along with targeted interventions for modifiable health behaviors such as nutrition and exercise.
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14
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Banday SZ, Guru F, Ayub M, Ahmed SN, Banday AZ, Mir MH, Nisar R, Hussain S, Bhat GM, Aziz SA. Long-Term Outcomes of Autologous Hematopoietic Stem Cell Transplant (HSCT) for Multiple Myeloma: While New Horizons Emerge, It Is Still Only a Silver Lining for Resource-Constrained Settings. Cureus 2023; 15:e36642. [PMID: 37155458 PMCID: PMC10122934 DOI: 10.7759/cureus.36642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 05/10/2023] Open
Abstract
Background Significant hurdles impede the optimal implementation of hematopoietic stem cell transplantation (HSCT) in low-middle income countries (LMICs). Herein, we highlight the challenges faced in LMICs while performing HSCT and report the long-term outcomes of patients with newly diagnosed multiple myeloma (MM) who underwent autologous HSCT (AHSCT) at our center. Besides, we provide a comprehensive review of studies reporting long-term outcomes of AHSCT in MM from the Indian subcontinent. Methodology This study was conducted at the State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India. Case records of all patients with MM who received AHSCT from December 2010 to July 2018 were reviewed retrospectively. A non-systematic literature search was performed using PubMed and Google Scholar databases. Data regarding clinicopathological parameters and long-term follow-up were extracted from relevant studies and for patients included in our study. Results At our center, 47 patients (median age 52.0 years) with MM underwent AHSCT. Majority of patients had stage III disease (ISS) and median time to transplant was 11.5 months. The five-year progression free survival (PFS) and overall survival (OS) were 59.1% and 81.2%, respectively. Studies from the Indian subcontinent have observed a five-year OS of ~50% to ~85%. However, a greater variability in the five-year PFS has been reported, ranging from ~20% to ~75%. The median time to transplant has ranged from seven to 17 months (indicating time delays) with median CD34 cell counts of 2.7-6.3×106 cells/kg (lower than developed countries). Conclusions Despite significant resource limitations in LMICs, AHSCT is increasingly been performed in MM with encouraging long-term outcomes.
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Affiliation(s)
- Saquib Z Banday
- Department of Medical Oncology, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Faisal Guru
- Department of Medical Oncology, Pediatrics Unit, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Maniza Ayub
- Department of Pathology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Syed N Ahmed
- Department of Medical Oncology, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Aaqib Z Banday
- Department of Pediatrics, Government Medical College, Srinagar, IND
| | - Mohmad H Mir
- Department of Medical Oncology, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Rahila Nisar
- Department of Microbiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Saleem Hussain
- Department of Laboratory Hematology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Gull M Bhat
- Department of Medical Oncology, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Sheikh A Aziz
- Department of Medical Oncology, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
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15
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Côté J, Kotb R, Bergstrom DJ, LeBlanc R, Mian HS, Othman I, Louzada ML. First Line Treatment of Newly Diagnosed Transplant Ineligible Multiple Myeloma: Recommendations from the Canadian Myeloma Research Group Consensus Guideline Consortium. Clin Lymphoma Myeloma Leuk 2023; 23:340-354. [PMID: 36925389 DOI: 10.1016/j.clml.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/14/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
Although the availability of effective novel treatments has positively impacted the quality of life and survival of newly diagnosed multiple myeloma (MM) patients, benefits in the transplant ineligible MM population may be limited by functional/frailty status. The Canadian Myeloma Research Group Consensus Guideline Consortium proposes consensus recommendations for the first-line treatment of transplant ineligible MM. To address the needs of physicians and people diagnosed with MM, this document further focuses on eligibility for transplant, frailty assessment, management of adverse events, assessment of treatment response, and monitoring for disease relapse. The Canadian Myeloma Research Group Consensus Guideline Consortium will periodically review the recommendations herein and update as necessary.
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Affiliation(s)
- Julie Côté
- Centre hospitalier universitaire de Québec, Quebec, QC, Canada.
| | - Rami Kotb
- CancerCare Manitoba, University of Manitoba, Winnipeg, MB, Canada
| | | | - Richard LeBlanc
- Hôpital Maisonneuve-Rosemont, University of Montreal, Montreal, QC, Canada
| | - Hira S Mian
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Ibraheem Othman
- Allan Blair Cancer Centre, University of Saskatchewan, Regina, SK, Canada
| | - Martha L Louzada
- London Health Sciences Centre, Western University, London, ON, Canada
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16
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Caravita di Toritto T, Rago A. Response to "Conditioning with melphalan (Mel) 200 mg/m 2 and subsequent autologous stem cell transplantation improves progression free survival and overall survival in elderly multiple myeloma patients compared to standard of care". Eur J Haematol 2023; 110:221. [PMID: 36300853 DOI: 10.1111/ejh.13888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 09/27/2022] [Indexed: 01/19/2023]
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17
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Mian O, Puts M, McCurdy A, Wildes TM, Fiala MA, Kang M, Salib M, Alibhai S, Mian H. Decision-making factors for an autologous stem cell transplant for older adults with newly diagnosed multiple myeloma: A qualitative analysis. Front Oncol 2023; 12:974038. [PMID: 36776355 PMCID: PMC9911655 DOI: 10.3389/fonc.2022.974038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/06/2022] [Indexed: 01/28/2023] Open
Abstract
Purpose A utologous stem cell transplant (ASCT) remains a standard of care among older adults (aged ≥65) with multiple myeloma (MM). However, heterogeneity in the eligibility and utilization of ASCT remains. We identified decision-making factors that influence ASCT eligibility and utilization among older adults with MM. Methods A qualitative study across two academic and two community centres in Ontario was conducted between July 2019-July 2020. Older adults with MM (newly diagnosed MM aged 65-75 in whom a decision had been made about ASCT in <12 months) and treating oncologists completed a baseline survey and a subsequent interview, which was analyzed using thematic analysis. Results Eighteen patients completed the survey and 9 follow-up interviews were conducted. Patients were happy with their treatment decision with "trust in their oncologist" and "wanting the best treatment" as the most important to proceed with ASCT. "Afraid of side effects" was the most common reason for declining ASCT. Fifteen oncologists completed the survey and 10 follow-up interviews were conducted. Most relied on the 'eye-ball' test for ASCT eligibility over geriatric screening tools. The lack of both high-quality evidence and local guidelines impacted decision-making. Both oncologists and patients felt that chronological age alone should not affect ASCT eligibility. Conclusion While decision-making factors regarding ASCT can be variable, both oncologists and patients indicated that chronological age alone should not represent a barrier for ASCT among older adults. Future simplification and incorporation of ASCT eligibility geriatric assessment tools in studies as well as the inclusion of these tools in local guidelines may further improve ASCT decision-making.
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Affiliation(s)
- Owais Mian
- Department of Internal Medicine, University of Toronto, Toronto, ON, Canada
| | - Martine Puts
- Department of Internal Medicine, University of Toronto, Toronto, ON, Canada
| | - Arleigh McCurdy
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, ON, Canada
| | - Tanya M. Wildes
- Division of Hematology and Oncology, Department of Internal Medicine, University of Nebraska Medical Center, Nebraska Medicine, Omaha, NE, United States
| | - Mark A. Fiala
- College for Public Health and Social Justice, Saint Louis University, St Louis, MO, United States,Department of Oncology, Washington University School of Medicine, St Louis, MO, United States
| | - Matthew Kang
- Department of Oncology, Joseph Brant Hospital, Burlington, ON, Canada
| | - Mary Salib
- Department of Oncology, Walker Family Cancer Centre St. Catherine’s General Hospital, St. Catherine, ON, Canada
| | - Shabbir Alibhai
- Department of Medicine, University Health Network & University of Toronto, Toronto, ON, Canada
| | - Hira Mian
- Department of Oncology, McMaster University, Hamilton, ON, Canada,*Correspondence: Hira Mian,
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D’Souza A, Brazauskas R, Stadtmauer EA, Pasquini MC, Hari P, Bashey A, Callander N, Devine S, Efebera Y, Ganguly S, Gasparetto C, Geller N, Horowitz MM, Koreth J, Landau H, Brunstein C, McCarthy P, Qazilbash MH, Giralt S, Krishnan A, Flynn KE. Trajectories of quality of life recovery and symptom burden after autologous hematopoietic cell transplantation in multiple myeloma. Am J Hematol 2023; 98:140-147. [PMID: 35567778 PMCID: PMC9659666 DOI: 10.1002/ajh.26596] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/11/2022] [Accepted: 05/09/2022] [Indexed: 02/04/2023]
Abstract
Early autologous hematopoietic cell transplantation (AHCT) with post-transplant maintenance therapy is standard of care in multiple myeloma (MM). While short-term quality of life (QOL) deterioration after AHCT is known, the long-term trajectories and symptom burden after transplantation are largely unknown. Toward this goal, a secondary analysis of QOL data of the BMT CTN 0702, a randomized controlled trial comparing outcomes of three treatment interventions after a single AHCT (N = 758), was conducted. FACT-BMT scores up to 4 years post-AHCT were analyzed. Symptom burden was studied using responses to 17 individual symptoms dichotomized as 'none/mild' for scores 0-2 and 'moderate/severe' for scores of 3 or 4. Patients with no moderate/severe symptom ratings were considered to have low symptom burden at 1-year. Mean age at enrollment was 55.5 years with 17% African Americans. Median follow-up was 6 years (range, 0.4-8.5 years). FACT-BMT scores improved between enrollment and 1-year and remained stable thereafter. Low symptom burden was reported by 27% of patients at baseline, 38% at 1-year, and 32% at 4 years post-AHCT. Predictors of low symptom burden at 1-year included low symptom burden at baseline: OR 2.7 (1.8-4.1), p < 0.0001; older age: OR 2.1 (1.3-3.2), p = 0.0007; and was related to being employed: OR 2.1 (1.4-3.2), p = 0.0004). We conclude that MM survivors who achieve disease control after AHCT have excellent recovery of FACT-BMT and subscale scores to population norms by 1-year post-transplant, though many patients continue to report moderate to severe severity in some symptoms at 1-year and beyond.
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Affiliation(s)
- Anita D’Souza
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ruta Brazauskas
- Institute of Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Edward A. Stadtmauer
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marcelo C. Pasquini
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Parameswaran Hari
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Asad Bashey
- Department of Hematology/Oncology, BMT Group of Georgia, Atlanta, Georgia, USA
| | - Natalie Callander
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - Steven Devine
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Yvonne Efebera
- Department of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Siddhartha Ganguly
- Department of Medicine, Kansas University Medical Center, Kansas City, Kansas, USA
| | | | - Nancy Geller
- National Heart Lung and Blood Institute, Bethesda, Maryland, USA
| | - Mary M. Horowitz
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - John Koreth
- Department of Medicine, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Heather Landau
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Claudio Brunstein
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Philip McCarthy
- Department of Medicine, Roswell Park Cancer Center, Buffalo, New York, USA
| | - Muzaffar H. Qazilbash
- Department of Stem Cell Transplantation, MD Anderson Cancer Center, Houston, Texas, USA
| | - Sergio Giralt
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amrita Krishnan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope Cancer Center, Duarte, California, USA
| | - Kathryn E. Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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19
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Abstract
As the aging population grows, so too does the number of well-tolerated antimyeloma therapies. Physicians will see an increasing volume of patients for subsequent lines of therapy, which could now extend this relationship for over a decade. For younger patients, treatment choices are infrequently impacted by concerns of fitness, but instead about effecting the deepest, most durable response. Older adults, in contrast, are more likely to experience under- than overtreatment, and therefore more objective (and ideally straightforward) ways to evaluate their fitness and ability to tolerate therapy will increasingly assist in decision-making. Post hoc analyses categorizing the fitness of trial patients in the modern treatment era globally demonstrate that even in highly selected populations, those that are recategorized as less fit or frail are consistently at higher risk of inferior outcomes and increased toxicities. Real-world data are comparatively lacking but do demonstrate that most patients with myeloma are not representative of those enrolled on clinical trials, generally more heavily burdened by comorbidities and more likely to be categorized as "less than fit." Simultaneously, the number of therapeutic options open to patients in the relapsed setting continues to grow, now including T-cell engagers and cellular therapies, with their unique toxicity profiles. The aim of this review is to summarize the available data, highlight some of the approaches possible to easily assess fitness and how results might inform treatment selection, and illustrate ways that patients' condition can be optimized rather than lead to exclusion from the more complex therapies newly available.
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Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Abdullah M Khan
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Ciara L Freeman
- H. Lee Moffitt Cancer Centre & Research Institute, Morsani College of Medicine, University of South Florida, Tampa, FL
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20
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Afram G, Chaireti R, Uttervall K, Luong V, Lund J, Kashif M, Gahrton G, Alici E, Nahi H. Conditioning with melphalan 200 mg/m 2 and subsequent ASCT improves progression-free and overall survival in elderly myeloma patients compared to standard of care. Eur J Haematol 2022; 109:749-754. [PMID: 36066204 PMCID: PMC9826071 DOI: 10.1111/ejh.13861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Despite the effectiveness of newer drugs for the treatment of multiple myeloma (MM), the outcomes are further improved by subsequent autologous stem cell transplantation (ASCT). Data on effectiveness in older patients are limited. We compared outcomes in patients aged 65-75 years depending on whether they were treated with ASCT or not and compared those to outcomes in patients <65 years. METHODS This was a retrospective, single-center study. We compared progression-free survival (PFS) and overall survival (OS) for all MM patients below and above the age of 65 years treated ± ASCT at the Karolinska University Hospital between 2010 and 2020. PFS and OS were calculated by the Kaplan-Meier method. Variables affecting PFS and OS were evaluated using Cox regression model. RESULTS Both PFS and OS were improved in the group 65-75 years treated +ASCT compared to those treated pharmacologically (p = 0.008 and p < 0.001, respectively). There were no significant differences between patients <65 years and those 65-75 years treated with ASCT. CONCLUSION The findings indicate that even patients >65 years should be evaluated as candidates for ASCT. An individualized approach supported by a frailty/geriatric assessment score could assist clinicians to select the appropriate treatment for each patient.
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Affiliation(s)
- Gabriel Afram
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden,Pfizer ABSollentunaSweden
| | - Roza Chaireti
- Department of HematologyKarolinska University HospitalStockholmSweden,Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Katarina Uttervall
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden
| | - Vincent Luong
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden
| | - Johan Lund
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
| | - Muhammad Kashif
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
| | - Gösta Gahrton
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
| | - Evren Alici
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden
| | - Hareth Nahi
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
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21
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Ali MO, Al Hadidi S. High dose (conditioning) regimens used prior to autologous stem cell transplantation in multiple myeloma. Transplant Cell Ther 2022; 28:572-580. [DOI: 10.1016/j.jtct.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/03/2022] [Accepted: 06/16/2022] [Indexed: 11/27/2022]
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22
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Suzuki T, Maruyama D, Iida S, Nagai H. Recent advances in the management of older adults with newly diagnosed multiple myeloma in Japan. Jpn J Clin Oncol 2022; 52:966-974. [PMID: 35830865 PMCID: PMC9486880 DOI: 10.1093/jjco/hyac111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/25/2022] [Indexed: 11/13/2022] Open
Abstract
Multiple myeloma is a cancer of plasma cells; the incidence rate of multiple myeloma is high among older adults. Although significant advances have been made in the clinical management of multiple myeloma driven by the introduction of novel drugs, such as proteasome inhibitors, immuno- modulators and antibodies, multiple myeloma remains incurable. Hence, the current therapeutic goal for multiple myeloma is to achieve long-term survival while maintaining a good quality of life. In this context, personalized treatment to balance the efficacy and safety of therapies is important, especially for older adults as they display diverse physical, cognitive or organ functioning. Furthermore, old age is also often associated with frailty. Several tools for evaluating frailty in older adults with multiple myeloma are now available, and frail patients defined by these tools have shown a poor prognosis and more treatment-related toxicities. In addition, it is important to evaluate other factors, such as the International Staging System, high-risk chromosomal abnormalities and treatment response, to predict the clinical course of patients. Further investigations are required to determine how these factors can optimize the treatment for multiple myeloma. In this review, we present a detailed account on the developments and issues related to the current treatment approaches for older adults with newly diagnosed multiple myeloma. We also discuss the ongoing phase III clinical study conducted by the lymphoma study group of the Japan Clinical Oncology Group, which targeted older adults with newly diagnosed multiple myeloma.
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Affiliation(s)
- Tomotaka Suzuki
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Dai Maruyama
- Department of Hematology Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hirokazu Nagai
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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23
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Phelan R, Chen M, Bupp C, Bolon YT, Broglie L, Brunner-Grady J, Burns LJ, Chhabra S, Christianson D, Cusatis R, Devine SM, D’Souza A, Eapen M, Hamadani M, Hengen M, Lee SJ, Moskop A, Page KM, Pasquini M, Pérez WS, Riches M, Rizzo D, Saber W, Spellman SR, Stefanski HE, Steinert P, Weisdorf D, Horowitz M, Auletta JJ, Shaw BE, Arora M. Updated Trends in Hematopoietic Cell Transplantation in the United States with an Additional Focus on Adolescent and Young Adult Transplantation Activity and Outcomes. Transplant Cell Ther 2022; 28:409.e1-409.e10. [PMID: 35447374 PMCID: PMC9840526 DOI: 10.1016/j.jtct.2022.04.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/30/2022] [Accepted: 04/11/2022] [Indexed: 01/17/2023]
Abstract
Hematopoietic cell transplantation (HCT) has been successfully used to treat many malignant and nonmalignant conditions. As supportive care, donor selection, and treatment modalities evolve, documenting HCT trends and outcomes is critical. This report from the Center for International Blood and Marrow Transplant Research (CIBMTR) provides an update on current transplantation activity and survival rates in the United States. Additional data on the use and outcomes of HCT in the adolescent and young adult (AYA) population are included. AYA patients more frequently receive peripheral blood stem cell grafts than pediatric patients, which may reflect differences in practice in pediatric versus adult treatment centers. The proportions of donor types also differ those in adult and pediatric populations. Outcomes for patients in the AYA age range are similar to those of pediatric patients for acute myelogenous leukemia but worse for acute lymphoblastic leukemia. Outcomes for both leukemias are better in AYA patients compared with older adults. Comparing the time periods 2000 to 2009 and 2010 to 2019 revealed significant improvement in overall survival across the age spectrum, but the greatest improvement in the AYA age group.
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Affiliation(s)
- Rachel Phelan
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Min Chen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Caitrin Bupp
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Yung-Tsi Bolon
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Larisa Broglie
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Janet Brunner-Grady
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Linda J. Burns
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI
| | - Saurabh Chhabra
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Debra Christianson
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Rachel Cusatis
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Steven M. Devine
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Anita D’Souza
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mary Eapen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mehdi Hamadani
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mary Hengen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Stephanie J. Lee
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI,Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Amy Moskop
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Kristin M. Page
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Marcelo Pasquini
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Waleska S. Pérez
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Marcie Riches
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Doug Rizzo
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Wael Saber
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Stephen R. Spellman
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Heather E. Stefanski
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Patricia Steinert
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Mary Horowitz
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jeffery J. Auletta
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Bronwen E. Shaw
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mukta Arora
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN,Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
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24
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Dhakal B, Shah N, Kansagra A, Kumar A, Lonial S, Garfall A, Cowan A, Poudyal BS, Costello C, Gay F, Cook G, Quach H, Einsele H, Schriber J, Hou J, Costa L, Aljurf M, Chaudhry M, Beksac M, Prince M, Mohty M, Janakiram M, Callander N, Biran N, Malhotra P, Otero PR, Moreau P, Abonour R, Iftikhar R, Silberman R, Mailankody S, Gregory T, Lin Y, Carpenter P, Hamadani M, Usmani S, Kumar S. ASTCT Clinical Practice Recommendations for Transplantation and Cellular Therapies in Multiple Myeloma. Transplant Cell Ther 2022; 28:284-293. [PMID: 35306217 DOI: 10.1016/j.jtct.2022.03.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
Over the past decade, therapeutic options in multiple myeloma (MM) have changed dramatically. Given the unprecedented efficacy of novel agents, the role of hematopoietic cell transplantation (HCT) in MM remains under scrutiny. Rapid advances in myeloma immunotherapy including the recent approval of chimeric antigen receptor (CAR) T-cell therapy will impact the MM therapeutic landscape. The American Society for Transplantation and Cellular Therapy convened an expert panel to formulate clinical practice recommendations for role, timing, and sequencing of autologous (auto-HCT), allogeneic (allo-HCT) and CAR T-cell therapy for patients with newly diagnosed (NDMM) and relapsed/refractory MM (RRMM). The RAND-modified Delphi method was used to generate consensus statements. Twenty consensus statements were generated. The panel endorsed continued use of auto-HCT consolidation for patients with NDMM as a standard-of-care option, whereas in the front line allo-HCT and CAR-T were not recommended outside the setting of clinical trial. For patients not undergoing auto-HCT upfront, the panel recommended its use in first relapse. Lenalidomide as a single agent was recommended for maintenance especially for standard risk patients. In the RRMM setting, the panel recommended the use of CAR-T in patients with 4 or more prior lines of therapy. The panel encouraged allo-HCT in RRMM setting only in the context of clinical trial. The panel found RAND-modified Delphi methodology effective in providing a formal framework for developing consensus recommendations for the timing and sequence of cellular therapies for MM.
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Affiliation(s)
- Binod Dhakal
- Blood and Marrow Transplant and Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nina Shah
- Division of Hematology-Oncology, University of California, San Francisco, California
| | - Ankit Kansagra
- Department of Hematology and Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ambuj Kumar
- Program for Comparative Effectiveness Research, University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Alfred Garfall
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew Cowan
- University of Washington, Seattle WA, and Fred Hutch, Seattle, Washington
| | - Bishesh Sharma Poudyal
- Department of Clinical Hematology and Bone Marrow Transplant, Civil Service Hospital, Kathmandu, Nepal
| | - Caitlin Costello
- UCSD/Sharp Healthcare Transplant Program, Blood & Marrow Transplant Services, Moore's Cancer Center, San-Diego, California
| | - Francesca Gay
- Division of Hematology 1 Clinical Trial Unit, AOU CIttà della salute e della Scienza, University of Torino, Turin, Italy
| | - Gordon Cook
- Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trial Research, University of Leeds, Leeds, United Kingdom
| | - Hang Quach
- University of Melbourne, St. Vincent's Hospital, Melbourne, Australia
| | - Herman Einsele
- Universitätsklinikum Würzburg, Department of Internal Medicine II, Würzburg, Germany
| | - Jeff Schriber
- Cancer Treatment Centers of America, Phoenix, Arizona
| | - Jian Hou
- Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Luciano Costa
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Maria Chaudhry
- Department of hematology/Oncology, George Washington University and Cancer Center, Washington, District of Columbia
| | - Meral Beksac
- Department of Hematology, Ankara University, Ankara, Turkey
| | - Miles Prince
- Epworth Healthcare and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France
| | - Murali Janakiram
- Division of Myeloma, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, California
| | | | - Noa Biran
- Hackensack Meridian Health, John Theurer Cancer Center, Multiple Myeloma Division, Hackensack, New Jersey
| | - Pankaj Malhotra
- Department of Clinical Hematology & Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Philippe Moreau
- Department of Hematology, University Hospital Hôtel-Dieu, Nantes, France
| | - Rafat Abonour
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Raheel Iftikhar
- Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan
| | - Rebecca Silberman
- Department of Medicine, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
| | - Sham Mailankody
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New, York, New York
| | - Tara Gregory
- Colorado Blood Cancer Institute, Sarah Cannon Cancer Network, Denver, Colorado
| | - Yi Lin
- Mayo Clinic, Rochester, Minnesota
| | - Paul Carpenter
- Division of Clinical Research, Fred Hutchinson Cancer Research Center and Department of Pediatrics, University of Washington, Seattle, Washington
| | - Mehdi Hamadani
- Blood and Marrow Transplant and Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Saad Usmani
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New, York, New York
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25
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Goel U, Usmani S, Kumar S. Current approaches to management of newly diagnosed multiple myeloma. Am J Hematol 2022; 97 Suppl 1:S3-S25. [PMID: 35234302 DOI: 10.1002/ajh.26512] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/16/2022]
Abstract
Major developments in the treatment of multiple myeloma (MM) over the past decade have led to a continued improvement in survival. Significant progress has been made with deeper and longer remissions seen with newer treatment approaches-both for induction as well as maintenance therapy. The treatment approach to MM is guided by several factors including patient age, frailty, comorbidities, eligibility for autologous stem cell transplantation (ASCT), and risk stratification into standard-risk or high-risk MM. High-risk MM is defined by the presence of t(4;14), t(14;16), t(14;20), del (17p), TP53 mutation, or gain (1q). Transplant eligible patients should receive 4-6 cycles of induction followed by stem cell collection. Patients can then undergo ASCT, or continue induction therapy and shift to maintenance, delaying ASCT till first relapse. Transplant ineligible patients should receive induction therapy followed by maintenance. For induction therapy prior to ASCT, a proteasome inhibitor-IMiD combination remains standard with monoclonal antibody-based quadruplets preferred in high-risk patients. Among transplant ineligible patients, those with standard-risk MM should receive DRd continued until disease progression, while bortezomib containing regimens (VRd or VRd lite) can be considered for high-risk patients. Finally, standard-risk patients should receive lenalidomide maintenance after induction/ASCT, while proteasome inhibitor-IMiD combinations should be used for high-risk patients.
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Affiliation(s)
- Utkarsh Goel
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
| | - Saad Usmani
- Multiple Myeloma Service, Department of medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Shaji Kumar
- Division of Hematology, Department of Medicine Mayo Clinic Rochester Minnesota USA
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26
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Munshi PN, Chen Y, Ahn KW, Awan FT, Cashen A, Shouse G, Shadman M, Shaughnessy P, Zurko J, Locke FL, Goodman AM, Bisneto JCV, Sauter C, Kharfan-dabaja MA, Meyers G, Jaglowski S, Herrera A. Outcomes of Autologous Hematopoietic Cell Transplantation in Older Patients with Diffuse Large B Cell Lymphoma. Transplant Cell Ther 2022. [PMID: 35609865 PMCID: PMC9375438 DOI: 10.1016/j.jtct.2022.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/13/2022] [Accepted: 05/15/2022] [Indexed: 11/17/2022]
Abstract
Data for outcomes after autologous hematopoietic cell transplantation (auto-HCT) in diffuse large B-cell lymphoma (DLBCL) patients ≥70 years are limited. Auto-HCT is feasible in older DLBCL patients. Using the Center for International Blood and Marrow Transplant Research database, we compared outcomes of auto-HCT in DLBCL patients aged 60 to 69 years (n = 363) versus ≥70 years (n = 103) between 2008 and 2019. Non-relapse mortality (NRM), relapse/progression (REL), progression-free survival (PFS), and overall survival (OS) were modeled using Cox proportional hazards models. All patients received BEAM conditioning (carmustine, etoposide, cytosine arabinoside and melphalan). On univariate analysis, in the 60 to 69 years versus ≥70 years cohorts, 100-day NRM was 3% versus 4%, 5-year REL was 47% versus 45%, 5-year PFS 40% versus 38% and 5-year OS 55% versus 41%, respectively. On multivariate analysis, patients ≥70 had no significant difference in NRM (hazard ratio [HR] 1.43, 95% confidence interval [CI] 0.85-2.39), REL (HR 1.11, 95% CI 0.79-1.56), PFS (HR 1.23, 95% CI 0.92-1.63) compared to patients 60 to 69 years. Patients ≥70 years had a higher mortality (HR 1.39, 95% CI 1.05-1.85, p=0.02), likely because of inferior post-relapse OS in this cohort (HR 1.82, 95% CI 1.27-2.61, P = .001). DLBCL was the major cause of death in both cohorts (62% versus 59%). Older patients should not be denied auto-HCT solely on the basis of chronological age.
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27
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Maakaron JE, Zhang MJ, Chen K, Abhyankar S, Bhatt VR, Chhabra S, El Jurdi N, Farag SS, He F, Juckett M, de Lima M, Majhail N, van der Poel M, Saad A, Savani B, Ustun C, Waller EK, Litzow M, Kebriaei P, Hourigan CS, Saber W, Weisdorf D. Age is no barrier for adults undergoing HCT for AML in CR1: contemporary CIBMTR analysis. Bone Marrow Transplant 2022; 57:911-917. [PMID: 35368040 PMCID: PMC9232949 DOI: 10.1038/s41409-022-01650-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 11/17/2022]
Abstract
Acute Myeloid Leukemia (AML) has a median age at diagnosis of 67 years. The most common curative therapy remains an allogeneic hematopoietic stem cell transplantation (HCT), yet it is complicated by treatment-related mortality (TRM) and ongoing morbidity including graft versus host disease (GVHD) that may impact survival, particularly in older patients. We examined the outcomes and predictors of success in 1,321 patients aged 60 years and older receiving a HCT for AML in first complete remission (CR1) from 2007–2017 and reported to the CIBMTR. Outcomes were compared in three age cohorts (60–64; 65–69; 70+). With median follow-up of nearly 3 years, patients aged 60–64 had modestly, though significantly better OS, DFS and lower TRM than those either 65–69 or 70+; cohorts with similar outcomes. Three-year OS for the 3 cohorts was 49.4%, 42.3%, and 44.7% respectively (p=0.026). TRM was higher with increasing age, cord blood as graft source and HCT-CI score of ≥ 3. Conditioning intensity was not a significant predictor of OS in the 60–69 cohort with 3-year OS of 46% for RIC and 49% for MAC (p=0.38); MAC was rarely used over age 70. There was no difference in the relapse rate, incidence of Grade III/IV acute GVHD, or moderate-severe chronic GVHD across the age cohorts. After adjusting for other predictors, age had a small effect on OS and TRM. High-risk features including poor cytogenetics and measurable residual disease (MRD) prior to HCT were each significantly associated with relapse and accounted for most of the adverse impact on OS and DFS. Age did not influence the incidence of either acute or chronic GVHD; while graft type and associated GVHD prophylaxis were most important. These data suggest that age alone is not a barrier to successful HCT for AML in CR1 and should not exclude patients from HCT. Efforts should focus on minimizing residual disease and better donor selection.
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28
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Pawlyn C, Cairns D, Menzies T, Jones J, Jenner M, Cook G, Boyd K, Drayson M, Kaiser M, Owen R, Gregory W, Morgan G, Jackson G, Davies F. Autologous stem cell transplantation is safe and effective for fit older myeloma patients: exploratory results from the Myeloma XI trial. Haematologica 2022; 107:231-242. [PMID: 33297668 PMCID: PMC8719065 DOI: 10.3324/haematol.2020.262360] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 11/25/2020] [Indexed: 12/03/2022] Open
Abstract
Autologous stem cell transplant (ASCT) remains standard of care for consolidation after induction therapy for eligible newly diagnosed myeloma patients. In recent clinical trials comparing ASCT to delayed ASCT, patients aged over 65 were excluded. In real-world practice stem cell transplants are not restricted to those aged under 65 and clinicians decide on transplant eligibility based on patient fitness rather than a strict age cut off. Data from the UK NCRI Myeloma XI trial, a large phase III randomised controlled trial with pathways for transplant-eligible (TE) and ineligible (TNE) patients, was used in an exploratory analysis to examine the efficacy and toxicity of ASCT in older patients including analysis using an agematched population to compare outcomes for patients receiving similar induction therapy with or without ASCT. Older patients within the TE pathway were less likely to undergo stem cell harvest at the end of induction than younger patients and of those patients undergoing ASCT there was a reduction in PFS associated with increasing age. ASCT in older patients was well tolerated with no difference in morbidity or mortality between patients aged.
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Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London.
| | - David Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - Tom Menzies
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - John Jones
- Kings Hospital NHS Foundation Trust, London
| | - Matthew Jenner
- University Hospital Southampton NHS Foundation Trust, Southampton
| | - Gordon Cook
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK; Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds
| | | | - Mark Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham
| | - Martin Kaiser
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London
| | - Roger Owen
- HMDS, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds
| | - Walter Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | | | - Graham Jackson
- Department of Haematology, Newcastle University, Newcastle
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29
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Abstract
Older adults with multiple myeloma (MM) are a growing population, and personalizing treatment based on disease and health status is imperative. Similar to MM staging systems that provide disease-related prognostic information, myeloma-specific frailty tools can better identify subgroups at greatest risk for treatment-related toxicity and early treatment discontinuation, as well as predict overall survival. Several myeloma-specific validated tools are well studied. Although these fitness/frailty scores have shaped our understanding of the heterogeneity among older adults with myeloma, the application of such scores in treatment decision making (ie, transplant considerations, relapse) is an unmet need. Here we outline how to incorporate frailty assessments in the evaluation of older adults with MM in the clinical setting with consideration of other factors such as patient preferences, treatment risks/benefits, life expectancy, and disease biology.
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Affiliation(s)
- Shakira J Grant
- Department of Medicine, Division of Hematology, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ciara L Freeman
- Division of Medical Oncology, University of British Columbia, Vancouver, BC, Canada
| | - Ashley E Rosko
- Division of Hematology, The Ohio State University, Columbus, OH
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30
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Möller MD, Gengenbach L, Graziani G, Greil C, Wäsch R, Engelhardt M. Geriatric assessments and frailty scores in multiple myeloma patients: a needed tool for individualized treatment? Curr Opin Oncol 2021; 33:648-657. [PMID: 34534141 PMCID: PMC8528138 DOI: 10.1097/cco.0000000000000792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Multiple myeloma is a disease of elderly adults. Improvement in survival has occurred because of biological insights and novel agents. Therapeutic options involve choices today, thus have become more complex. Demographics have led to an increased number of elderly patients and age may be associated with a poorer outcome but is not the only prognostic predictor today. RECENT FINDINGS To evaluate patients' health status rather than their chronological age alone, frailty scores and functional geriatric assessments are used to identify prognostic groups, avoid adverse events, compare clinical trials and tailor treatment. As most clinical trials exclude frail elderly patients, those enrolled therein are often younger and healthier than the typical multiple myeloma patient. This represents a challenge for frail cohorts because of their increased risk of adverse events, overtreatment and undertreatment and/or therapy discontinuation, which may lead to poorer survival and quality of life (QoL). Reassessing patients' status via geriatric assessments is also relevant during treatment to adjust interventions appropriately. SUMMARY Integrating geriatric assessments may lead to individual treatment decisions, dose adjustments, better clinical outcome and QoL. Prospective clinical trials that enroll elderly multiple myeloma patients with comorbidities, incorporate frailty scores/geriatric assessments and help with prognostication, adverse event avoidance and QoL maintenance, remain warranted.
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Parmar H, Vesole DH, Biran N. From VAD to VRD: Is Transplant Still Needed in the Upfront Setting of Myeloma? ACTA ACUST UNITED AC 2021; 27:190-5. [PMID: 34549906 DOI: 10.1097/PPO.0000000000000522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT High-dose therapy followed by autologous stem cell transplantation (ASCT) is considered the standard of care for transplant-eligible patients with newly diagnosed multiple myeloma (MM). With new treatment combinations offering the advantage of improved clinical outcomes of MM patients, the utilization of ASCT is again being addressed in the evolving treatment landscape. In this article, we review the role of frontline ASCT in the management of patients with MM.
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32
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Nooka AK, Joseph NS, Lonial S. "I took the road less traveled, and that has made all the difference": Making a case for high-dose therapy and autologous stem cell transplantation in elderly patients with newly diagnosed multiple myeloma. Cancer 2021; 127:4133-4136. [PMID: 34374440 DOI: 10.1002/cncr.33825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 01/19/2023]
Abstract
LAY SUMMARY Elderly patients with myeloma derive benefits from transplantation similar to those for younger patients. Age should not be the sole criterion for determining transplant eligibility. Performance status assessment and other tools for assessing comorbidities such as the Charlson comorbidity score may potentially help in determining transplant eligibility and will allow us to move away from our heavy reliance on numerical age.
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Affiliation(s)
- Ajay K Nooka
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nisha S Joseph
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sagar Lonial
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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33
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Munshi PN, Vesole DH, St Martin A, Davila O, Kumar S, Qazilbash M, Shah N, Hari PN, D'Souza A. Outcomes of upfront autologous hematopoietic cell transplantation in patients with multiple myeloma who are 75 years old or older. Cancer 2021; 127:4233-4239. [PMID: 34374445 DOI: 10.1002/cncr.33831] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Consolidative autologous hematopoietic stem cell transplantation (AHCT) is commonly used for patients with multiple myeloma (MM). We studied AHCT use and outcomes in patients with MM ≥75 years old. METHODS Patients with MM ≥75 years old receiving AHCT between 2013 and 2017 in the United States were identified using the Center for International Blood and Marrow Transplant Research database. Relapse and/or progression (REL), progression-free survival (PFS), and overall survival (OS) were modeled using Cox proportional hazards models. Covariates used were age, sex, Karnofsky performance score (KPS), HCT-comorbidity index (HCT-CI), International Staging System and/or Durie-Salmon stage, high-risk cytogenetics, melphalan dose, and disease status at and 1 year after transplant. AHCT utilization rate using the Surveillance, Epidemiology, and End Results database was used to estimate specific incidence among ≥75 years old by race and gender. RESULTS Of 360 patients, 63% were male, 84% were White, 56% had KPS <90, and 57% had HCT-CI ≥3. The 100-day transplant-related mortality was 1% (0%-2%) with a 2-year REL rate of 27% (95% confidence interval [CI], 22%-33%), PFS of 66% (95% CI, 60%-72%), and OS of 83% (95% CI, 78%-87%). On multivariate analysis, only high-risk cytogenetics was associated with REL risk and decreased PFS. In White males, transplant utilization rate was 5.2%-5.8% compared to 3.5%-4.0% in African American males (P = .02). There was 3.37-3.79% transplant utilization in White females compared to 1.88-2.12% in African American females (P < .01). CONCLUSIONS The use of AHCT was associated with excellent 2-year outcomes in this selected MM population ≥75 years old. Transplant utilization for patients ≥75 years old remains low with significant racial and gender disparities.
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Affiliation(s)
| | - David H Vesole
- Georgetown University Hospital, Washington, DC.,John Theurer Cancer Center at Hackensack UMC, Hackensack, New Jersey
| | - Andrew St Martin
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Omar Davila
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | - Nina Shah
- Division of Hematology-Oncology, University of California-San Francisco, San Francisco, California
| | - Parameswaran N Hari
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anita D'Souza
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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34
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Rosko AE, Cordoba R, Abel G, Artz A, Loh KP, Klepin HD. Advances in Management for Older Adults With Hematologic Malignancies. J Clin Oncol 2021; 39:2102-2114. [PMID: 34043442 PMCID: PMC8260925 DOI: 10.1200/jco.21.00242] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ashley E. Rosko
- Division of Hematology, The Ohio State University, Columbus, OH
| | - Raul Cordoba
- Lymphoma Unit, Department of Hematology, Fundacion Jimenez Diaz University Hospital, Health Research Institute IIS-FJD, Madrid, Spain
| | - Gregory Abel
- Leukemia Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Andrew Artz
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Heidi D. Klepin
- Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC
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35
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Abstract
The plasma cell neoplasm multiple myeloma (MM) is currently considered incurable. However, significant advances in treatment options over the past 20 years have led to unprecedented response rates to initial therapy as well as prolonged survival rates. Induction regimens have evolved from alkylator-based therapies to those consisting of immunomodulatory drugs and proteasome inhibitors. The combination of bortezomib/lenalidomide/dexamethasone (VRd) has emerged as a standard regimen for both transplant-eligible (TE) and transplant-ineligible (TI) patient populations. More recent efforts have focused on the incorporation of monoclonal antibody therapy into the newly diagnosed setting, particularly anti-CD38 monoclonal antibodies. In the TI patient population, the combination of daratumumab/lenalidomide/dexamethasone is now considered another standard therapy. In the TE setting, it remains to be determined whether the addition of daratumumab to the VRd backbone results in improved long-term outcomes. Recent studies have confirmed the progression-free survival benefit of upfront autologous stem cell transplant and have established lenalidomide maintenance as a standard of care. Multiple studies are evaluating whether inclusion of monoclonal antibody therapy in the maintenance setting will improve outcomes. The optimal management of newly diagnosed patients with high-risk cytogenetics remains to be determined. We discuss the emerging therapies that will likely shape management of newly diagnosed MM in the future.
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Affiliation(s)
- Radowan A Elnair
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Sarah A Holstein
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA.
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36
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Fiala MA, King J, Feinberg D, Goldsmith SR, Schroeder MA, Ghobadi A, Stockerl-Goldstein KE, Vij R, Wildes TM. Autologous stem cell transplant for patients with multiple myeloma between ages 75 and 78. Bone Marrow Transplant 2021; 56:2016-2018. [PMID: 33875814 DOI: 10.1038/s41409-021-01295-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/03/2021] [Accepted: 03/30/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Mark A Fiala
- Washington University School of Medicine, St Louis, MO, USA.
| | - Justin King
- Washington University School of Medicine, St Louis, MO, USA
| | | | | | | | - Armin Ghobadi
- Washington University School of Medicine, St Louis, MO, USA
| | | | - Ravi Vij
- Washington University School of Medicine, St Louis, MO, USA
| | - Tanya M Wildes
- Washington University School of Medicine, St Louis, MO, USA
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37
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UNCU ULU B, BAKIRTAŞ M, YİĞENOĞLU TN, BAŞCI S, YILDIZ J, ŞAHİN D, DARÇIN T, MERDİN A, BATGİ H, İSKENDER D, BAYSAL NA, DAL S, KIZIL ÇAKIR M, ALTUNTAŞ F. Efficacy of reduced dose melphalan conditioning for multiple myeloma patients undergoing autologous stem cell transplantation: in the era of combined induction with novel agents. Journal of Health Sciences and Medicine 2021. [DOI: 10.32322/jhsm.868279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
Allogeneic transplantation remains the most definitive curative option for patients with acute myeloid leukemia (AML). However, given the median age of diagnosis of AML in the late 60s, patients and clinicians have been reluctant to offer transplant to many in the older population. In this age group, AML presents with higher risk molecular and cytogenetic phenotype and patients' comorbidities, performance status, frailty and life views all impact the decision-making about whether to proceed with transplantation. Recent analyses suggest promising outcomes and thus acknowledgement of chronological age should be tempered with assessments of performance status, frailty, donor availability and careful balancing of a patient's wishes, life goals and understanding of the risks before restricting access of older patients to the curative potential of allotransplantation.
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Affiliation(s)
- Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, MMC 480, Minneapolis, MN, 55455, USA.
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39
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Bal S, Giri S, Godby KN, Costa LJ. New regimens and directions in the management of newly diagnosed multiple myeloma. Am J Hematol 2021; 96:367-378. [PMID: 33393136 DOI: 10.1002/ajh.26080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/19/2020] [Accepted: 12/20/2020] [Indexed: 12/20/2022]
Abstract
The introduction of novel agents over the last decade has rapidly expanded the therapeutic landscape of multiple myeloma (MM) for both transplant-eligible and transplant-ineligible patients. The assessment of minimal residual disease (MRD) by next-generation flow cytometry or next-generation sequencing is established as a powerful predictor of long-term outcomes. The use of MRD in response-adapted clinical trials may provide opportunities to identify candidates for treatment escalation and de-escalation. Agents with proven activity in the relapsed and refractory setting are being studied in the management of high-risk newly diagnosed MM (NDMM). Here, we summarize the most recent clinical trials that have led to the current paradigms in the management of NDMM. We also discuss how novel agents could be incorporated in the newly diagnosed setting and potential clinical trial designs that could leverage MRD information with the goal of treatment optimization.
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Affiliation(s)
- Susan Bal
- O'Neal Comprehensive Cancer Center University of Alabama at Birmingham Birmingham Alabama USA
| | - Smith Giri
- O'Neal Comprehensive Cancer Center University of Alabama at Birmingham Birmingham Alabama USA
| | - Kelly N. Godby
- O'Neal Comprehensive Cancer Center University of Alabama at Birmingham Birmingham Alabama USA
| | - Luciano J. Costa
- O'Neal Comprehensive Cancer Center University of Alabama at Birmingham Birmingham Alabama USA
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40
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Bonello F, Grasso M, D’Agostino M, Celeghini I, Castellino A, Boccadoro M, Bringhen S. The Role of Monoclonal Antibodies in the First-Line Treatment of Transplant-Ineligible Patients with Newly Diagnosed Multiple Myeloma. Pharmaceuticals (Basel) 2020; 14:20. [PMID: 33383757 PMCID: PMC7823261 DOI: 10.3390/ph14010020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/21/2020] [Accepted: 12/24/2020] [Indexed: 12/16/2022] Open
Abstract
Elderly transplant-ineligible (NTE) patients represent the majority of patients affected by multiple myeloma (MM). Elderly patients are a highly heterogeneous population, with large variability in health and functional status. Thus, choosing their optimal treatment is challenging. A wide range of first-line treatments is available, and novel-agent combinations, including monoclonal antibodies (mAbs), have recently entered clinical practice. The combination of the anti-CD38 mAb daratumumab with bortezomib, melphalan and prednisone (Dara-VMP) or lenalidomide and dexamethasone (Dara-Rd) demonstrated impressive advantages in terms of progression-free survival and minimal residual disease negativity, as compared to VMP and Rd, without safety concerns. Another anti-CD38 mAb, isatuximab, is showing encouraging results, and new isatuximab-based combinations might enter clinical practice in the future. Nevertheless, available data come from clinical trials with selected patient populations and, to date, the manageability of these regimens in real-life patients or in frail patients remains unknown. Frailty-tailored treatments, including mAbs, are under evaluation in preliminary studies. In this review, we analyze recently approved mAb-based treatments for NTE newly diagnosed MM patients and new combinations under evaluation, focusing on the efficacy and safety of these regimens and on open issues regarding the choice of therapy for elderly patients.
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Affiliation(s)
- Francesca Bonello
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Mariella Grasso
- S.C. Ematologia, Azienda Ospedaliera Santa Croce-Carle, 88900 Cuneo, Italy
| | - Mattia D’Agostino
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Ivana Celeghini
- S.C. Ematologia, Azienda Ospedaliera Santa Croce-Carle, 88900 Cuneo, Italy
| | - Alessia Castellino
- S.C. Ematologia, Azienda Ospedaliera Santa Croce-Carle, 88900 Cuneo, Italy
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | - Sara Bringhen
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, 10126 Torino, Italy
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41
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Vaxman I, Visram A, Kumar S, Dispenzieri A, Buadi F, Dingli D, Lacy M, Muchtar E, Kapoor P, Hogan W, Hayman S, Leung N, Gonsalves W, Kourelis T, Warsame R, Berger T, Gertz MA. Autologous stem cell transplantation for multiple myeloma patients aged ≥ 75 treated with novel agents. Bone Marrow Transplant 2020; 56:1144-1150. [PMID: 33273658 DOI: 10.1038/s41409-020-01159-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/06/2020] [Accepted: 11/17/2020] [Indexed: 12/22/2022]
Abstract
Autologous stem cell transplantation (ASCT) has been used for treating multiple myeloma (MM) for over three decades and is generally reserved for patients younger than 65. Herein we report on outcomes of outpatient ASCT in a cohort of patients with MM aged ≥75 years. Between October 2005 and August 2020, 50 patients aged ≥75 years, received an ASCT at Mayo Clinic, Rochester. Median time from diagnosis to ASCT was 6.85 months (IQR 5.2-10.52) and 50%. received reduced intensity conditioning with melphalan 140 mg/m2. 48% of patients completed the ASCT without requiring hospitalization and 52% (n = 26) of patients required hospitalization with a median duration of hospital admission of 9 days (IQR 5-13). Reasons for hospitalization included fever or infection (32%), cardiac arrhythmia (36%), and dehydration (32%). Overall response rate was 100% with a complete response seen in 57% of patients. Median overall survival and progression free survival for the cohort were 82 months and 33 months, respectively. One patient died within 100 days of transplant representing a 2% 100-day mortality rate. ASCT is safe and efficacious in carefully selected MM patients aged 75 or above and we believe that age should not be an exclusion factor for ASCT in MM.
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Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center Petah, Tikvah, Israel.,Sackler Faculty of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Alissa Visram
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Francis Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Martha Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - William Hogan
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Tamar Berger
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center Petah, Tikvah, Israel.,Sackler Faculty of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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42
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Bal S, Costa LJ. Age is just a number, the wrong number. Cancer 2020; 126:5014-5016. [PMID: 32965676 DOI: 10.1002/cncr.33170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Susan Bal
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Luciano J Costa
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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