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Lupia T, Cani L, Bringhen S, De Rosa FG, Bruno B, Mikulska M, Corcione S, Mina R. Risk of Infection in Patients With Multiple Myeloma Treated With T-Cell Redirecting Approaches: A Call Out for Clinicians. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00175-7. [PMID: 38849284 DOI: 10.1016/j.clml.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/14/2024] [Accepted: 05/01/2024] [Indexed: 06/09/2024]
Abstract
T-cell redirecting therapies such as chimeric antigen receptor T-cells and bispecific antibodies, are emerging as a novel class of immunotherapeutic agents for treatment of relapsed refractory multiple myeloma (MM). Their use is associated with an increased risk of infectious adverse events, fostered by cytopenias, hypogammaglobulinemia and T-cell exhaustion. Multiple ongoing clinical trials and real-world studies are investigating safety of T-cell therapy, highlighting the need for strategies to prevent and monitor the risk of infection. Recommended measures for risk mitigation include intravenous immunoglobulin supplementation, adequate prophylaxis therapy, vaccination and careful assessment for early diagnosis and treatment of infection. Here, we summarize available data on the risk of infections with approved and under development T-cell redirecting therapies for the treatment of MM.
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Affiliation(s)
- Tommaso Lupia
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Lorenzo Cani
- Myeloma Unit, Division of Hematology, University of Turin and Azienda Ospedaliero-Universitaria (AOU) Città della Salute e della Scienza di Torino, Turin, Italy
| | - Sara Bringhen
- Myeloma Unit, Division of Hematology, University of Turin and Azienda Ospedaliero-Universitaria (AOU) Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Benedetto Bruno
- Myeloma Unit, Division of Hematology, University of Turin and Azienda Ospedaliero-Universitaria (AOU) Città della Salute e della Scienza di Torino, Turin, Italy
| | - Malgorzata Mikulska
- Department of Health Sciences, Division of Infectious Diseases, University of Genova, Genova, Italy; Division of Infectious Diseases, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy; Division of Geographic Medicine and Infectious Disease, School of Medicine, Tufts University, Boston, MA
| | - Roberto Mina
- Myeloma Unit, Division of Hematology, University of Turin and Azienda Ospedaliero-Universitaria (AOU) Città della Salute e della Scienza di Torino, Turin, Italy.
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LeBlanc MR, Zhou X, Baggett CD, Tuchman SA, Jensen CE, Lichtman EI, Rubinstein SM. Second Line Therapy in Multiple Myeloma: A SEER Medicare Analysis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00154-X. [PMID: 38760283 DOI: 10.1016/j.clml.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION The therapeutic landscape in relapsed/refractory multiple myeloma (RRMM) has changed rapidly, with twenty-two drug approvals since 2012. We characterized population-level trends in RRMM therapy selection, survival and cost outcomes associated with RRMM treatment over time. MATERIALS AND METHODS Our cohort included adults diagnosed with multiple myeloma (MM) in the SEER-Medicare database from 2007-2017 who received at least one antimyeloma agent. MM-directed therapies and lines of therapy were identified. Changes in 2LT regimens over time were described. Trends in overall survival from 2LT initiation over time were analyzed using a Cox proportional hazards model adjusting for factors associated with survival in MM. Trends in mean inflation-adjusted cost per 12 months of 2LT were analyzed using JoinPoint analysis. RESULTS A total of 9,822 patients met eligibility criteria, of whom 5,866 (59.7%) received 2LT. By 2018, 46% of 2LT regimens contained at least one agent approved in 2012 or later. Year of 2LT initiation was associated with improved overall survival (HR 0.78 per 5 years, 95% CI 0.74-0.84) after adjustment. Costs associated with 2LT increased over the study period, and the rate of cost increase increased significantly after 2012 (0.89%/year vs. 9.9%/year, P < .001), with higher total costs for regimens containing newer novel agents (mean $224,193 vs. $189,381, P < .001) CONCLUSION: Overall survival after initiation of 2LT has improved, however this has been accompanied by significant increases in costs of RRMM treatment, particularly for patients receiving newer novel agents. These findings provide useful context for existing and future drug approvals in RRMM.
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Affiliation(s)
- Matthew R LeBlanc
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, North Carolina, USA; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA.
| | - Xi Zhou
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
| | | | - Sascha A Tuchman
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA; University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Christopher E Jensen
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA; University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Eben I Lichtman
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA; University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Samuel M Rubinstein
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA; University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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McQuilten ZK, Weinkove R, Thao LTP, Crispin P, Degelia A, Dendle C, Gilbertson M, Johnston A, Keegan A, Pepperell D, Pullon H, Reynolds J, van Tonder T, Trotman J, Waters N, Wellard C, Weston H, Morrissey CO, Wood EM. Immunoglobulin replacement vs prophylactic antibiotics for hypogammaglobulinemia secondary to hematological malignancy. Blood Adv 2024; 8:1787-1795. [PMID: 38592710 PMCID: PMC11006812 DOI: 10.1182/bloodadvances.2023011231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/20/2023] [Indexed: 04/10/2024] Open
Abstract
ABSTRACT Immunoglobulin replacement and prophylactic antibiotics are commonly used to prevent infections in patients with secondary hypogammaglobulinemia due to hematological malignancies but have never been directly compared. In this randomized controlled feasibility trial conducted in 7 hospitals in Australia and New Zealand, we enrolled patients with secondary hypogammaglobulinemia with either a history of recurrent/severe infection or an immunoglobulin G level <4 g/L. Participants were randomized in a 1:2 ratio to immunoglobulin (0.4 g/kg per 4 weeks IV) or daily antibiotics (trimethoprim-sulfamethoxazole 160 mg/800 mg or, if contraindicated, 100 mg doxycycline) for 12 months. Participants allocated to antibiotics were allowed to crossover after grade ≥3 infections. The primary outcome was proportion of patients alive on the assigned treatment 12 months after randomization. Between August 2017 and April 2019, 63 patients were randomized: 42 to antibiotics and 21 to immunoglobulin. Proportion of participants alive on allocated treatment at 12 months was 76% in the immunoglobulin and 71% in the antibiotic arm (Fisher exact test P=.77; odds ratio, 0.78; 95% CI, 0.22-2.52). The lower quartile for time to first major infection (median, not reached) was 11.1 months for the immunoglobulin and 9.7 months for the antibiotic arm (log-rank test, P=.65). Three participants in the immunoglobulin and 2 in the antibiotic arm had grade ≥3 treatment-related adverse events. A similar proportion of participants remained on antibiotic prophylaxis at 12 months to those on immunoglobulin, with similar rates of major infections. Our findings support the feasibility of progressing to a phase 3 trial. Trial registration #ACTRN12616001723471.
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Affiliation(s)
- Zoe K. McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
| | - Robert Weinkove
- Te Rerenga Ora Wellington Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital, Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology & Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Le Thi Phuong Thao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Philip Crispin
- Department of Haematology, Canberra Hospital, Canberra, Australia
| | - Amber Degelia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Claire Dendle
- Monash Infectious Diseases, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | | | - Anna Johnston
- Department of Haematology, Royal Hobart Hospital, Hobart, Australia
- Department of Medicine, University of Tasmania, Hobart, Australia
| | - Anastazia Keegan
- PathWest Laboratory Medicine, King Edward Memorial Hospital, Perth, Australia
| | | | - Humphrey Pullon
- Department of Haematology, Waikato Hospital, Hamilton, New Zealand
| | - John Reynolds
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Tina van Tonder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Judith Trotman
- Department of Haematology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
| | - Neil Waters
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Cameron Wellard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Helen Weston
- Department of Haematology, Sunshine Coast University Hospital, Sunshine Coast, Australia
| | - C. Orla Morrissey
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia
| | - Erica M. Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
| | - Australasian Leukaemia and Lymphoma Group
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
- Te Rerenga Ora Wellington Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital, Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology & Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
- Department of Haematology, Canberra Hospital, Canberra, Australia
- Monash Infectious Diseases, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
- Department of Haematology, Royal Hobart Hospital, Hobart, Australia
- Department of Medicine, University of Tasmania, Hobart, Australia
- PathWest Laboratory Medicine, King Edward Memorial Hospital, Perth, Australia
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
- Department of Haematology, Waikato Hospital, Hamilton, New Zealand
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Haematology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- Department of Haematology, Sunshine Coast University Hospital, Sunshine Coast, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia
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4
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Reynolds G, Lindsay J. Antibacterial prophylaxis for neutropenic and high-risk hematology patients-Do the benefits outweigh the risk? Transpl Infect Dis 2024; 26:e14255. [PMID: 38459753 PMCID: PMC11009044 DOI: 10.1111/tid.14255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Gemma Reynolds
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases and Immunology, Austin Health, Melbourne, Victoria, Australia
| | - Julian Lindsay
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Geraldes C, Roque A, Sarmento-Ribeiro AB, Neves M, Ionita A, Gerivaz R, Tomé A, Afonso S, Silveira MP, Sousa P, Bergantim R, João C. Practical management of disease-related manifestations and drug toxicities in patients with multiple myeloma. Front Oncol 2024; 14:1282300. [PMID: 38585008 PMCID: PMC10995327 DOI: 10.3389/fonc.2024.1282300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/07/2024] [Indexed: 04/09/2024] Open
Abstract
Multiple myeloma (MM) is a very heterogeneous disease with multiple symptoms and clinical manifestations. MM affects mainly elderly patients and is difficult to manage in the presence of comorbidities, polypharmacy, frailty and adverse events of disease-targeted drugs. The rapid changes in MM treatment resulting from constant innovations in this area, together with the introduction of numerous new drugs with distinct mechanisms of action and toxicity profiles, have led to an increased complexity in the therapeutic decision-making and patient management processes. The prolonged exposure to novel agents, sometimes in combination with conventional therapies, makes this management even more challenging. A careful balance between treatment efficacy and its tolerability should be considered for every patient. During treatment, a close monitoring of comorbidities, disease-related manifestations and treatment side effects is recommended, as well as a proactive approach, with reinforcement of information and patient awareness for the early recognition of adverse events, allowing prompt therapeutic adjustments. In this review, we discuss various issues that must be considered in the treatment of MM patients, while giving practical guidance for monitoring, prevention and management of myeloma-related manifestations and treatment-related toxicities.
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Affiliation(s)
- Catarina Geraldes
- Serviço de Hematologia Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Adriana Roque
- Serviço de Hematologia Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Institute of Physiology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Ana Bela Sarmento-Ribeiro
- Serviço de Hematologia Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Manuel Neves
- Hemato-Oncology Unit, Champalimaud Foundation, Lisboa, Portugal
| | - Alina Ionita
- Hematology Department, Portuguese Institute of Oncology Francisco Gentil, Lisboa, Portugal
| | - Rita Gerivaz
- Serviço de Hemato-oncologia, Hospital Garcia de Orta, Lisboa, Portugal
| | - Ana Tomé
- Serviço de Hemato-oncologia, Hospital Garcia de Orta, Lisboa, Portugal
| | - Sofia Afonso
- Serviço de Hematologia Clínica, Centro Hospitalar Universitário Cova da Beira, Covilhã, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - Maria Pedro Silveira
- Serviço de Imuno-Hemoterapia, Hospital Prof. Doutor Fernando Fonseca, EPE, Amadora, Portugal
| | - Patrícia Sousa
- Serviço de Imuno-Hemoterapia, Hospital Prof. Doutor Fernando Fonseca, EPE, Amadora, Portugal
| | - Rui Bergantim
- Serviço de Hematologia Clínica, Centro Hospitalar Universitário de São João (CHUSJ), Porto, Portugal
- Instituto de Investigação e Inovaçáo em Saúde, Universidade do Porto, Porto, Portugal
- Institute of Pathology and Molecular Immunology, Abel Salazar Institute of Biomedical Sciences, University of Porto, Porto, Portugal
| | - Cristina João
- Hemato-Oncology Unit, Champalimaud Foundation, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
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6
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Mai EK, Hielscher T, Bertsch U, Salwender HJ, Zweegman S, Raab MS, Munder M, Pantani L, Mancuso K, Brossart P, Beksac M, Blau IW, Dürig J, Besemer B, Fenk R, Reimer P, van der Holt B, Hänel M, von Metzler I, Graeven U, Müller-Tidow C, Boccadoro M, Scheid C, Dimopoulos MA, Hillengass J, Weisel KC, Cavo M, Sonneveld P, Goldschmidt H. Predictors of early morbidity and mortality in newly diagnosed multiple myeloma: data from five randomized, controlled, phase III trials in 3700 patients. Leukemia 2024; 38:640-647. [PMID: 38062124 PMCID: PMC10912032 DOI: 10.1038/s41375-023-02105-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 01/10/2024]
Abstract
Early morbidity and mortality affect patient outcomes in multiple myeloma. Thus, we dissected the incidence and causes of morbidity/mortality during induction therapy (IT) for newly diagnosed multiple myeloma (NDMM), and developed/validated a predictive risk score. We evaluated 3700 transplant-eligible NDMM patients treated in 2005-2020 with novel agent-based triplet/quadruplet IT. Primary endpoints were severe infections, death, or a combination of both. Patients were divided in a training (n = 1333) and three validation cohorts (n = 2367). During IT, 11.8%, 1.8%, and 12.5% of patients in the training cohort experienced severe infections, death, or both, respectively. Four major, baseline risk factors for severe infection/death were identified: low platelet count (<150/nL), ISS III, higher WHO performance status (>1), and age (>60 years). A risk score (1 risk factor=1 point) stratified patients in low (39.5%; 0 points), intermediate (41.9%; 1 point), and high (18.6%; ≥2 points) risk. The risk for severe infection/death increased from 7.7% vs. 11.5% vs. 23.3% in the low- vs. intermediate- vs. high-risk groups (p < 0.001). The risk score was independently validated in three trials incorporating quadruplet IT with an anti-CD38 antibody. Our analyses established a robust and easy-to-use score to identify NDMM patients at risk of severe infection/death, covering the latest quadruplet induction therapies. Trial registrations: HOVON-65/GMMG-HD4: EudraCT No. 2004-000944-26. GMMG-MM5: EudraCT No. 2010-019173-16. GMMG-HD6: NCT02495922. EMN02/HOVON-95: NCT01208766. GMMG-HD7: NCT03617731.
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Affiliation(s)
- Elias K Mai
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany.
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Uta Bertsch
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
| | - Hans J Salwender
- Tumorzentrum Asklepios Hamburg, AK Altona and AK St. Georg, Hamburg, Germany
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Marc S Raab
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Munder
- Department of Internal Medicine III, University Medical Center Mainz, Mainz, Germany
| | - Lucia Pantani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Azienda Ospedaliero-Universitaria di Bologna, Università di Bologna, Bologna, Italy
| | - Katia Mancuso
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Azienda Ospedaliero-Universitaria di Bologna, Università di Bologna, Bologna, Italy
| | - Peter Brossart
- Department of Internal Medicine III, University Hospital Bonn, Bonn, Germany
| | - Meral Beksac
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Igor W Blau
- Medical Clinic, Charité University Medicine Berlin, Berlin, Germany
| | - Jan Dürig
- Department of Hematology, University Clinic Essen, Essen, Germany
| | - Britta Besemer
- Department of Hematology, Oncology and Immunology, University Hospital Tübingen, Tübingen, Germany
| | - Roland Fenk
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Peter Reimer
- Klinik für Hämatologie, Evangelische Kliniken Essen Mitte, Evangelisches Krankenhaus Essen-Werden, Essen, Germany
| | - Bronno van der Holt
- HOVON Data Center, Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Mathias Hänel
- Department of Internal Medicine III, Klinikum Chemnitz, Chemnitz, Germany
| | - Ivana von Metzler
- Medical Clinic II, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Ullrich Graeven
- Department of Internal Medicine I, Hospital Maria Hilf GmbH, Mönchengladbach, Germany
| | - Carsten Müller-Tidow
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Christof Scheid
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Katja C Weisel
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Azienda Ospedaliero-Universitaria di Bologna, Università di Bologna, Bologna, Italy
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Hartmut Goldschmidt
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
- National Center for Tumor Diseases (NCT) Heidelberg, Heidelberg, Germany
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7
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Facon T, Leleu X, Manier S. How I treat multiple myeloma in geriatric patients. Blood 2024; 143:224-232. [PMID: 36693134 PMCID: PMC10808246 DOI: 10.1182/blood.2022017635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023] Open
Abstract
ABSTRACT Multiple myeloma (MM) is primarily a disease of older patients. Until recently, geriatric aspects in the context of MM have been poorly investigated. Treatment outcomes for geriatric patients with MM are often compromised by comorbidities and an enhanced susceptibility to adverse events from therapy. Assessment of patient frailty has become more frequent and will be useful in the context of significant and continuous advances in therapy. The recent emergence of immunotherapy with CD38 monoclonal antibodies and upcoming immunooncology drugs, such as bispecific antibodies, will lead to additional therapeutic progress. The applicability of these new molecules to older and frail patients is a key clinical question. Here, we present 2 patient cases derived from clinical practice. We review current frailty scores and standards of care for older, newly diagnosed patients with MM, including frail subgroups, and discuss ways to tailor treatment, as well as treatment perspectives in this population.
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Affiliation(s)
- Thierry Facon
- Department of Hematology, University of Lille, Centre Hospitalier Universitaire Lille, Lille, France
| | - Xavier Leleu
- Department of Hematology, University of Poitiers, Centre Hospitalier Universitaire Poitiers, Poitiers, France
| | - Salomon Manier
- Department of Hematology, University of Lille, Centre Hospitalier Universitaire Lille, Lille, France
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8
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Frerichs KA, Verkleij CPM, Mateos MV, Martin TG, Rodriguez C, Nooka A, Banerjee A, Chastain K, Perales-Puchalt A, Stephenson T, Uhlar C, Kobos R, van der Holt B, Kruyswijk S, Kuipers MT, Groen K, Vishwamitra D, Skerget S, Cortes-Selva D, Doyle M, Zaaijer HL, Zweegman S, Verona RI, van de Donk NWCJ. Teclistamab impairs humoral immunity in patients with heavily pretreated myeloma: importance of immunoglobulin supplementation. Blood Adv 2024; 8:194-206. [PMID: 38052042 PMCID: PMC10787247 DOI: 10.1182/bloodadvances.2023011658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/07/2023] Open
Abstract
ABSTRACT Teclistamab and other B-cell maturation antigen (BCMA)-targeting bispecific antibodies (BsAbs) have substantial activity in patients with heavily pretreated multiple myeloma (MM) but are associated with a high rate of infections. BCMA is also expressed on normal plasma cells and mature B cells, which are essential for the generation of a humoral immune response. The aim of this study was to improve the understanding of the impact of BCMA-targeting BsAbs on humoral immunity. The impact of teclistamab on polyclonal immunoglobulins and B cell counts was evaluated in patients with MM who received once-weekly teclistamab 1.5 mg/kg subcutaneously. Vaccination responses were assessed in a subset of patients. Teclistamabinduced rapid depletion of peripheral blood B cells in patients with MM and eliminated normal plasma cells in ex vivo assays. In addition, teclistamab reduced the levels of polyclonal immunoglobulins (immunoglobulin G [IgG], IgA, IgE, and IgM), without recovery over time while receiving teclistamab therapy. Furthermore, response to vaccines against Streptococcus pneumoniae, Haemophilus influenzae type B, and severe acute respiratory syndrome coronavirus 2 was severely impaired in patients treated with teclistamab compared with vaccination responses observed in patients with newly diagnosed MM or relapsed/refractory MM. Intravenous immunoglobulin (IVIG) use was associated with a significantly lower risk of serious infections among patients treated with teclistamab (cumulative incidence of infections at 6 months: 5.3% with IVIG vs 54.8% with observation only [P < .001]). In conclusion, our data show severe defects in humoral immunity induced by teclistamab, the impact of which can be mitigated by the use of immunoglobulin supplementation. This trial was registered at www.ClinicalTrials.gov as #NCT04557098.
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Affiliation(s)
- Kristine A Frerichs
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - Christie P M Verkleij
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | | | | | | | - Ajay Nooka
- Winship Cancer Institute, Emory University, Atlanta, GA
| | | | | | | | | | | | - Rachel Kobos
- Janssen Research & Development, Spring House, PA
| | - Bronno van der Holt
- HOVON Foundation, Rotterdam, The Netherlands
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sandy Kruyswijk
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - Maria T Kuipers
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - Kaz Groen
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | | | | | | | | | - Hans L Zaaijer
- Department of Medical Microbiology, Amsterdam UMC location, Academic Medical Center, Amsterdam, The Netherlands
| | - Sonja Zweegman
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | | | - Niels W C J van de Donk
- Department of Hematology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
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9
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Zhang M, Cheng Q, Zhao F, Xu A, Li Q, Hu Y, Sun C. Development of a nomogram prognostic model for early Grade ≥ 3 infection in newly diagnosed multiple myeloma based on immunoparesis. Int Immunopharmacol 2024; 126:111277. [PMID: 38061120 DOI: 10.1016/j.intimp.2023.111277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/08/2023] [Accepted: 11/20/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Infection, a significant cause of death in multiple myeloma (MM) patients, is a common complication and is closely associated with immunoparesis. There exists no clear definition of early infection, so early infection is defined in this paper as the occurrence within 3 months after diagnosis, considering the high incidence of infections within 3 months after diagnosis. This study established a new nomogram model based on immunoparesis to identify MM patients with high-risk early infection. METHODS A retrospective collection of 430 NDMM patients from June 2013 to June 2022 was conducted, and the patients were further divided into a training cohort and a validation cohort. In the training cohort, the least absolute shrinkage and selection operator (LASSO) was used to select the best variables that can be used to establish a new nomogram prediction model. Validation was performed in the validation and entire cohorts. RESULTS After diagnosis, 67.7 % of the patients suffered from severe infection within 1 year, and 59.5 % experienced the first severe infection within 3 months. Variables associated with an increased risk of severe infection in the first 3 months included: BMPC, D-dimer, serum β2 microglobulin, immunoparesis, albumin, and eGFR. The nomogram based on the above six factors achieved a good C-index of 0.754, 0.73, and 0.731 in predicting early infection in the training cohort, validation cohort, and entire cohort, respectively. Finally, the time-dependent receiver operating characteristic (ROC) curve and decision curve analysis (DCA) of the nomogram showed that the model provided superior diagnostic capacity and clinical net benefit. CONCLUSION In this study, we established a nomogram model to predict early grade ≥ 3 infection in NDMM patients. This model can assist clinicians in identifying NDMM patients with high-risk infections and improve their prognosis through early intervention.
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Affiliation(s)
- Min Zhang
- Institute of Hematology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China.
| | - Qianwen Cheng
- Emergency Department, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China.
| | - Fei Zhao
- Institute of Hematology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China.
| | - Aoshuang Xu
- Institute of Hematology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China.
| | - Qun Li
- Institute of Hematology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China.
| | - Yu Hu
- Institute of Hematology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China; Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan 430000, China.
| | - Chunyan Sun
- Institute of Hematology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, China; Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan 430000, China.
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10
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Wu J, Wu H, Chen L, Liang H, Huang G, Yang S, Chen B, Noguchi Y, Shen Y. Safety of daratumumab in the real-world: a pharmacovigilance study based on FAERS database. Expert Opin Drug Saf 2023:1-12. [PMID: 38108285 DOI: 10.1080/14740338.2023.2296966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 11/28/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Daratumumab is widely used in multiple myeloma (MM) and light chain amyloidosis (AL amyloidosis). The purpose of this study was to identify adverse event (AE) signals for daratumumab through the FDA Adverse Event Reporting System (FAERS) database to assess its safety in a large sample of people. METHODS Based on data from the FAERS database, three disproportionality analysis methods were used to mine AE signals for daratumumab, including reporting odd ratio (ROR), proportional reporting ratio (PRR), and bayesian configuration promotion neural network (BCPNN). RESULTS A total of 9220 AE reports with daratumumab as the primary suspect drug were collected, containing 23,946 AEs. Within these reports, 252 preferred terms (PT) levels, 73 high level term (HLT) levels and 11 system organ class (SOC) levels of AE signals were detected, along with some new AEs. Most AEs occurred within the first month after drug administration. CONCLUSION Our findings were consistent with the results of established studies that daratumumab has a good safety profile. The newly identified AEs are of concern and prospective clinical studies are needed to confirm whether they are causally related to daratumumab. This study provided an early warning for the safe use of daratumumab and also provided guidance for further safety studies.
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Affiliation(s)
- Junlin Wu
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Hanbiao Wu
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Lili Chen
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Haiping Liang
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Guoning Huang
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Sensen Yang
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Bishan Chen
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
| | - Yoshihiro Noguchi
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Yonggang Shen
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, Guangdong Province, China
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11
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Mohan M, Chakraborty R, Bal S, Nellore A, Baljevic M, D’Souza A, Pappas PG, Berdeja JG, Callander N, Costa LJ. Recommendations on prevention of infections during chimeric antigen receptor T-cell and bispecific antibody therapy in multiple myeloma. Br J Haematol 2023; 203:736-746. [PMID: 37287117 PMCID: PMC10700672 DOI: 10.1111/bjh.18909] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/26/2023] [Accepted: 05/29/2023] [Indexed: 06/09/2023]
Abstract
Chimeric antigen receptor T (CAR T) cell and bispecific antibody therapies have shown unprecedented efficacy in heavily pretreated patients with multiple myeloma (MM). However, their use is associated with a significant risk of severe infections, which can be attributed to various factors such as hypogammaglobulinemia, neutropenia, lymphopenia, T-cell exhaustion, cytokine-release syndrome and immune-effector cell-associated neurotoxicity syndrome. As these therapies have been recently approved by regulatory agencies, it is crucial to establish practical guidelines for infection monitoring and prevention until robust data from prospective clinical trials become available. To address this issue, a panel of experienced investigators from the Academic Consortium to Overcome Multiple Myeloma through Innovative Trials (COMMIT) developed consensus recommendations for mitigating infections associated with CAR T-cell and bispecific antibody therapies in MM patients.
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Affiliation(s)
- Meera Mohan
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, U.S.A
| | - Rajshekhar Chakraborty
- Multiple Myeloma and Amyloidosis Program, Columbia University, Herbert Irving Comprehensive Cancer Center, NY, U.S.A
| | - Susan Bal
- Division of Hematology and Medical Oncology, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - Anoma Nellore
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - Muhamed Baljevic
- Division of Hematology/Oncology, Vanderbilt-Ingram Cancer Center, TN, U.S.A
| | - Anita D’Souza
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, U.S.A
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | | | | | - Luciano J. Costa
- Division of Hematology and Medical Oncology, University of Alabama at Birmingham, Birmingham, AL, U.S.A
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12
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Mainou M, Bougioukas KI, Malandris K, Liakos A, Klonizakis P, Avgerinos I, Haidich AB, Tsapas A. Reporting of adverse events of treatment interventions in multiple myeloma: an overview of systematic reviews. Ann Hematol 2023:10.1007/s00277-023-05517-7. [PMID: 37935924 DOI: 10.1007/s00277-023-05517-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/18/2023] [Indexed: 11/09/2023]
Abstract
The present study is an overview of systematic reviews focusing on adverse events of antimyeloma treatments. It provides a systematic description of adverse events as they are reported in the systematic reviews as well as a critical appraisal of included reviews. We conducted a comprehensive literature search in the most widely used electronic databases looking for systematic reviews that had an adverse event of an antimyeloma treatment intervention as primary outcome. Two independent reviewers conducted selection of included studies and data extraction on predesigned online forms and assessed study quality using AMSTAR 2. Overall corrected covered area (CCA) was calculated to examine the overlap of primary studies across systematic reviews. After screening eligible studies, 23 systematic reviews were included in this overview. Seven reviews with overall CCA of 14.7% examined cardiovascular adverse events of different drugs, including immunomodulatory drugs and proteasome inhibitors (mainly carfilzomib). Nine focused on infections, presenting with overall CCA of 5.8%, each one focused on a different drug or drug class. Three studied thromboembolism in patients treated either with lenalidomide, any immunomodulatory drug, or with daratumumab and had an overall CCA equal to 1.5%. Four more reviews focused on bortezomib-associated neurotoxicity, carfilzomib-associated renal toxicity, or second primary malignancies as an adverse event of lenalidomide or anti-CD38 monoclonal antibody treatment. The quality of included studies as judged by AMSTAR 2 was mostly critically low. Absence of a priori registered protocol and formal assessment of risk of bias of included primary studies were the most common shortcomings. Reporting of antimyeloma drug-associated toxicity is supported by multiple systematic reviews; nevertheless, methodological quality of existing reviews is mostly low.
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Affiliation(s)
- Maria Mainou
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Konstantinos I Bougioukas
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece
| | - Konstantinos Malandris
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aris Liakos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Philippos Klonizakis
- Adult Thalassemia Unit, Second Department of Internal Medicine, Hippokration Hospital, Thessaloniki, Greece
| | - Ioannis Avgerinos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna-Betinna Haidich
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece
| | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, UK
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13
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Singh N, Thursky K, Maron G, Wolf J. Fluoroquinolone prophylaxis in patients with neutropenia at high risk of serious infections: Exploring pros and cons. Transpl Infect Dis 2023; 25 Suppl 1:e14152. [PMID: 37746769 DOI: 10.1111/tid.14152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND The use of fluoroquinolones to prevent infections in neutropenic patients with cancer or undergoing hematopoietic stem cell transplantation (HSCT) is a controversial issue, with international guidelines providing conflicting recommendations. Although potential benefits are clear, concerns revolve around efficacy, potential harms, and antimicrobial resistance (AMR) implications. DISCUSSION Fluoroquinolone prophylaxis reduces neutropenic fever (NF) bloodstream infections and other serious bacterial infections, based on evidence from systematic reviews, randomized controlled trials, and observational studies in adults and children. Fluoroquinolone prophylaxis may also reduce infection-related morbidity and healthcare costs; however, evidence is conflicting. Adverse effects of fluoroquinolones are well recognized in the general population; however, studies in the cancer cohort where it is used for a defined period of neutropenia have not reflected this. The largest concern for routine use of fluoroquinolone prophylaxis remains AMR, as many, but not all, observational studies have found that fluoroquinolone prophylaxis might increase the risk of AMR, and some studies have suggested negative impacts on patient outcomes as a result. CONCLUSIONS The debate surrounding fluoroquinolone prophylaxis calls for individualized risk assessment based on patient characteristics and local AMR patterns, and prophylaxis should be restricted to patients at the highest risk of serious infection during the highest risk periods to ensure that the risk-benefit analysis is in favor of individual and community benefit. More research is needed to address important unanswered questions about fluoroquinolone prophylaxis in neutropenic patients with cancer or receiving HSCT.
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Affiliation(s)
- Nikhil Singh
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Pharmacy, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Karin Thursky
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Melbourne, Australia
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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14
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Riva E, Garrido D, Villano F, Bove V. Epidemiology and risk factors for the development of infectious complications in newly diagnosed multiple myeloma: a multicenter prospective cohort study in Uruguay. Hematol Transfus Cell Ther 2023:S2531-1379(23)02581-6. [PMID: 38307822 DOI: 10.1016/j.htct.2023.09.2362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/20/2023] [Accepted: 09/05/2023] [Indexed: 02/04/2024] Open
Abstract
INTRODUCTION Infections represent a significant cause of morbidity and mortality in patients with multiple myeloma (MM). In Latin America, data on infectious complications in newly diagnosed MM (NDMM) patients are limited. METHODS We conducted a multicenter, prospective cohort study of patients with NDMM in Uruguay between June 2019 and December 2020. Patients with active disease, on active therapy and who provided written informed consent were included. Elegible patients were followed for 6 months from the time of diagnosis and before proceeding to autologous stem cell transplantation or until death, whichever occurred first. Our primary endpoint was the number of infectious events that required hospitalization for ≥ 24 h. MAIN RESULTS Of 124 patients with NDMM, 54 (43.5 %) had infectious complications (74 infectious events), the majority (74.3 %) within the first 3 months from diagnosis. The most common sites of infection were urinary (39.2 %) and respiratory tracts (33.8 %). The microbial agent was identified in 60.8 % of patients with Gram-negative bacteria (71.4 %) as the most common pathogen. Viral and fungal infections were infrequent. In the multivariable analysis, the Eastern Cooperative Oncology Group (ECOG) performance status was ≥ 2 (odds ratio [OR], 2.16; 95 % confidence interval [95 %CI], 1.23 - 3.79; p = 0.008) and creatinine ≥ 2 mg/dl (OR, 2.33; 95 %CI, 1.33 - 4.07; p = 0.003) were independent factors associated with bacterial infections. At 6 months, 14 patients (11.3 %) had died, 50 % related to infectious complications. CONCLUSION Bacterial infections are a substantial cause of hospital admissions and early death in patients with NDMM. Antibiotic prophylaxis should be considered to reduce infectious complications in patients with MM.
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Affiliation(s)
- Eloísa Riva
- Hospital de Clínicas, Montevideo, Uruguay; Hospital Británico, Montevideo, Uruguay
| | | | | | - Virginia Bove
- Hospital Central de las FF.AA., Montevideo, Uruguay.
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15
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Giralt S, Jolles S, Kerre T, Lazarus HM, Mustafa SS, Papanicolaou GA, Ria R, Vinh DC, Wingard JR. Recommendations for Management of Secondary Antibody Deficiency in Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:719-732. [PMID: 37353432 DOI: 10.1016/j.clml.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/05/2023] [Accepted: 05/18/2023] [Indexed: 06/25/2023]
Abstract
Secondary antibody deficiency (SAD) is a subtype of secondary immunodeficiency characterized by low serum antibody concentrations (hypogammaglobulinemia) or poor antibody function. SAD is common in patients with multiple myeloma (MM) due to underlying disease pathophysiology and treatment-related immune system effects. Patients with SAD are more susceptible to infections and infection-related morbidity and mortality. With therapeutic advancements improving MM disease control and survival, it is increasingly important to recognize and treat the often-overlooked concurrent immunodeficiency present in patients with MM. The aims of this review are to define SAD and its consequences in MM, increase SAD awareness, and provide recommendations for SAD management. Based on expert panel discussions at a standalone meeting and supportive literature, several recommendations were made. Firstly, all patients with MM should be suspected to have SAD regardless of serum antibody concentrations. Patients should be evaluated for immunodeficiency at MM diagnosis and stratified into management categories based on their individualized risk of SAD and infection. Infection-prevention strategy education, early infection reporting, and anti-infective prophylaxis are key. We recommend prophylactic antibiotics or immunoglobulin replacement therapy (IgRT) should be considered in patients with severe hypogammaglobulinemia associated with a recurrent or persistent infection. To ensure an individualized and efficient treatment approach is utilized, patient's immunoglobin G concentration and infection burden should be closely monitored throughout treatment. Patient choice regarding route and IgRT treatment is also key in reducing treatment burden. Together, these recommendations and proposed management algorithms can be used to aid physician decision-making to improve patient outcomes.
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Affiliation(s)
- Sergio Giralt
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
| | - Tessa Kerre
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Hillard M Lazarus
- Department of Medicine, Division of Hematology and Oncology, Case Western Reserve University, Cleveland, OH, United States
| | - S Shahzad Mustafa
- Rochester Regional Health, Rochester, NY, United States; University of Rochester School of Medicine & Dentistry, Rochester, NY, United States
| | - Genovefa A Papanicolaou
- Department of Medicine, Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Roberto Ria
- Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Bari, Italy
| | - Donald C Vinh
- Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| | - John R Wingard
- Department of Medicine, Division of Hematology Oncology, University of Florida, Gainesville, FL, United States
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16
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Jandial A, Lad D, Jain A, Khadwal A, Singh C, Prakash G, Suri V, Sreedharanunni S, Sachdeva MUS, Ray P, Varma N, Varma S, Malhotra P. Characteristics and outcome of infectious complications after autologous hematopoietic cell transplantation in multiple myeloma patients. Transpl Infect Dis 2023; 25:e14123. [PMID: 37573150 DOI: 10.1111/tid.14123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Infections are a significant cause of morbidity and mortality after autologous hematopoietic cell transplantation (AHCT) in multiple myeloma (MM) patients. There has been a rapid advancement and evolution in MM treatment landscape in the last decade. There is limited information on post-AHCT infectious complications among MM patients with or without levofloxacin prophylaxis from developing countries. MATERIALS AND METHODS We performed a retrospective study to explore the incidence, pattern, and clinical outcome of infections following AHCT in MM patients from 2010 to 2019 at our center. Patient-specific, disease-specific, and transplant-specific details were retrieved from the case files. The characteristics of infectious complications (site, intensity, organism, treatment, and outcomes) were analyzed. All patients who underwent transplantation from 2010 to 2016 received levofloxacin antibiotic prophylaxis. Common terminology criteria for adverse events (CTCAE) criteria (v5.0) were used for the grading of infections and regimen-related toxicity. International Myeloma Working Group updated criteria were used for the assessment of disease response before transplant and at day +100. RESULTS Ninety-five consecutive patients with newly diagnosed multiple myeloma (NDMM) (n = 85), RRMM (n = 7), plasma cell leukemia (n = 2), and Polyneuropathy, Orgaomegaly, Endocrinopathy, Monoclonal gammopathy, skin abnormalities (POEMS) syndrome (n = 1) underwent AHCT during the study period. Their median age was 55 years (range 33-68); 55.8% were males. Immunoglobulin IgG kappa was the most common monoclonal protein (32.6%), International Staging System stage III disease was present in 45.3%, and 84.2% of patients achieved more than very good partial response before AHCT. The median time from diagnosis to AHCT was 10 months (range 4-144). Eighty-nine patients (93.7%) developed fever after AHCT. Fever of unknown focus, microbiologically confirmed infections, and clinically suspected infections were found in 50.5%, 37.9%, and 5.3% of patients, respectively. Clostridiodes difficile-associated diarrhea was observed in eight patients (8.4%). Neutrophil and platelet engraftment occurred after a median of 11 days (range 9-14) and 12 days (range 9-23), respectively. The median duration of hospital stay was 16 days (range 9-29). Only two patients (2.1%) required readmission for infections within 100 days of AHCT. Transplant-related mortality (TRM) in the study population was 4.2% (n = 4). The levofloxacin prophylaxis group (n = 32, 33.7%) had earlier neutrophil engraftment (day +10 vs. day +11) and platelet engraftment (day +11 vs. day +12), but time to fever onset, duration of fever, hospital stay, TRM, and day +100 readmission rates were not significantly different from those of patients without levofloxacin prophylaxis. There was no significant difference in the spectrum of infections between patients with and without levofloxacin prophylaxis. The overall survival and progression-free survival of the study population at 5 years were 72.7% and 64.8%, respectively. CONCLUSION This study shows that the incidence of infections and TRM are higher in MM patients from lower-middle income countries after AHCT than in those from developed countries. The majority of such patients lack clinical localization and microbiological proof of infection. There was no significant difference in the spectrum of infections and their outcomes in patients with and without levofloxacin prophylaxis.
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Affiliation(s)
- Aditya Jandial
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh Lad
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arihant Jain
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Khadwal
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Charanpreet Singh
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Prakash
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Suri
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreejesh Sreedharanunni
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Man Updesh Singh Sachdeva
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Varma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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17
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Teh BW, Reynolds G, Slavin MA, Cooley L, Roberts M, Liu E, Thursky K, Talaulikar D, Mollee P, Szabo F, Ward C, Chan H, Prince HM, Harrison SJ. Executive summary of consensus clinical practice guidelines for the prevention of infection in patients with multiple myeloma. Intern Med J 2023; 53:1469-1477. [PMID: 37093163 DOI: 10.1111/imj.16100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 04/10/2023] [Indexed: 04/25/2023]
Abstract
Infection remains a significant contributor to morbidity and mortality in patients with myeloma. This guideline was developed by a multidisciplinary group of clinicians who specialise in the management of patients with myeloma and infection from the medical and scientific advisory group from Myeloma Australia and the National Centre for Infections in Cancer. In addition to summarising the current epidemiology and risk factors for infection in patients with myeloma, this guideline provides recommendations that address three key areas in the prevention of infection: screening for latent infection, use of antimicrobial prophylaxis and immunoglobulin replacement and vaccination against leading respiratory infections (severe acute respiratory syndrome coronavirus 2, influenza and Streptococcus pneumoniae) and other preventable infections. This guideline provides a practical approach to the prevention of infection in patients with myeloma and harmonises the clinical approach to screening for infection, use of prophylaxis and vaccination to prevent infectious complications.
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Affiliation(s)
- Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Gemma Reynolds
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Austin Health, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Louise Cooley
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Matthew Roberts
- Department of Infectious Diseases, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eunice Liu
- Department of Infectious Diseases, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Karin Thursky
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Dipti Talaulikar
- Department of Haematology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Peter Mollee
- Queensland Haematology Department, Princess Alexandra Hospital, Sydney, Queensland, Australia
- School of Medicine, University of Queensland, Sydney, Queensland, Australia
| | - Ferenc Szabo
- Haematology Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Menzies School of Health Research, Darwin, Northern Territory, Australia
- Flinders University, Adelaide, South Australia, Australia
| | - Chris Ward
- Department of Haematology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Henry Chan
- Department of Haematology, Waitemata District Health Board, Auckland, New Zealand
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - H Miles Prince
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Epworth Healthcare, Melbourne, Victoria, Australia
| | - Simon J Harrison
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Victoria, Australia
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18
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O'Neill C, van de Donk NWCJ. T-cell redirecting bispecific antibodies in multiple myeloma: Current landscape and future directions. EJHAEM 2023; 4:811-822. [PMID: 37601851 PMCID: PMC10435697 DOI: 10.1002/jha2.729] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 08/22/2023]
Abstract
T-cell engaging bispecific antibodies (BsAbs) have substantial activity in heavily pretreated patients with multiple myeloma (MM). The overall response rate obtained with B-cell maturation antigen (BCMA)-targeting BsAbs is approximately 60%-70%, including a high proportion of patients achieving very good partial response or complete response. Comparable efficacy is seen with BsAbs targeting GPRC5D or FcRH5. Cytokine release syndrome is frequently observed with BsAb treatment, but mostly during the step-up doses and the first full dose. Early intervention with IL-6 receptor blocking antibodies (e.g., tocilizumab) prevents escalation to severe manifestations. Infections are also common during treatment and related to the extent of exposure to immune suppressive anti-MM agents, as well as development of hypogammaglobulinemia due to elimination of normal plasma cells, and probably because of T-cell exhaustion resulting from continuous BsAb-mediated T-cell activation. Adequate monitoring for infections and institution of infectious prophylaxis are essential. Patients treated with GPRC5D-targteing BsAbs often develop skin and nail disorders and loss of taste, which is likely related to GPRC5D expression in cells that produce hard keratin. Currently ongoing studies are aiming at further improving these results by evaluating BsAbs in combination with other drugs, such as immunomodulatory agents and anti-CD38 antibodies, as well as the application of BsAbs in earlier lines of therapy, including patients with newly diagnosed disease. We expect that the outcomes of patients with MM will further improve by the introduction of this novel type of T-cell immunotherapy.
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Affiliation(s)
- Chloe O'Neill
- Amsterdam UMC, Vrije Universiteit AmsterdamDepartment of HematologyAmsterdamThe Netherlands
- Cancer Center AmsterdamCancer Biology and ImmunologyAmsterdamThe Netherlands
| | - Niels W. C. J. van de Donk
- Amsterdam UMC, Vrije Universiteit AmsterdamDepartment of HematologyAmsterdamThe Netherlands
- Cancer Center AmsterdamCancer Biology and ImmunologyAmsterdamThe Netherlands
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19
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Raje N, Anderson K, Einsele H, Efebera Y, Gay F, Hammond SP, Lesokhin AM, Lonial S, Ludwig H, Moreau P, Patel K, Ramasamy K, Mateos MV. Monitoring, prophylaxis, and treatment of infections in patients with MM receiving bispecific antibody therapy: consensus recommendations from an expert panel. Blood Cancer J 2023; 13:116. [PMID: 37528088 PMCID: PMC10394080 DOI: 10.1038/s41408-023-00879-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/25/2023] [Accepted: 06/21/2023] [Indexed: 08/03/2023] Open
Abstract
Bispecific antibodies (BsAbs) are emerging as an important novel class of immunotherapeutic agents for the treatment of multiple myeloma (MM), and are set to be more widely used in clinical practice. However, this new class of therapies is associated with a distinct adverse event (AE) profile that includes cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, as well as AEs leading to increased infection risk such as cytopenias and hypogammaglobulinemia, and infections themselves. As preliminary data with this class of agents shows an increased risk of infections as compared with conventional MM treatment regimens, such as immunomodulatory drugs, proteasome inhibitors, and anti-CD38 monoclonal antibodies (mAbs), guidance on infection monitoring, prophylaxis and treatment is required. This review provides consensus recommendations from a panel of 13 global experts, following a meeting in August 2022. The meeting objective was to review existing literature and identify relevant information on infections with all BsAbs in patients with MM, as well as to discuss clinical experience of experts in managing these infections. The recommendations outlined here can be used to guide management of infection risk factors, such as hypogammaglobulinemia and neutropenia. In addition, they can be used to guide the monitoring, prophylaxis, and treatment of bacterial, viral and fungal infections, including emerging infections of interest, such as coronavirus 2019 (COVID-19), and the use of vaccinations prior to and during BsAb treatment. The recommendations have been graded by the panel based on level of data available. Key recommendations include universal herpes simplex and varicella zoster virus prophylaxis, screening for hepatitis B virus reactivation risk in all patients, monthly intravenous immunoglobulin treatment for immunoparesis and in the absence of life-threatening infectious manifestations, use of colony-stimulating factors in patients with Grade 3 neutropenia, universal pneumocystis jirovecii pneumonia prophylaxis and no routine anti-fungal prophylaxis.
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Affiliation(s)
- Noopur Raje
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA.
| | - Kenneth Anderson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Yvonne Efebera
- Division of Blood and Marrow Transplant, OhioHealth, Columbus, OH, USA
| | - Francesca Gay
- Division of Hematology 1, Clinical trial Unit, AOU Città della Salute e della Scienza di Torino, University of Torino, Turin, Italy
| | - Sarah P Hammond
- Division of Hematology and Oncology, Massachusetts General Hospital, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Alexander M Lesokhin
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Sagar Lonial
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, Department of Medicine I, Center for Oncology, Hematology and Palliative Care, Klinik Ottakring, Vienna, Austria
| | - Philippe Moreau
- Department of Hematology, University Hospital of Nantes, Nantes, France
| | - Krina Patel
- Department of Lymphoma and Myeloma, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karthik Ramasamy
- Oxford University Hospitals, Oxford University, NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, Oxford University, NHS Foundation Trust, Oxford, UK
| | - Maria-Victoria Mateos
- Department of Hematology, University Hospital of Salamanca, IBSAL and Center for Cancer Research, Salamanca, Spain
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20
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Bowcock S, Atkin C, Iqbal G, Pratt G, Yong K, Neal RD, Planche T, Karunanithi K, Jenkins S, Stern S, Arnott S, Toth P, Wandroo F, Dunn J, Drayson MT. Presenting Symptoms in Newly Diagnosed Myeloma, Relation to Organ Damage, and Implications for Symptom-Directed Screening: A Secondary Analysis from the Tackling Early Morbidity and Mortality in Myeloma (TEAMM) Trial. Cancers (Basel) 2023; 15:3337. [PMID: 37444449 PMCID: PMC10341254 DOI: 10.3390/cancers15133337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/26/2023] [Accepted: 06/09/2023] [Indexed: 07/15/2023] Open
Abstract
Multiple myeloma (MM) patients risk diagnostic delays and irreversible organ damage. In those with newly diagnosed myeloma, we explored the presenting symptoms to identify early signals of MM and their relationships to organ damage. The symptoms were recorded in patients' own words at diagnosis and included diagnostic time intervals. Those seen by a haematologist >6 months prior to MM diagnosis were classified as precursor disease (PD). Most (962/977) patients provided data. Back pain (38%), other pain (31%) and systemic symptoms (28%) predominated. Patients rarely complain of 'bone pain', simply 'pain'. Vertebral fractures are under-recognised as pathological and are the predominant irreversible organ damage (27% of patients), impacting the performance status (PS) and associated with back pain (odds ratio (OR) 6.14 [CI 4.47-8.44]), bone disease (OR 3.71 [CI 1.88-7.32]) and age >65 years (OR 1.58 [CI 1.15-2.17]). Renal failure is less frequent and associated with gastrointestinal symptoms (OR 2.23 [CI1.28-3.91]), age >65 years (OR 2.14 [CI1.28-3.91]) and absence of back pain (OR 0.44 [CI 0.29-0.67]). Patients with known PD (n = 149) had fewer vertebral fractures (p = 0.001), fewer adverse features (p = 0.001), less decline in PS (p = 0.001) and a lower stage (p = 0.04) than 813 with de novo MM. Our data suggest subgroups suitable for trials of 'symptom-directed' screening: those with back pain, unexplained pain, a general decline in health or low-impact vertebral compression fractures.
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Affiliation(s)
- Stella Bowcock
- Department of Haematological Medicine, King’s College Hospital NHS Trust, London SE5 9RS, UK
- Princess Royal Hospital, King’s College Hospital NHS Trust, Orpington Common, London BR6 8ND, UK
| | - Catherine Atkin
- Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham B15 2GW, UK
| | - Gulnaz Iqbal
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Guy Pratt
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham B15 2TH, UK
| | - Kwee Yong
- Department of Haematology, UCL Cancer Institute, London NW1 2BU, UK
| | - Richard D. Neal
- Department of Primary Care Medicine, University of Exeter, Exeter EX1 2LU, UK
| | - Tim Planche
- Department of Medical Microbiology, St George’s Hospital NHS Trust, London SW17 0QT, UK
| | - Kamaraj Karunanithi
- Royal Stoke University Hospital, University Hospitals North Midlands NHS Trust, Stoke-on-Trent ST4 6QG, UK
| | - Stephen Jenkins
- Russell Halls Hospital, The Dudley Group NHS Foundation Trust, Dudley DY1 2HQ, UK
| | - Simon Stern
- Epsom and St Helier NHS Trust, London SM5 1AA, UK
| | | | - Peter Toth
- Sheffield Teaching Hospitals NHS Trust, Sheffield S10 2JF, UK
| | - Farooq Wandroo
- Sandwell General Hospital, Lyndon, West Bromwich, West Midlands B71 4HJ, UK
| | - Janet Dunn
- Warwick Clinical Trials Unit, University of Warwick, Coventry CV4 7AL, UK
| | - Mark T. Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
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21
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Drummond PLM, Santos RMMD, Reis AMM, Malta JS, Silveira LP, Costa IHFD, Menezes de Pádua CA. Real-world effectiveness and safety of multiple myeloma treatments based on thalidomide and bortezomib: A retrospective cohort study from 2009 to 2020 in a Brazilian metropolis. Cancer Epidemiol 2023; 85:102377. [PMID: 37163919 DOI: 10.1016/j.canep.2023.102377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/27/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Multiple myeloma (MM) is an incurable cancer of plasma cells; the survival of which has improved over the years with the emergence of new treatments. In Brazil, the availability of treatment-regimens is different from developed countries. Real-world evidence with Brazilian patients is lacking. OBJECTIVES Our aim was to evaluate the effectiveness and the safety of MM treatments in a Brazilian metropolis. METHODS This was a retrospective cohort study with MM patients, beginning MM treatment from 2009 to 2020 (i.e., before bortezomib became available in public health services). Patients' medical records were revised to obtain clinical variables. The primary outcomes were Overall Survival (OS) and Progression Free Survival (PFS, measured as time to next treatment), and the secondary outcomes were Adverse Events (AE). Kaplan-Meier curves were obtained and the Cox proportional hazards model was performed for univariate and multivariate analyses. The incidence of AE was estimated and the chi-squared test was performed to evaluate the association between AE and MM regimens. RESULTS In total, 278 patients participated in the study with median age of 64 years; 50.4 % were females, 55.8 % attended a private clinic, 34.9 % received autologous stem cell transplantation (ASCT) and 32.4 % were on polypharmacy. Most patients from public services used thalidomide-based regimens (40.3 %) and at private clinics used bortezomib-based regimens (38.1 %) as first-line treatment. Patients had a median OS of 99 months. Patients had median PFS of 28 months in first-line treatment, which was significantly different for age (p = 0.0055), polypharmacy (p = 0.0094) and ASCT (p < 0.0001). PFS was independently associated to polypharmacy and ASCT. The incidence of peripheral neuropathy (39.6 %) was high. In contrast, the incidence of severe AE was low. We found significant difference between first-line T + B-based regimens and leukopenia (p = 0.012). CONCLUSION Our study showed that patients on polypharmacy and who did not receive ASCT had worse PFS. Similar to other Latin countries, most patients used thalidomide- and bortezomib-based regimens as first-line treatments having similar OS and PFS. Treatments were considered relatively safe, especially regarding serious AE.
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Affiliation(s)
- P L M Drummond
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Brazil; Ezequiel Dias Foundation, Brazil
| | | | | | | | - Lívia Pena Silveira
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Brazil; Hospital das Clínicas, Universidade Federal de Minas Gerais, Brazil
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22
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Dima D, Ullah F, Mazzoni S, Williams L, Faiman B, Kurkowski A, Chaulagain C, Raza S, Samaras C, Valent J, Khouri J, Anwer F. Management of Relapsed-Refractory Multiple Myeloma in the Era of Advanced Therapies: Evidence-Based Recommendations for Routine Clinical Practice. Cancers (Basel) 2023; 15:2160. [PMID: 37046821 PMCID: PMC10093129 DOI: 10.3390/cancers15072160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/14/2023] Open
Abstract
Multiple myeloma (MM) is the second most common hematologic malignancy in adults worldwide. Over the past few years, major therapeutic advances have improved progression-free and overall survival, as well as quality of life. Despite this recent progress, MM remains incurable in the vast majority of cases. Patients eventually relapse and become refractory to multiple drug classes, making long-term management challenging. In this review, we will focus on the treatment paradigm of relapsed/refractory MM (RRMM) in the era of advanced therapies emphasizing the available novel modalities that have recently been incorporated into routine practice, such as chimeric antigen receptor T-cell therapy, bispecific antibodies, and other promising approaches. We will also discuss major factors that influence the selection of appropriate drug combinations or cellular therapies, such as relapse characteristics, and other disease and patient related parameters. Our goal is to provide insight into the currently available and experimental therapies for RRMM in an effort to guide the therapeutic decision-making process.
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Affiliation(s)
- Danai Dima
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Fauzia Ullah
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Sandra Mazzoni
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Louis Williams
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Beth Faiman
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Austin Kurkowski
- Department of Pharmacy, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Chakra Chaulagain
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Maroone Cancer Center, Weston, FL 33331, USA
| | - Shahzad Raza
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Christy Samaras
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Jason Valent
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Jack Khouri
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Faiz Anwer
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH 44106, USA
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23
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Yang Q, Wei Y, Zhu Y, Guo J, Zhang J, He Y, Li X, Liu J, Zhou W. The Interaction between Gut Microbiota and Host Amino Acids Metabolism in Multiple Myeloma. Cancers (Basel) 2023; 15:cancers15071942. [PMID: 37046603 PMCID: PMC10093363 DOI: 10.3390/cancers15071942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/18/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
Although novel therapies have dramatically improved outcomes for multiple myeloma (MM) patients, relapse is inevitable and overall outcomes are heterogeneous. The gut microbiota is becoming increasingly recognized for its influence on host metabolism. To date, evidence has suggested that the gut microbiota contributes to MM, not only via the progressive activities of specific bacteria but also through the influence of the microbiota on host metabolism. Importantly, the abnormal amino acid metabolism, as well as the altered microbiome in MM, is becoming increasingly apparent, as is the influence on MM progression and the therapeutic response. Moreover, the gut-microbiota-host-amino-acid metabolism interaction in the progression of MM has been highlighted. Modulation of the gut microbiota (such as fecal microbiota transplantation, FMT) can be modified, representing a new angle in MM treatment that can improve outcomes. In this review, the relationship between gut microbiota, metabolism, and MM, together with strategies to modulate the microbiota, will be discussed, and some unanswered questions for ongoing and future research will be presented.
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Affiliation(s)
- Qin Yang
- Haihe Laboratory of Cell Ecosystem, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Geriatric Disorders, Department of Hematology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Yumou Wei
- Key Laboratory for Carcinogenesis and Invasion, Chinese Ministry of Education, Key Laboratory of Carcinogenesis, Chinese Ministry of Health, Cancer Research Institute, School of Basic Medical Sciences, Central South University, Changsha 410008, China
| | - Yinghong Zhu
- Haihe Laboratory of Cell Ecosystem, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Geriatric Disorders, Department of Hematology, Xiangya Hospital, Central South University, Changsha 410008, China
- Key Laboratory for Carcinogenesis and Invasion, Chinese Ministry of Education, Key Laboratory of Carcinogenesis, Chinese Ministry of Health, Cancer Research Institute, School of Basic Medical Sciences, Central South University, Changsha 410008, China
| | - Jiaojiao Guo
- Haihe Laboratory of Cell Ecosystem, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Geriatric Disorders, Department of Hematology, Xiangya Hospital, Central South University, Changsha 410008, China
- Key Laboratory for Carcinogenesis and Invasion, Chinese Ministry of Education, Key Laboratory of Carcinogenesis, Chinese Ministry of Health, Cancer Research Institute, School of Basic Medical Sciences, Central South University, Changsha 410008, China
| | - Jingyu Zhang
- Haihe Laboratory of Cell Ecosystem, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Geriatric Disorders, Department of Hematology, Xiangya Hospital, Central South University, Changsha 410008, China
- Key Laboratory for Carcinogenesis and Invasion, Chinese Ministry of Education, Key Laboratory of Carcinogenesis, Chinese Ministry of Health, Cancer Research Institute, School of Basic Medical Sciences, Central South University, Changsha 410008, China
| | - Yanjuan He
- Haihe Laboratory of Cell Ecosystem, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Geriatric Disorders, Department of Hematology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Xin Li
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Jing Liu
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha 410013, China
| | - Wen Zhou
- Haihe Laboratory of Cell Ecosystem, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Geriatric Disorders, Department of Hematology, Xiangya Hospital, Central South University, Changsha 410008, China
- Key Laboratory for Carcinogenesis and Invasion, Chinese Ministry of Education, Key Laboratory of Carcinogenesis, Chinese Ministry of Health, Cancer Research Institute, School of Basic Medical Sciences, Central South University, Changsha 410008, China
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24
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Thompson MA, Boccadoro M, Leleu X, Vela-Ojeda J, van Rhee F, Weisel KC, Rifkin RM, Usmani SZ, Hájek R, Cook G, Abonour R, Armour M, Morgan KE, Yeh SP, Costello CL, Berdeja JG, Davies FE, Zonder JA, Lee HC, Omel J, Spencer A, Terpos E, Hungria VTM, Puig N, Fu C, Ferrari RH, Ren K, Stull DM, Chari A. Rates of Influenza and Pneumococcal Vaccination and Correlation With Survival in Multiple Myeloma Patients. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e171-e181. [PMID: 36641358 DOI: 10.1016/j.clml.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Infections are a common reason for hospitalization and death in multiple myeloma (MM). Although pneumococcal vaccination (PV) and influenza vaccination (FV) are recommended for MM patients, data on vaccination status and outcomes are limited in MM. MATERIALS AND METHODS We utilized data from the global, prospective, observational INSIGHT MM study to analyze FV and PV rates and associated outcomes of patients with MM enrolled 2016-2019. RESULTS Of the 4307 patients enrolled, 2543 and 2500 had study-entry data on FV and PV status. Overall vaccination rates were low (FV 39.6%, PV 30.2%) and varied by region. On separate multivariable analyses of overall survival (OS) by Cox model, FV in the prior 2 years and PV in the prior 5 years impacted OS (vs. no vaccination; FV: HR, 0.73; 95% CI, 0.60-0.90; P = .003; PV: HR, 0.51; 95% CI, 0.42-0.63; P < .0001) when adjusted for age, region, performance status, disease stage, cytogenetics at diagnosis, MM symptoms, disease status, time since diagnosis, and prior transplant. Proportions of deaths due to infections were lower among vaccinated versus non-vaccinated patients (FV: 9.8% vs. 15.3%, P = .142; PV: 9.9% vs. 18.0%, P = .032). Patients with FV had generally lower health resource utilization (HRU) versus patients without FV; patients with PV had higher or similar HRU versus patients without PV. CONCLUSION Vaccination is important in MM and should be encouraged. Vaccination status should be recorded in prospective clinical trials as it may affect survival. This trial was registered at www. CLINICALTRIALS gov as #NCT02761187.
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Affiliation(s)
- Michael A Thompson
- Aurora Cancer Care, Advocate Aurora Research Institute, Advocate Aurora Health, Milwaukee, WI,.
| | | | - Xavier Leleu
- Pôle Régional de Cancérologie, Department of Hematology, CHU La Milétrie-Poitiers, Poitiers, France
| | - Jorge Vela-Ojeda
- Department of Hematology, UMAE Hospital de Especialidades Centro Medico La Raza IMSS, Mexico City, Mexico
| | - Frits van Rhee
- University of Arkansas for Medical Sciences, Little Rock, AR
| | - Katja C Weisel
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Robert M Rifkin
- Rocky Mountain Cancer Centers/US Oncology Research, Denver, CO
| | | | - Roman Hájek
- Department of Hemato-oncology, University Hospital Ostrava, and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Gordon Cook
- Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Rafat Abonour
- Indiana University School of Medicine, Indianapolis, IN
| | - Mira Armour
- Mijelom CRO, Croatian Myeloma Support Association, Zagreb, Croatia
| | | | - Su-Peng Yeh
- China Medical University Hospital, Taichung City, P.R.China
| | | | - Jesus G Berdeja
- Department of Hematology, Tennessee Oncology and Sarah Cannon Research Institute, Nashville, TN
| | | | - Jeffrey A Zonder
- Department of Malignant Hematology, Barbara Ann Karmanos Cancer Institute/Wayne State University School of Medicine, Detroit, MI
| | - Hans C Lee
- Department of Lymphoma and Myeloma, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Jim Omel
- The Central Nebraska Myeloma Support Group, Grand Island, NE
| | - Andrew Spencer
- Malignant Haematology and Stem Cell Transplantation Service, Alfred Health Monash University, Melbourne, Australia
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Vania T M Hungria
- Department of Hematology, Clinica São Germano and Santa Casa Medical School, São Paulo, Brazil
| | - Noemi Puig
- Hematology Department, Hospital Universitario de Salamanca (HUSAL), IBSAL, IBMCC (USAL-CSIC), CIBERONC, Salamanca, Spain
| | - Chengcheng Fu
- First Affiliated Hospital, Soochow University, Suzhou Jiangsu, P.R.China
| | | | - Kaili Ren
- Takeda Development Center Americas, Inc. (TDCA), Lexington, MA
| | | | - Ajai Chari
- Department of Hematology-Oncology, Mount Sinai School of Medicine, New York, NY
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25
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Ludwig H, Kumar S. Prevention of infections including vaccination strategies in multiple myeloma. Am J Hematol 2023; 98 Suppl 2:S46-S62. [PMID: 36251367 DOI: 10.1002/ajh.26766] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/12/2022]
Abstract
Infections are a major cause of morbidity and mortality in multiple myeloma. The increased risk for bacterial and viral infections results mainly from the disease-inherent and treatment-induced immunosuppression. Additional risk factors are older age with immune senescence, T cell depletion, polymorbidity, and male gender. Hence, every effort should be taken to reduce the risk for infections by identifying patients at higher risk for these complications and by implementing prophylactic measures, including chemoprophylaxis and immunization against various relevant pathogens. Here, we review the available evidence and provide recommendations for medical prophylaxis and vaccination in clinical practice.
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Affiliation(s)
- Heinz Ludwig
- Department of Medicine I, Center for Medical Oncology and Hematology with Outpatient Department and Palliative Care, Wilhelminen Cancer Research Institute, Vienna, Austria
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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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. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 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] [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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Bici A, Pianko MJ, Nachar VR. Incidence and risk factors for bacterial infection using bortezomib, lenalidomide, and dexamethasone (RVd) in newly diagnosed multiple myeloma. Leuk Lymphoma 2023; 64:407-414. [PMID: 36308285 PMCID: PMC9993956 DOI: 10.1080/10428194.2022.2138380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/28/2022] [Accepted: 10/06/2022] [Indexed: 02/17/2023]
Abstract
Infections are an important cause of morbidity and mortality in newly diagnosed multiple myeloma (NDMM), but the real-world risk using modern induction regimens such as bortezomib, lenalidomide, and dexamethasone (RVd) is not well described. We performed a retrospective single-center cohort study to identify infections and risk factors in patients treated with first-line RVd from January 2014 to January 2020 and collected demographic and clinical data. Of 144 patients treated with RVd for NDMM, 21 patients (14.5%) experienced a bacterial infection during induction, of which 8 (5.5%) were grade 3 infections despite a low rate of antibiotic prophylaxis use (12%). Grade 3 neutropenia occurred in 11% of patients, 2% had febrile neutropenia and there were no deaths from infection. On multivariable analysis, age, smoking history, diabetes, antibiotic use in the 60 days preceding the start of RVd, and high-risk cytogenetics were associated with higher risk of bacterial infection.
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Affiliation(s)
- Anisa Bici
- Department of Pharmacy Services, Michigan Medicine and the University of Michigan College of Pharmacy, Ann Arbor, MI, United States
| | - Matthew J. Pianko
- Division of Hematology and Oncology, Department of Internal Medicine, Rogel Cancer Center, University of Michigan, Ann Arbor, MI, United States
| | - Victoria R Nachar
- Department of Pharmacy Services, University of Michigan Rogel Cancer Center, Ann Arbor, MI, United States
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Alkharabsheh O, Bellman P, Mahmoudjafari Z, Cui W, Atrash S, Paul B, Hashmi H, Shune L, Ahmed N, Abdallah AO. Adverse Hematological and Non-Hematological Events in Patients With Relapsed/Refractory Multiple Myeloma That Are Responsive to Daratumumab, Pomalidomide and Dexamethasone. J Hematol 2023; 12:1-6. [PMID: 36895290 PMCID: PMC9990715 DOI: 10.14740/jh1085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 02/16/2023] [Indexed: 03/11/2023] Open
Abstract
Background Daratumumab, pomalidomide, and dexamethasone (DPd) is an effective option for treatment of patients with relapsed/refractory multiple myeloma (RRMM). In this study, we sought to analyze the risk of hematological and non-hematological toxicities in patients who responded to DPd treatment. Methods We analyzed 97 patients with RRMM who were treated with DPd between January 2015 and June 2022. The patients and disease characteristics, as well as safety and efficacy outcomes were summarized as descriptive analysis. Results The overall response rate for the entire group was 74% (n = 72). The most common grade III/IV hematological toxicities in those who responded to treatment were neutropenia (79%), leukopenia (65%), lymphopenia (56%), anemia (18%), and thrombocytopenia (8%). The most common grade III/IV non-hematological toxicities were pneumonia (17%) and peripheral neuropathy (8%). The incidence of dose reduction/interruption was 76% (55/72), which was due to hematological toxicity in 73% of the cases. The most common reason for discontinuing treatment was disease progression in 61% (44 out of 72 patients). Conclusions Our study revealed that patients who respond to DPd are at high risk of dose reduction or treatment interruption because of hematological toxicity, typically due to neutropenia and leukopenia leading to increased risk of hospitalization and pneumonia.
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Affiliation(s)
- Omar Alkharabsheh
- Division of Medical Oncology, University of South Alabama Mitchell Cancer Institute, Mobile, AL, USA.,US Myeloma Innovations Research Collaborative (USMIRC), Westwood, KS, USA
| | | | - Zahra Mahmoudjafari
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, KS, USA.,University of Kansas Medical Center, Westwood, KS, USA
| | - Wei Cui
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, KS, USA.,Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Shebli Atrash
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, KS, USA.,Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Barry Paul
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, KS, USA.,Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Hamza Hashmi
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, KS, USA.,Division of Hematology/Oncology, Medical University of South Carolina, Charleston, SC, USA
| | - Leyla Shune
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, KS, USA.,Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, KS, USA
| | - Nausheen Ahmed
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, KS, USA.,Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, KS, USA
| | - Al-Ola Abdallah
- US Myeloma Innovations Research Collaborative (USMIRC), Westwood, KS, USA.,Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Westwood, KS, USA
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Peng T, Liu L, Liu F, Ding L, Liu J, Zhou H, Liu C. Machine learning-based infection prediction model for newly diagnosed multiple myeloma patients. Front Neuroinform 2023; 16:1063610. [PMID: 36713288 PMCID: PMC9880856 DOI: 10.3389/fninf.2022.1063610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/12/2022] [Indexed: 01/15/2023] Open
Abstract
Objective To understand the infection characteristics and risk factors for infection by analyzing multicenter clinical data of newly diagnosed multiple myeloma (NDMM) patients. Methods This study reviewed 564 NDMM patients from 2 large tertiary hospitals from January 2018 to December 2021, of whom 395 comprised the training set and 169 comprised the validation set. Thirty-eight variables from first admission records were collected, including patient demographic characteristics, clinical scores and characteristics, laboratory indicators, complications, and medication history, and key variables were screened using the Lasso method. Multiple machine learning algorithms were compared, and the best performing algorithm was used to build a machine learning prediction model. The model performance was evaluated using the AUC, accuracy, and Youden's index. Finally, the SHAP package was used to assess two cases and demonstrate the application of the model. Results In this study, 15 important key variables were selected, namely, age, ECOG, osteolytic disruption, VCD, neutrophils, lymphocytes, monocytes, hemoglobin, platelets, albumin, creatinine, lactate dehydrogenase, affected globulin, β2 microglobulin, and preventive medicine. The predictive performance of the XGBoost model was significantly better than that of the other models (AUROC: 0.8664), and it also performed well for the expected dataset (accuracy: 68.64%). Conclusion A machine learning algorithm was used to establish an infection prediction model for NDMM patients that was simple, convenient, validated, and performed well in reducing the incidence of infection and improving the prognosis of patients.
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Affiliation(s)
- Ting Peng
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Leping Liu
- Department of Pediatrics, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Feiyang Liu
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Liang Ding
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Jing Liu
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China,*Correspondence: Jing Liu,
| | - Han Zhou
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Chong Liu
- Department of Hematology, The Third Xiangya Hospital of Central South University, Changsha, China
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Shah N, Mustafa SS, Vinh DC. Management of secondary immunodeficiency in hematological malignancies in the era of modern oncology. Crit Rev Oncol Hematol 2023; 181:103896. [PMID: 36528276 DOI: 10.1016/j.critrevonc.2022.103896] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 11/29/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
Secondary immunodeficiency (SID) in patients with B-cell hematological malignancies is a common condition that presents with recurrent infection. SID is due to both the inherent immune defects due to the malignancy, as well as secondary to cancer therapies, many of which have B-cell depleting properties. The early diagnosis of SID and the optimization of intervention strategies are key to delivering the most effective cancer treatments and reducing infection-related morbidity and mortality. This review discusses current practice, recommendations, and challenges for SID diagnosis, based on the evaluation of clinical history and laboratory assessments, and the effectiveness of specific vaccines and immunoglobulin replacement therapy in reducing the frequency and recurrence of infections in patients with SID, and the healthcare system-associated costs.
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Affiliation(s)
- Nina Shah
- Department of Medicine, University of California San Francisco, San Francisco, CA, United States.
| | - S Shahzad Mustafa
- Rochester Regional Health, Rochester, NY, United States; Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, United States
| | - Donald C Vinh
- Department of Medicine, McGill University Health Centre, Montreal, Canada
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Dao A, McDonald MM, Savage PB, Little DG, Schindeler A. Preventing osteolytic lesions and osteomyelitis in multiple myeloma. J Bone Oncol 2022; 37:100460. [DOI: 10.1016/j.jbo.2022.100460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/16/2022] [Accepted: 10/27/2022] [Indexed: 11/05/2022] Open
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Iula R, De Novellis D, Trastulli F, Della Pepa R, Fontana R, Carobene A, Di Perna M, D’Ambrosio A, Romano M, Leone A, De Fazio L, Fiumarella A, Gaeta G, Marafioti V, Barbato S, Palmieri S, Rocco S, Serio B, Califano C, Pane F, Ferrara F, Giudice V, Selleri C, Catalano L. Efficacy and safety of belantamab-mafodotin in triple-refractory multiple myeloma patients: A multicentric real-life experience. Front Oncol 2022; 12:1026251. [PMID: 36457484 PMCID: PMC9705330 DOI: 10.3389/fonc.2022.1026251] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/24/2022] [Indexed: 07/30/2023] Open
Abstract
Belantamab-mafodotin is an innovative and selective treatment for multi-refractory/relapsed multiple myeloma (MM) patients; however, available real-life experiences on efficacy and safety are limited. In this real-world multicentric retrospective study, we enrolled 28 MM patients treated in four Hematology units of Campania region, Italy, who received a median of six treatment lines prior to belantamab-mafodotin. The overall response rate (ORR) was 40% (complete remission, CR, 11%; very good partial remission, VGPR, 11%; and partial remission, PR, 18%), with a median progression-free survival (PFS) and overall survival (OS) of 3 and 8 months, respectively. One of the most frequent drug-related adverse events was keratopathy observed in nine (32%) patients, leading to therapy discontinuation in only three (11%) of them. Moreover, 22 out of 28 total patients who were treated with at least two administrations achieved an ORR of 50% (CR, 14%; VGPR, 14%; and PR, 22%) with a median PFS and OS of 5 and 11 months, respectively. In conclusion, our multicentric study confirmed efficacy and safety of belantamab-mafodotin in triple-refractory MM patients even in the real-life setting.
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Affiliation(s)
- Rossella Iula
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Danilo De Novellis
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, Italy
| | - Fabio Trastulli
- Hematology and Transplant Program, AORN “A. Cardarelli” Hospital, Naples, Italy
| | - Roberta Della Pepa
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Raffaele Fontana
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
| | - Angela Carobene
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
| | - Maria Di Perna
- Onco-Hematology Unit, “A. Tortora” Hospital, Pagani, Italy
| | - Alessandro D’Ambrosio
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Martina Romano
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Aldo Leone
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Laura De Fazio
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Alfonso Fiumarella
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Giuseppe Gaeta
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Violetta Marafioti
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Serafina Barbato
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Salvatore Palmieri
- Hematology and Transplant Program, AORN “A. Cardarelli” Hospital, Naples, Italy
| | - Stefano Rocco
- Hematology and Transplant Program, AORN “A. Cardarelli” Hospital, Naples, Italy
| | - Bianca Serio
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
| | | | - Fabrizio Pane
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Felicetto Ferrara
- Hematology and Transplant Program, AORN “A. Cardarelli” Hospital, Naples, Italy
| | - Valentina Giudice
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, Italy
| | - Carmine Selleri
- Hematology and Transplant Center, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, Italy
| | - Lucio Catalano
- Hematology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
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Parker CM, Karchmer AW, Fisher MC, Muhammad KM, Yu PA. Safety of Antimicrobials for Postexposure Prophylaxis and Treatment of Anthrax: A Review. Clin Infect Dis 2022; 75:S417-S431. [PMID: 36251549 PMCID: PMC9649414 DOI: 10.1093/cid/ciac592] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Bacillus anthracis, the causative agent for anthrax, poses a potential bioterrorism threat and is capable of causing mass morbidity and mortality. Antimicrobials are the mainstay of postexposure prophylaxis (PEP) and treatment of anthrax. We conducted this safety review of 24 select antimicrobials to identify any new or emerging serious or severe adverse events (AEs) to help inform their risk-benefit evaluation for anthrax. METHODS Twenty-four antimicrobials were included in this review. Tertiary data sources (e.g. Lactmed, Micromedex, REPROTOX) were reviewed for safety information and summarized to evaluate the known risks of these antimicrobials. PubMed was also searched for published safety information on serious or severe AEs with these antimicrobials; AEs that met inclusion criteria were abstracted and reviewed. RESULTS A total of 1316 articles were reviewed. No consistent observations or patterns were observed among the abstracted AEs for a given antimicrobial; therefore, the literature review did not reveal evidence of new or emerging AEs that would add to the risk-benefit profiles already known from tertiary data sources. CONCLUSIONS The reviewed antimicrobials have known and/or potential serious or severe risks that may influence selection when recommending an antimicrobial for PEP or treatment of anthrax. Given the high fatality rate of anthrax, the risk-benefit evaluation favors use of these antimicrobials for anthrax. The potential risks of antimicrobials should not preclude these reviewed antimicrobials from clinical consideration for anthrax but rather guide appropriate antimicrobial selection and prioritization across different patient populations with risk mitigation measures as warranted.
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Affiliation(s)
- Corinne M Parker
- Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adolf W Karchmer
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret C Fisher
- Clinical Professor of Pediatrics, Rutgers Robert Wood Johnson School of Medicine, Monmouth Medical Center, Long Branch, New Jersey, USA
| | - Kalimah M Muhammad
- Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Oak Ridge Institute for Science and Education Centers for Disease Control and Prevention Fellowship Program, Atlanta, Georgia, USA
| | - Patricia A Yu
- Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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McCaughan GJ, Gandolfi S, Moore JJ, Richardson PG. Lenalidomide, bortezomib and dexamethasone induction therapy for the treatment of newly diagnosed multiple myeloma: a practical review. Br J Haematol 2022; 199:190-204. [PMID: 35796524 PMCID: PMC9796722 DOI: 10.1111/bjh.18295] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/10/2022] [Accepted: 05/20/2022] [Indexed: 01/07/2023]
Abstract
For patients with newly diagnosed multiple myeloma, survival outcomes continue to improve significantly: however, nearly all patients will relapse following induction treatment. Optimisation of induction therapy is essential to provide longer term disease control and the current standard of care for most patients incorporates an immunomodulatory agent and proteasome inhibitor, most commonly lenalidomide and bortezomib in combination with dexamethasone (RVD), with maintenance until progression. Historically there has been limited access to RVD as an induction strategy outside of the United States; fortunately, there is now increasing access worldwide. This review discusses the rationale for use of RVD as induction therapy and aims to provide guidance in prescribing this regimen in order to optimise efficacy while minimising the toxicities of treatment. We also highlight the increasing evidence for the utility of addition of a monoclonal antibody to the RVD backbone to deepen responses and potentially provide longer disease control.
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Affiliation(s)
- Georgia J. McCaughan
- Department of HaematologySt Vincent's HospitalSydneyAustralia
- University of New South Wales, Medicine and HealthSydneyAustralia
| | - Sara Gandolfi
- Translational Research ProgramUniversity of HelsinkiHelsinkiFinland
- Haematology Research UnitUniversity of Helsinki and Helsinki University HospitalHelsinkiFinland
| | - John J. Moore
- Department of HaematologySt Vincent's HospitalSydneyAustralia
- University of New South Wales, Medicine and HealthSydneyAustralia
| | - Paul G. Richardson
- Dana‐Farber Cancer Institute, Jerome Lipper Multiple Myeloma Center, Department of Medical OncologyBostonMassachusettsUSA
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Clinical Efficacy and Safety Analysis of Levofloxacin for the Prevention of Infection after Traumatic Osteoarthrosis and Internal Fixation: Systematic Review and Meta-Analysis. Emerg Med Int 2022; 2022:8788365. [PMID: 36213001 PMCID: PMC9537031 DOI: 10.1155/2022/8788365] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/28/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022] Open
Abstract
Objective Levofloxacin has been widely used in clinical anti-infection treatment; however, its adverse reactions to levofloxacin were also obvious in patients. Herein we aimed to systematically evaluate the clinical efficacy and safety of systemic administration of levofloxacin in the prevention of postoperative infection after traumatic osteoarthrosis and internal fixation. Methods PubMed, Cochrane Library, OVID, EBSCO, CNKI, VIP database, and Wanfang Database were searched from December 1993 to December 2021. Meanwhile, China ADR Information Bulletin and WHO Pharmaceutical were searched manually. Newsletter and FDA Drug Safety Newsletter, also to retrieve the Websites of Chinese, Chinese, and drug regulatory authorities; To obtain data on adverse events in children with systemic administration of levofloxacin. The literature was screened according to inclusion and exclusion criteria. The risk of bias was evaluated for the included RCT literature. Results There was a statistical difference in the comparison of the incidence of fever between the experimental group and the control group (OR = 2.29, 95% CI (1.75,2.98),P < 0.00001, I2 = 0%, Z = 6.11); elevated white blood cell count (OR = 1.82, 95% CI (1.31,2.52),P=0.0003, I2 = 0%, Z = 3.60); incidence of wound infection (OR = 2.11, 95% CI (1.54,2.90),P < 0.00001, I2 = 0%, Z = 4.64); adverse drug reaction (OR = 1.82, 95% CI (1.21,2.74),P=0.004, I2 = 0%, Z = 2.86). Conclusion In the clinical use of levofloxacin, adverse drug reactions including fever, elevated white blood cell count, and wound infection should be concerned.
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Huynh L, Birsen R, Mora L, Couderc AL, Mitha N, Farcet A, Chebib A, Chaibi P. Multiple Myeloma in Patients over 80: A Real World Retrospective Study of First Line Conservative Approach with Bortezomib Dexamethasone Doublet Therapy and Mini-Review of Literature. Cancers (Basel) 2022; 14:cancers14194741. [PMID: 36230662 PMCID: PMC9564122 DOI: 10.3390/cancers14194741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 11/16/2022] Open
Abstract
Data on octogenarian patients with MM are scarce, and optimal management remains controversial. We report a retrospective cohort of unselected octogenarian patients with NDMM treated with bortezomib dexamethasone (Vd). Seventy-four patients were treated with an initial doublet therapy (Vd regimen, 2−3 cycles, induction). A dose escalation with an adjunction of melphalan or cyclophosphamide was proposed for patients who had an insufficient response after induction and who could tolerate it. In responders, the treatment was continued until progression or a plateau response for 6 months (consolidation). The overall response rate was 73%. After a median follow-up of 31.4 months, median progression-free survival (PFS) and overall survival (OS) were 13.2 and 26.9 months, respectively. PFS and OS of patients with ECOG PS < 3 (25.4 and 54.9 months, respectively) were better in comparison to PFS and OS of patients with ECOG PS ≥ 3 (9.3 and 11.3 months, respectively). Thirteen patients (17.6%) died during induction. Twelve patients (16.2%) died during consolidation. In conclusion, a conservative therapeutic strategy based on Vd resulted in a good response rate. However, the survival remains poor in the population of patients with an ECOG PS ≥ 3, mainly because of early mortality not related to progressive disease.
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Affiliation(s)
- Laurence Huynh
- Service d’Hématologie et Oncologie Gériatrique, Hôpital Charles Foix, APHP, 94200 Ivry Sur Seine, France
- Correspondence:
| | - Rudy Birsen
- Service d’Hématologie, Hôpital Cochin, APHP, Université de Paris Cité, 75014 Paris, France
| | - Lucie Mora
- Service d’Hématologie et Oncologie Gériatrique, Hôpital Charles Foix, APHP, 94200 Ivry Sur Seine, France
| | - Anne-Laure Couderc
- Service d’Hématologie et Oncologie Gériatrique, Hôpital Charles Foix, APHP, 94200 Ivry Sur Seine, France
| | - Nathalie Mitha
- Service d’Hématologie et Oncologie Gériatrique, Hôpital Charles Foix, APHP, 94200 Ivry Sur Seine, France
| | - Anaïs Farcet
- Service d’Hématologie et Oncologie Gériatrique, Hôpital Charles Foix, APHP, 94200 Ivry Sur Seine, France
| | - Amale Chebib
- Service d’Hématologie et Oncologie Gériatrique, Hôpital Charles Foix, APHP, 94200 Ivry Sur Seine, France
| | - Pascal Chaibi
- Service d’Hématologie et Oncologie Gériatrique, Hôpital Charles Foix, APHP, 94200 Ivry Sur Seine, France
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Tam T, Smith E, Lozoya E, Heers H, Andrew Allred P. Roadmap for new practitioners to navigate the multiple myeloma landscape. Heliyon 2022; 8:e10586. [PMID: 36164513 PMCID: PMC9508512 DOI: 10.1016/j.heliyon.2022.e10586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/17/2022] [Accepted: 09/05/2022] [Indexed: 10/25/2022] Open
Abstract
Multiple myeloma (MM) is a blood cancer in which monoclonal plasma cells cause end organ damage resulting in hypercalcemia, renal failure, anemia, and bone lesions. MM is considered incurable, however, recent advances in treatment have improved survival. Historically, MM has been treated with immunomodulatory drugs (IMiDs), proteosome inhibitors (PIs), and corticosteroids. While newer therapeutic approaches such as monoclonal antibodies and cellular therapies have broadened the treatment horizon, the selection and sequencing of these therapies has become more complex. This review aims to help advanced practice providers navigate through the diagnosis, staging, treatment, and supportive care considerations in the MM space.
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Affiliation(s)
- Tiffany Tam
- Banner MD Anderson Cancer Center, 2946 E Banner Gateway Drive, Gilbert, AZ 85295, United States
| | - Eric Smith
- Banner MD Anderson Cancer Center, 2946 E Banner Gateway Drive, Gilbert, AZ 85295, United States
| | - Evelyn Lozoya
- Banner MD Anderson Cancer Center, 2946 E Banner Gateway Drive, Gilbert, AZ 85295, United States
| | - Hayley Heers
- Banner MD Anderson Cancer Center, 2946 E Banner Gateway Drive, Gilbert, AZ 85295, United States
| | - P Andrew Allred
- Banner MD Anderson Cancer Center, 2946 E Banner Gateway Drive, Gilbert, AZ 85295, United States
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Vaxman I, Gertz MA. How I approach smoldering multiple myeloma. Blood 2022; 140:828-838. [PMID: 35576526 PMCID: PMC9412010 DOI: 10.1182/blood.2021011670] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 04/28/2022] [Indexed: 11/30/2022] Open
Abstract
The current standard of care in smoldering multiple myeloma (SMM) is close surveillance, outside of clinical trials. Efforts are being made to understand the pathobiologic process that leads to the progression of SMM to active MM. This review provides a critical description of available data, including risk factors and risk models of progression, as well as clinical trials investigating interventions for this patient population. We describe 2 cases in which patients were seen before the concept of a myeloma-defining event was established. Today, based on the International Myeloma Working Group criteria, both patients would have been identified as experiencing myeloma-defining events, and therapy would have been initiated. These cases show that occasionally, patients can undergo observation only, even when they exceed criteria for high-risk SMM.
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Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; and
- Department of Hematology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Interventions to reduce infections in patients with hematological malignancies: a systematic review and meta-analysis. Blood Adv 2022; 7:20-31. [PMID: 35882473 PMCID: PMC9813525 DOI: 10.1182/bloodadvances.2022008073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 12/29/2022] Open
Abstract
Acquired hypogammaglobulinemia is common in chronic lymphocytic leukemia (CLL), non-Hodgkin lymphoma (NHL), and multiple myeloma (MM). No previous systematic reviews (SRs) have compared different approaches to infection prevention. We sought to assess the efficacy and safety of prophylactic immunoglobulin, antibiotics, and vaccination in these patients. We performed an SR and meta-analysis of randomized controlled trials (RCTs) evaluating the efficacy and safety of prophylactic immunoglobulin, antibiotics, and vaccination in adult patients with hematological malignancies commonly associated with acquired hypogammaglobulinemia, specifically, CLL, NHL, and MM. We searched PubMed (MEDLINE), EMBASE, and Cochrane Registry up to 9 January 2021. Results for dichotomous data were expressed as relative risk (RR) with 95% confidence interval (CI) and pooled in a random-effects model. This review was registered with PROSPERO CRD42017070825. From 10 576 studies screened, there were 21 completed RCTs and 1 ongoing. Of these, 8 evaluated prophylactic immunoglobulin (n = 370; 7 published before 2000), 5 evaluated prophylactic antibiotics (n = 1587), 7 evaluated vaccination (n = 3996), and 1 compared immunoglobulin to antibiotics (n = 60). Prophylactic immunoglobulin reduced the risk of clinically documented infection (CDI) by 28% (n = 2 trials; RR, 0.72; 95% CI, 0.54-0.96), and vaccination reduced the risk by 63% (RR, 0.37; 95% CI, 0.30-0.45). Prophylactic antibiotics did not reduce the risk. No intervention reduced all-cause mortality. Prophylactic immunoglobulin and antibiotics increased the risk of adverse events. Findings should be interpreted with caution, given the high risk of bias in many studies. There is a clear need for high-quality contemporary trials to establish the effectiveness of different approaches to preventing infection.
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Bove V, Riva E, Vásquez J, Peña C, Seehaus C, Samanez C, Bustos J, Hernández M, Fernández J, Ríos O, Rodríguez Y, Figueredo I, Fantl D, Malpica L. Epidemiology and Risk Factors for the Development of Infectious Complications in Newly Diagnosed Multiple Myeloma: A Multicenter Prospective Cohort Study in Latin America. JCO Glob Oncol 2022; 8:e2200068. [PMID: 35867949 PMCID: PMC9812460 DOI: 10.1200/go.22.00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Infections are a significant cause of morbidity and mortality in patients with multiple myeloma (MM). In Latin America, data on infectious complications in this patient population are lacking. METHODS We conducted a prospective cohort study of patients with newly diagnosed MM (NDMM) in seven Latin American countries between June 2019 and May 2020. Patients with active disease, on active therapy, and with a follow-up of 6 months from the time of diagnosis were included. Our primary end point was the number of infectious events that required hospitalization for ≥ 24 hours. RESULTS Of 248 patients with NDMM, 89 (35.9%) had infectious complications (113 infectious events), the majority (67.3%) within the first 3 months from diagnosis. The most common sites of infection were respiratory (38%) and urinary tract (31%). The microbial agent was identified in 57.5% of patients with gram-negative bacteria (73.5%) as the most common pathogen. Viral infections were infrequent, and no patients with fungal infection were reported. In the multivariable analysis, diabetes mellitus (odds ratio [OR], 2.71; 95% CI, 1.23 to 6.00; P = .014), creatinine ≥ 2 mg/dL (OR, 4.87; 95% CI, 2.29 to 10.35; P < .001), no use of trimethoprim-sulfamethoxazole prophylaxis (OR, 6.66; 95% CI, 3.43 to 12.92; P < .001), and treatment with immunomodulatory drugs (OR, 3.02; 95% CI, 1.24 to 6.29; P = .003) were independent factors associated with bacterial infections. At 6 months, 21 patients (8.5%) had died, 47.6% related to infectious complications. CONCLUSION Bacterial infections are a substantial cause of hospital admissions and early death in patients with NDMM. Antibiotic prophylaxis should be considered to reduce infectious complications in patients with MM.
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Affiliation(s)
- Virginia Bove
- Department of Hematology, Hospital Central de las FF.AA., Montevideo, Uruguay,Virginia Bove, MD, Department of Hematology, Hospital Central de las FF.AA., Av. 8 de Octubre 3060, Montevideo 11600, Uruguay; Twitter: @VirginiaBove10; e-mail:
| | - Eloísa Riva
- Department of Hematology, Hospital de Clínicas, Montevideo, Uruguay
| | - Jule Vásquez
- Department of Medical Oncology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Camila Peña
- Department of Hematology, Hospital del Salvador, Santiago, Chile
| | - Cristian Seehaus
- Department of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - César Samanez
- Department of Medical Oncology, Oncosalud—AUNA, Lima, Peru
| | - Justina Bustos
- Department of Hematology and Bone Marrow Transplantation, Instituto Oncológico Nacional, Panamá, Panamá
| | - Marcos Hernández
- Department of Hematology, Universidad de Carabobo, Hospital Metropolitano del Norte, Carabobo, Venezuela
| | - Julio Fernández
- Department of Hematology, Hospital General Universitario Dr Gustavo Aldereguía Lima, Cienfuegos, Cuba
| | - Oliday Ríos
- Department of Hematology, Hospital Hermanos Ameijeiras, La Habana, Cuba
| | - Yusaima Rodríguez
- Department of Hematology, Hospital Hermanos Ameijeiras, La Habana, Cuba
| | - Irving Figueredo
- Department of Hematology, Centro de Investigaciones Médico Quirúrgicas, La Habana, Cuba
| | - Dorotea Fantl
- Department of Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Luis Malpica
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
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Abstract
Multiple myeloma (MM) is a type of haematological bone marrow malignancy. Cancer Research UK reports that MM is the 18th most common cancer in the UK, accounting for 2% of all new cancer cases, yet, non-haematologists often lack familiarity with the pathology and initial investigations. This paper aims to demonstrate the diagnostic features, relevant investigations and basic management plan for the non-specialist.
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Affiliation(s)
- Taran K Nandra
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | | - John R Jones
- Brighton and Sussex Medical School, Falmer, UK, King's College Hospital, London, UK and Eastbourne District General Hospital, Eastbourne, UK
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Chahin M, Branham Z, Fox A, Leurinda C, Keruakous AR. Clinical Considerations for Immunoparesis in Multiple Myeloma. Cancers (Basel) 2022; 14:cancers14092278. [PMID: 35565407 PMCID: PMC9104750 DOI: 10.3390/cancers14092278] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/13/2022] [Accepted: 05/02/2022] [Indexed: 11/30/2022] Open
Abstract
Simple Summary Immunoparesis in multiple myeloma is defined as the suppression of one or more of the uninvolved immunoglobulins, AKA, polyclonal immunoglobulin. The extent of immunoparesis is an independent prognostic factor in patients with newly diagnosed multiple myeloma. Myeloma patients with suppressed uninvolved immunoglobulins at diagnosis have shorter median overall survival (OS) and progression-free survival (PFS). This review article summarizes immunoparesis in myeloma patients, contributing factors, its impact on myeloma progression, general outcomes, and infectious complications. Abstract Multiple myeloma is a relatively common clonal plasma cell disorder, comprising 17% of hematologic malignancies. One of the hallmark features of this disease is immunoparesis, which is characterized by the suppression of immunoglobulin polyclonality. Though not entirely elucidated, the mechanism behind this process can be attributed to the changes in the tumor microenvironment. All treating clinicians must consider potential complications related to immunoparesis in the management of multiple myeloma. Though not explicitly described in large data series, the increased risk of infection in multiple myeloma is likely, at least in part, due to immunoglobulin suppression. Additionally, the presence of immunoparesis serves as a prognostic factor, conveying poorer survival and a higher risk of relapse. Even in the era of novel agents, these findings are preserved, and immunoglobulin recovery also serves as a sign of improved outcome following autologous HSCT. Though not within the diagnostic criteria for multiple myeloma, the presence and degree of immunoparesis should be at diagnosis for prognostication, and immunoglobulin recovery should be tracked following myeloablative therapy and autologous HSCT.
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Affiliation(s)
- Michael Chahin
- Section of Hematology and Oncology, Georgia Cancer Center, Augusta University, Augusta, GA 30912, USA;
| | - Zachery Branham
- Internal Medicine, Augusta University, Augusta, GA 30912, USA; (Z.B.); (A.F.); (C.L.)
| | - Ashley Fox
- Internal Medicine, Augusta University, Augusta, GA 30912, USA; (Z.B.); (A.F.); (C.L.)
| | - Christian Leurinda
- Internal Medicine, Augusta University, Augusta, GA 30912, USA; (Z.B.); (A.F.); (C.L.)
| | - Amany R. Keruakous
- Section of Hematology and Oncology, Georgia Cancer Center, Augusta University, Augusta, GA 30912, USA;
- Correspondence: ; Tel.: +1-216-571-3654; Fax: +1-706-721-5566
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43
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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] [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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44
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Pianko MJ, Golob JL. Host-microbe interactions and outcomes in multiple myeloma and hematopoietic stem cell transplantation. Cancer Metastasis Rev 2022; 41:367-382. [PMID: 35488106 DOI: 10.1007/s10555-022-10033-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/16/2022] [Indexed: 12/12/2022]
Abstract
Microbiota are essential to normal immune development and there is growing recognition of its importance to human health and disease and deepening understanding of the complexity of host-microbe interactions in the human gut and other tissues. Commensal microbes not only can influence host immunity locally through impacts of bioactive microbial metabolites and direct interactions with epithelial cells and innate immune receptors but also can exert systemic immunomodulatory effects via impacts on host immune cells capable of trafficking beyond the gut. Emerging data suggest microbiota influence the development of multiple myeloma (MM), a malignancy of the immune system derived from immunoglobulin-producing bone marrow plasma cells, through the promotion of inflammation. Superior treatment outcomes for MM correlate with a higher abundance of commensal microbiota capable of influencing inflammatory responses through the production of butyrate. In patients with hematologic malignancies, higher levels of diversity of the gut microbiota correlate with superior outcomes after hematopoietic stem cell transplantation. Correlative data support the impact of commensal microbiota on survival, risk of infection, disease relapse, and graft-versus-host disease (GVHD) after transplant. In this review, we will discuss the current understanding of the role of host-microbe interactions and the inflammatory tumor microenvironment of multiple myeloma, discuss data describing the key role of microbiota in hematopoietic stem cell transplantation for treatment of hematologic malignancies, and highlight several possible concepts for interventions directed at the gut microbiota to influence treatment outcomes.
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Affiliation(s)
- Matthew J Pianko
- Department of Internal Medicine, Division of Hematology/Oncology, University of Michigan, Ann Arbor, MI, USA.
| | - Jonathan L Golob
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.,Department of Microbiology & Immunology, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA
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45
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Encinas C, Hernandez-Rivas JÁ, Oriol A, Rosiñol L, Blanchard MJ, Bellón JM, García-Sanz R, de la Rubia J, de la Guía AL, Jímenez-Ubieto A, Jarque I, Iñigo B, Dourdil V, de Arriba F, Pérez-Ávila CC, Gonzalez Y, Hernández MT, Bargay J, Granell M, Rodríguez-Otero P, Silvent M, Cabrera C, Rios R, Alegre A, Gironella M, Gonzalez MS, Sureda A, Sampol A, Ocio EM, Krsnik I, García A, García-Mateo A, Soler JA, Martín J, Arguiñano JM, Mateos MV, Bladé J, San-Miguel JF, Lahuerta JJ, Martínez-López J. A simple score to predict early severe infections in patients with newly diagnosed multiple myeloma. Blood Cancer J 2022; 12:68. [PMID: 35440057 PMCID: PMC9018751 DOI: 10.1038/s41408-022-00652-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/21/2022] [Accepted: 03/21/2022] [Indexed: 12/30/2022] Open
Abstract
Infections remain a common complication in patients with multiple myeloma (MM) and are associated with morbidity and mortality. A risk score to predict the probability of early severe infection could help to identify the patients that would benefit from preventive measures. We undertook a post hoc analysis of infections in four clinical trials from the Spanish Myeloma Group, involving a total of 1347 patients (847 transplant candidates). Regarding the GEM2010 > 65 trial, antibiotic prophylaxis was mandatory, so we excluded it from the final analysis. The incidence of severe infection episodes within the first 6 months was 13.8%, and majority of the patients experiencing the first episode before 4 months (11.1%). 1.2% of patients died because of infections within the first 6 months (1% before 4 months). Variables associated with increased risk of severe infection in the first 4 months included serum albumin ≤30 g/L, ECOG > 1, male sex, and non-IgA type MM. A simple risk score with these variables facilitated the identification of three risk groups with different probabilities of severe infection within the first 4 months: low-risk (score 0-2) 8.2%; intermediate-risk (score 3) 19.2%; and high-risk (score 4) 28.3%. Patients with intermediate/high risk could be candidates for prophylactic antibiotic therapies.
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Affiliation(s)
- Cristina Encinas
- Hospital General Universitario Gregorio Marañón (HGUGM), IiSGM, Madrid, Spain
| | | | - Albert Oriol
- Hospital Universitario Germans Trias i Pujol, Badalona (Barcelona), Barcelona, Spain
| | | | | | - José-María Bellón
- Hospital General Universitario Gregorio Marañón (HGUGM), IiSGM, Madrid, Spain
| | - Ramón García-Sanz
- University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), Salamanca, Spain
| | | | | | | | - Isidro Jarque
- Hospital Universitario la Fe, CIBERONC, Valencia, Spain
| | | | - Victoria Dourdil
- Hospital Clínico Universitario "Lozano Blesa", Zaragoza, IIS Aragón, Spain
| | | | | | | | | | - Joan Bargay
- Hospital Son Llatzer, Palma de Mallorca, Spain
| | | | | | | | | | - Rafael Rios
- Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Adrián Alegre
- Hospital Universitario de la Princesa y Hospital Universitario Quirónsalud, Madrid, Spain
| | | | | | - Anna Sureda
- ICO-L'Hospitalet, IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | - Antonia Sampol
- Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Enrique M Ocio
- Hospital Universitario Marqués de Valdecilla, (IDIVAL). Universidad de Cantabria, Santander, Spain
| | - Isabel Krsnik
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | | | | | | | - Jesús Martín
- Complejo Hospitalario Regional Virgen del Rocío, CIBERONC, Sevilla, Spain
| | | | - María-Victoria Mateos
- University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Joan Bladé
- Hospital Clinic, CIBERONC, Barcelona, Spain
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Kim SI, Jung SH, Yhim HY, Jo JC, Song GY, Kim M, Ahn SY, Ahn JS, Yang DH, Kim HJ, Lee JJ. Real-world evidence of levofloxacin prophylaxis in elderly patients with newly diagnosed multiple myeloma who received bortezomib, melphalan, and prednisone regimen. Blood Res 2022; 57:51-58. [PMID: 35197371 PMCID: PMC8958375 DOI: 10.5045/br.2021.2021176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/03/2021] [Accepted: 12/29/2021] [Indexed: 11/29/2022] Open
Abstract
Background Although survival outcomes of multiple myeloma (MM) have improved with the development of new and effective agents, infection remains the major cause of morbidity and mortality. Here, we evaluated the efficacy of levofloxacin prophylaxis (in a real-world setting) during bortezomib, melphalan, and prednisone (VMP) therapy in elderly patients with newly diagnosed MM. Methods This study retrospectively analyzed the records of patients with newly diagnosed MM treated with the VMP regimen between February 2011 and September 2020 at three institutes of the Republic of Korea. Results Of a total of 258 patients, 204 (79.1%) received levofloxacin prophylaxis during VMP therapy. The median number of levofloxacin prophylaxis cycles was 4 (range, 1‒9), but 10 patients did not complete the planned prophylaxis because of side effects. Sixty-six patients (25.5%) experienced severe infections during VMP therapy, most of which (74.7%) occurred within the first four cycles of VMP therapy regardless of levofloxacin prophylaxis status. Early severe infection was significantly associated with poor survival. In multivariate analysis, levofloxacin prophylaxis was significantly associated with a lower risk in early severe infection. Conclusion Our findings suggest that levofloxacin prophylaxis should be considered at least during the first four cycles of VMP therapy in elderly patients with newly diagnosed MM.
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Affiliation(s)
- Su-In Kim
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Korea
| | - Sung-Hoon Jung
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Korea
| | - Ho-Young Yhim
- Jeonbuk National University Hospital, Jeonbuk National university Medical School, Jeonju, Korea
| | - Jae-Cheol Jo
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Ga-Young Song
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Korea
| | - Mihee Kim
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Korea
| | - Seo-Yeon Ahn
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Korea
| | - Jae-Sook Ahn
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Korea
| | - Deok-Hwan Yang
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Korea
| | - Hyeoung-Joon Kim
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Korea
| | - Je-Jung Lee
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, Korea
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Girmenia C, Cavo M, Corso A, Di Raimondo F, Musto P, Offidani M, Petrucci MT, Rosato A, Barosi G. Management of infectious risk of daratumumab therapy in multiple myeloma: a consensus-based position paper from an ad hoc Italian expert panel. Crit Rev Oncol Hematol 2022; 172:103623. [PMID: 35151867 DOI: 10.1016/j.critrevonc.2022.103623] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 01/27/2022] [Accepted: 02/07/2022] [Indexed: 12/28/2022] Open
Abstract
Daratumumab is approved for newly diagnosed or relapsed/refractory multiple myeloma (MM). The use of daratumumab has improved patient outcomes but has changed the frequency and epidemiology of infections. However, the optimal approach to prophylaxis and supportive therapy for daratumumab-emergent infections is unknown and represents an unmet clinical need in MM. Consequently, an expert panel convened to compose recommendations for optimal infection control in patient candidates to or under daratumumab treatment for MM. Scientific evidence on infections secondary to daratumumab was evaluated, and a consensus was developed by group discussion for key questions selected according to the clinical relevance. The following key issues were addressed: infectious risk assessment and risk stratification, infection mitigation strategies, and management of infectious complications in patients with MM treated with daratumumab.
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Affiliation(s)
- Corrado Girmenia
- Dipartimento di Ematologia, Oncologia, e Dermatologia, AOU Policlinico Umberto I, Sapienza Università di Roma, Rome, Italy.
| | - Michele Cavo
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli",Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | | | - Francesco Di Raimondo
- Dipartimento di specialità medico-chirurgiche - sezione di Ematologia, Università di Catania. Divisione di Ematologia con Trapianto di midollo osseo - Azienda ospedaliero, universitaria Policlinico Vittorio Emanuele, Catania, Italy
| | - Pellegrino Musto
- Department of Emergency and Organ Transplantation, "Aldo Moro" University School of Medicine, Unit of Hematology and Stem Cell Transplantation, AOUC Policlinico, Bari, Italy
| | - Massimo Offidani
- Clinica di Ematologia, AOU Ospedali Riuniti di Ancona, Ancona, Italy
| | - Maria Teresa Petrucci
- Dipartimento di Ematologia, Oncologia, e Dermatologia, AOU Policlinico Umberto I, Sapienza Università di Roma, Rome, Italy
| | - Antonio Rosato
- Department of Surgery, Oncology and Gastroenterology, University of Padua. Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Giovanni Barosi
- Center for the Study of Myelofibrosis. IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
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48
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Geraldes C, Neves M, Chacim S, da Costa FL. Practical Considerations for the Daratumumab Management in Portuguese Routine Clinical Practice: Recommendations From an Expert Panel of Hematologists. Front Oncol 2022; 11:817762. [PMID: 35186719 PMCID: PMC8855501 DOI: 10.3389/fonc.2021.817762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/15/2021] [Indexed: 11/13/2022] Open
Abstract
The recent therapeutic progress in multiple myeloma (MM) has led to the introduction of novel and highly potent drug classes. Daratumumab was the first CD38-targeting antibody showing to be effective and safe in MM patients as monotherapy and in combination regimens, which led to its rapid implementation in clinical practice. Considering that treatment discontinuation for drug-related adverse events can impact patients’ quality of life and outcomes, the treatment decision should consider different factors and be weighted for each patient individually. Here, we aimed to guide clinicians using daratumumab treatment for MM by addressing practical real-world considerations based on an expert panel of Portuguese hematologists. Carefully following the recommendations mentioned in daratumumab’s SmPC, and of those from other drugs used in combination regimens, along with ensuring a good communication with all healthcare professionals involved, is critical to prevent any complications arising from treatment. The risk of infection should be assessed for all patients under treatment with daratumumab and patients should be educated on the potential adverse events. Recommendations on prophylaxis and vaccination should be considered to avoid infections, and delays in the planned therapeutic schedule may be required to prevent adverse consequences of hematological toxicity. Daratumumab treatment is effective and feasible in patients with renal impairment, although careful patient monitoring and a frequent communication with the Nephrology department are of the utmost importance. Sharing clinical practice plays an important role in medical education by allowing to maximize treatment efficacy and minimize its safety risks.
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Affiliation(s)
- Catarina Geraldes
- Departamento de Hematologia Clínica, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Laboratório de Oncobiologia e Hematologia e Clínica Universitária de Hematologia, Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Centro Académico-Clínico de Coimbra (CACC), Coimbra, Portugal
- *Correspondence: Catarina Geraldes,
| | | | - Sérgio Chacim
- Instituto Português de Oncologia do Porto, Porto, Portugal
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Caro J, Braunstein M, Williams L, Bruno B, Kaminetzky D, Siegel A, Razzo B, Alfandari S, Morgan GJ, Davies FE, Boyle EM. Inflammation and infection in plasma cell disorders: how pathogens shape the fate of patients. Leukemia 2022; 36:613-624. [PMID: 35110727 PMCID: PMC8809233 DOI: 10.1038/s41375-021-01506-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 12/26/2022]
Abstract
The role of infection and chronic inflammation in plasma cell disorders (PCD) has been well-described. Despite not being a diagnostic criterion, infection is a common complication of most PCD and represents a significant cause of morbidity and mortality in this population. As immune-based therapeutic agents are being increasingly used in multiple myeloma, it is important to recognize their impact on the epidemiology of infections and to identify preventive measures to improve outcomes. This review outlines the multiple factors attributed to the high infectious risk in PCD (e.g. the underlying disease status, patient age and comorbidities, and myeloma-directed treatment), with the aim of highlighting future prophylactic and preventive strategies that could be implemented in the clinic. Beyond this, infection and pathogens as an entity are believed to also influence disease biology from initiation to response to treatment and progression through a complex interplay involving pathogen exposure, chronic inflammation, and immune response. This review will outline both the direct and indirect role played by oncogenic pathogens in PCD, highlight the requirement for large-scale studies to decipher the precise implication of the microbiome and direct pathogens in the natural history of myeloma and its precursor disease states, and understand how, in turn, pathogens shape plasma cell biology.
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Affiliation(s)
- Jessica Caro
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Marc Braunstein
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Louis Williams
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Benedetto Bruno
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - David Kaminetzky
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Ariel Siegel
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Beatrice Razzo
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Serge Alfandari
- Service de Réanimation et Maladies Infectieuses, CH Gustave Dron, Tourcoing, France
| | - Gareth J Morgan
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Faith E Davies
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Eileen M Boyle
- Myeloma Research Program, Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA.
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50
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Cowan AJ, Green DJ, Kwok M, Lee S, Coffey DG, Holmberg LA, Tuazon S, Gopal AK, Libby EN. Diagnosis and Management of Multiple Myeloma: A Review. JAMA 2022; 327:464-477. [PMID: 35103762 DOI: 10.1001/jama.2022.0003] [Citation(s) in RCA: 298] [Impact Index Per Article: 149.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Multiple myeloma is a hematologic malignancy characterized by presence of abnormal clonal plasma cells in the bone marrow, with potential for uncontrolled growth causing destructive bone lesions, kidney injury, anemia, and hypercalcemia. Multiple myeloma is diagnosed in an estimated 34 920 people in the US and in approximately 588 161 people worldwide each year. OBSERVATIONS Among patients with multiple myeloma, approximately 73% have anemia, 79% have osteolytic bone disease, and 19% have acute kidney injury at the time of presentation. Evaluation of patients with possible multiple myeloma includes measurement of hemoglobin, serum creatinine, serum calcium, and serum free light chain levels; serum protein electrophoresis with immunofixation; 24-hour urine protein electrophoresis; and full-body skeletal imaging with computed tomography, positron emission tomography, or magnetic resonance imaging. The Revised International Staging System combines data from the serum biomarkers β2 microglobulin, albumin, and lactate dehydrogenase in conjunction with malignant plasma cell genomic features found on fluorescence in situ hybridization-t(4;14), del(17p), and t(14;16)-to assess estimated progression-free survival and overall survival. At diagnosis, 28% of patients are classified as having Revised International Staging stage I multiple myeloma, and these patients have a median 5-year survival of 82%. Among all patients with multiple myeloma, standard first-line (induction) therapy consists of a combination of an injectable proteasome inhibitor (ie, bortezomib), an oral immunomodulatory agent (ie, lenalidomide), and dexamethasone and is associated with median progression-free survival of 41 months, compared with historical reports of 8.5 months without therapy. This induction therapy combined with autologous hematopoietic stem cell transplantation followed by maintenance lenalidomide is standard of care for eligible patients. CONCLUSIONS AND RELEVANCE Approximately 34 920 people in the US and 155 688 people worldwide are diagnosed with multiple myeloma each year. Induction therapy with an injectable proteasome inhibitor, an oral immunomodulatory agent and dexamethasone followed by treatment with autologous hematopoietic stem cell transplantation, and maintenance therapy with lenalidomide are among the treatments considered standard care for eligible patients.
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Affiliation(s)
- Andrew J Cowan
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
| | - Damian J Green
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
| | - Mary Kwok
- Seattle Cancer Care Alliance, Seattle, Washington
- Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Sarah Lee
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
| | - David G Coffey
- Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, Florida
| | - Leona A Holmberg
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
| | - Sherilyn Tuazon
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Now with Bristol Myers Squibb, Seattle, Washington
| | - Ajay K Gopal
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
| | - Edward N Libby
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Seattle Cancer Care Alliance, Seattle, Washington
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