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Piechotta V, Jakob T, Langer P, Monsef I, Scheid C, Estcourt LJ, Ocheni S, Theurich S, Kuhr K, Scheckel B, Adams A, Skoetz N. Multiple drug combinations of bortezomib, lenalidomide, and thalidomide for first-line treatment in adults with transplant-ineligible multiple myeloma: a network meta-analysis. Cochrane Database Syst Rev 2019; 2019:CD013487. [PMID: 31765002 PMCID: PMC6876545 DOI: 10.1002/14651858.cd013487] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Multiple myeloma is a bone marrow-based hematological malignancy accounting for approximately two per cent of cancers. First-line treatment for transplant-ineligible individuals consists of multiple drug combinations of bortezomib (V), lenalidomide (R), or thalidomide (T). However, access to these medicines is restricted in many countries worldwide. OBJECTIVES To assess and compare the effectiveness and safety of multiple drug combinations of V, R, and T for adults with newly diagnosed transplant-ineligible multiple myeloma and to inform an application for the inclusion of these medicines into the World Health Organization's (WHO) list of essential medicines. SEARCH METHODS We searched CENTRAL and MEDLINE, conference proceedings and study registries on 14 February 2019 for randomised controlled trials (RCTs) comparing multiple drug combinations of V, R and T for adults with newly diagnosed transplant-ineligible multiple myeloma. SELECTION CRITERIA We included RCTs comparing combination therapies of V, R, and T, plus melphalan and prednisone (MP) or dexamethasone (D) for first-line treatment of adults with transplant-ineligible multiple myeloma. We excluded trials including adults with relapsed or refractory disease, trials comparing drug therapies to other types of therapy and trials including second-generation novel agents. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias of included trials. As effect measures we used hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS) and risk ratios (RRs) for adverse events. An HR or RR < 1 indicates an advantage for the intervention compared to the main comparator MP. Where available, we extracted quality of life (QoL) data (scores of standardised questionnaires). Results quoted are from network meta-analysis (NMA) unless stated. MAIN RESULTS We included 25 studies (148 references) comprising 11,403 participants and 21 treatment regimens. Treatments were differentiated between restricted treatment duration (treatment with a pre-specified amount of cycles) and continuous therapy (treatment administered until disease progression, the person becomes intolerant to the drug, or treatment given for a prolonged period). Continuous therapies are indicated with a "c". Risk of bias was generally high across studies due to the open-label study design. Overall survival (OS) Evidence suggests that treatment with RD (HR 0.63 (95% confidence interval (CI) 0.40 to 0.99), median OS 55.2 months (35.2 to 87.0)); TMP (HR 0.75 (95% CI 0.58 to 0.97), median OS: 46.4 months (35.9 to 60.0)); and VRDc (HR 0.49 (95% CI 0.26 to 0.92), median OS 71.0 months (37.8 to 133.8)) probably increases survival compared to median reported OS of 34.8 months with MP (moderate certainty). Treatment with VMP may result in a large increase in OS, compared to MP (HR 0.70 (95% CI 0.45 to 1.07), median OS 49.7 months (32.5 to 77.3)), low certainty). Progression-free survival (PFS) Treatment withRD (HR 0.65 (95% CI0.44 to 0.96), median PFS: 24.9 months (16.9 to 36.8)); TMP (HR 0.63 (95% CI 0.50 to 0.78), median PFS:25.7 months (20.8 to 32.4)); VMP (HR 0.56 (95% CI 0.35 to 0.90), median PFS: 28.9 months (18.0 to 46.3)); and VRDc (HR 0.34 (95% CI 0.20 to 0.58), median PFS: 47.6 months (27.9 to 81.0)) may result in a large increase in PFS (low certainty) compared to MP (median reported PFS: 16.2 months). Adverse events The risk of polyneuropathies may be lower with RD compared to treatment with MP (RR 0.57 (95% CI 0.16 to 1.99), risk for RD: 0.5% (0.1 to 1.8), mean reported risk for MP: 0.9% (10 of 1074 patients affected), low certainty). However, the CIs are also compatible with no difference or an increase in neuropathies. Treatment with TMP (RR 4.44 (95% CI1.77 to 11.11), risk: 4.0% (1.6 to 10.0)) and VMP (RR 88.22 (95% CI 5.36 to 1451.11), risk: 79.4% (4.8 to 1306.0)) probably results in a large increase in polyneuropathies compared to MP (moderate certainty). No study reported the amount of participants with grade ≥ 3 polyneuropathies for treatment with VRDc. VMP probably increases the proportion of participants with serious adverse events (SAEs) compared to MP (RR 1.28 (95% CI 1.06 to 1.54), risk for VMP: 46.2% (38.3 to 55.6), mean risk for MP: 36.1% (177 of 490 patients affected), moderate certainty). RD, TMP, and VRDc were not connected to MP in the network and the risk of SAEs could not be compared. Treatment with RD (RR 4.18 (95% CI 2.13 to 8.20), NMA-risk: 38.5% (19.6 to 75.4)); and TMP (RR 4.10 (95% CI 2.40 to 7.01), risk: 37.7% (22.1 to 64.5)) results in a large increase of withdrawals from the trial due to adverse events (high certainty) compared to MP (mean reported risk: 9.2% (77 of 837 patients withdrew)). The risk is probably slightly increased with VMP (RR 1.06 (95% CI 0.63 to 1.81), risk: 9.75% (5.8 to 16.7), moderate certainty), while it is much increased with VRDc (RR 8.92 (95% CI 3.82 to 20.84), risk: 82.1% (35.1 to 191.7), high certainty) compared to MP. Quality of life QoL was reported in four studies for seven different treatment regimens (MP, MPc, RD, RMP, RMPc, TMP, TMPc) and was measured with four different tools. Assessment and reporting differed between studies and could not be meta-analysed. However, all studies reported an improvement of QoL after initiation of anti-myeloma treatment for all assessed treatment regimens. AUTHORS' CONCLUSIONS Based on our four pre-selected comparisons of interest, continuous treatment with VRD had the largest survival benefit compared with MP, while RD and TMP also probably considerably increase survival. However, treatment combinations of V, R, and T also substantially increase the incidence of AEs, and lead to a higher risk of treatment discontinuation. Their effectiveness and safety profiles may best be analysed in further randomised head-to-head trials. Further trials should focus on consistent reporting of safety outcomes and should use a standardised instrument to evaluate QoL to ensure comparability of treatment-combinations.
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Affiliation(s)
- Vanessa Piechotta
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Tina Jakob
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Peter Langer
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Ina Monsef
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Christof Scheid
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Stem Cell Transplantation Program, Kerpener Str. 62, Cologne, NRW, Germany, 50937
| | - Lise J Estcourt
- NHS Blood and Transplant, Haematology/Transfusion Medicine, Level 2, John Radcliffe Hospital, Headington, Oxford, UK, OX3 9BQ
| | - Sunday Ocheni
- University of Nigeria, Department of Haematology & Immunology, Ituku-Ozalla Campus, Enugu, Enugu State, Nigeria
| | - Sebastian Theurich
- University Hospital LMU, Ludwig-Maximilians-Universität München, Department of Medicine III, Marchioninistrasse 15, Munich, Bavaria, Germany, 81377
| | - Kathrin Kuhr
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Medical Statistics and Computational Biology, Kerpener Str. 62, Cologne, Germany, 50937
| | - Benjamin Scheckel
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, NRW, Germany, 50937
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Institute of Health Economics and Clinical Epidemiology, Gleueler Str. 176-178, Cologne, NRW, Germany, 50935
| | - Anne Adams
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Institute of Medical Statistics and Computational Biology, Kerpener Str. 62, Cologne, Germany, 50937
| | - Nicole Skoetz
- Faculty of Medicine and University Hospital Cologne, University of Cologne, Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Kerpener Str. 62, Cologne, Germany, 50937
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Chen RA, Tu Y, Cao Y, Liu L, Liang Y. Bortezomib-Dexamethasone or Vincristine-Doxorubicin-Dexamethasone as Induction Therapy Followed by Thalidomide as Maintenance Therapy in Untreated Multiple Myeloma Patients. J Int Med Res 2011; 39:1975-84. [PMID: 22118002 DOI: 10.1177/147323001103900544] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
This randomized, retrospective study evaluated the effect of thalidomide combined with bortezomib-dexamethasone (TBD) or vincristine-doxorubicin-dexamethasone (T-VAD) on 46 patients with multiple myeloma. Newly diagnosed patients were randomly allocated to receive TBD ( n = 24) or T-VAD ( n = 22). The high-quality response rate (complete response plus very good partial response) was 62.5% in the TBD group and 45.4% for T-VAD. The complete response rate was 29.2% for TBD and 13.6% for T-VAD. Overall survival at 2 and 3 years, respectively, was 91.7% and 62.5% for TBD versus 86.4% and 54.5% for T-VAD. Most of the toxic effects of treatment were well tolerated. Both regimens were effective in the treatment of newly diagnosed multiple myeloma patients. Further studies are required to determine the role of thalidomide in these two regimens.
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Affiliation(s)
- RA Chen
- Department of Haematology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Y Tu
- Department of Emergency, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Y Cao
- Department of Emergency, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - L Liu
- Department of Haematology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Y Liang
- Department of Haematology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
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Lin CK, Sung YC. Newly diagnosed multiple myeloma in Taiwan: the evolution of therapy, stem cell transplantation and new treatment agents. Hematol Oncol Stem Cell Ther 2010; 2:385-93. [PMID: 20139051 DOI: 10.1016/s1658-3876(09)50006-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Multiple myeloma is a clonal plasma cell dyscrasia with clinical heterogeneity. As of now, two key questions need to be answered before starting to treat a newly diagnosed myeloma patient. One is whether the patient is a candidate for high-dose chemotherapy with stem cell support and the other is risk stratification. As novel therapeutics have emerged, it is increasingly important to introduce a risk-adapted approach. The heterogeneity of the disease is established, for the most part, by disease biology, predominantly genetics. Cytogenetic analysis by either banding technique or fluorescent in situ hybridization is able to identify high-risk subpopulations. The new international staging system based on beta2-microglobulin and albumin levels in serum is also very helpful in defining the high-risk group (stage 3). This group of patients may not respond well to high-dose chemotherapy and require early introduction of newer treatments such as the bortezomib-containing regimen. The main factor in determining the eligibility for stem cell transplants is age. Based on the current literature and situation in Taiwan, we suggest stem cell transplantation if the patient is younger than 55 years of age. Each case should be considered individually if the age of the patient is between 55 and 70 years. Finally, we have also reviewed the status and the treatment of multiple myeloma in Taiwan. Fortunately, there has been an improvement in awareness, diagnosis and treatment. Cytogenetic studies have been applied in risk evaluations, but are limited in a few centers due to lack of availability. With the exception of the agent lenalidomide, new novel agents are available for treating of myeloma in Taiwan.
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Facon T, Darre S. Frontline treatment in multiple myeloma patients not eligible for stem-cell transplantation. Best Pract Res Clin Haematol 2008; 20:737-46. [PMID: 18070716 DOI: 10.1016/j.beha.2007.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Melphalan-prednisone-thalidomide (MPT) currently appears to be the treatment of choice for a large proportion of elderly patients ineligible for autologous stem-cell transplantation (ASCT). It seems certain that in the near future melphalan-prednisone-Velcade (MPV) and melphalan-prednisone-lenalidomide (MPR) will also be proved superior to melphalan-prednisone (MP), thus providing three therapeutic options (MPT, MPV and MPR) in this patient group with multiple myeloma (MM). These therapeutic options could lead to more personalized treatment approaches, based on patient comorbidities, as the three novel therapies have somewhat different toxicity profiles. MP would be appropriate for only a minority of patients with poor performance status and/or significant comorbidities, such as severe neuropathy or a contraindication to anticoagulants. Questions regarding the relative efficacy of melphalan-based regimens versus dexamethasone-based regimens (preferably with low-dose dexamethasone) will require randomized phase-III trials. More intensive approaches with new drug combinations or with the incorporation of polyethylene glycolated (PEGylated) liposomal doxorubicin will also require additional studies. Additionally, the important issue of maintenance treatment needs to be further investigated, especially in elderly patients.
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Affiliation(s)
- Thierry Facon
- Service des Maladies du Sang, Hôpital Claude Huriez, CHU, rue Michel Polonovski, 59037 Lille Cedex, France.
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Facon T, Mary JY, Hulin C, Benboubker L, Attal M, Pegourie B, Renaud M, Harousseau JL, Guillerm G, Chaleteix C, Dib M, Voillat L, Maisonneuve H, Troncy J, Dorvaux V, Monconduit M, Martin C, Casassus P, Jaubert J, Jardel H, Doyen C, Kolb B, Anglaret B, Grosbois B, Yakoub-Agha I, Mathiot C, Avet-Loiseau H. Melphalan and prednisone plus thalidomide versus melphalan and prednisone alone or reduced-intensity autologous stem cell transplantation in elderly patients with multiple myeloma (IFM 99-06): a randomised trial. Lancet 2007; 370:1209-18. [PMID: 17920916 DOI: 10.1016/s0140-6736(07)61537-2] [Citation(s) in RCA: 634] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND In multiple myeloma, combination chemotherapy with melphalan plus prednisone is still regarded as the standard of care in elderly patients. We assessed whether the addition of thalidomide to this combination, or reduced-intensity stem cell transplantation, would improve survival. METHODS Between May 22, 2000, and Aug 8, 2005, 447 previously untreated patients with multiple myeloma, who were aged between 65 and 75 years, were randomly assigned to receive either melphalan and prednisone (MP; n=196), melphalan and prednisone plus thalidomide (MPT; n=125), or reduced-intensity stem cell transplantation using melphalan 100 mg/m2 (MEL100; n=126). The primary endpoint was overall survival. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00367185. FINDINGS After a median follow-up of 51.5 months (IQR 34.4-63.2), median overall survival times were 33.2 months (13.8-54.8) for MP, 51.6 months (26.6-not reached) for MPT, and 38.3 months (13.0-61.6) for MEL100. The MPT regimen was associated with a significantly better overall survival than was the MP regimen (hazard ratio 0.59, 95% CI 0.46-0.81, p=0.0006) or MEL100 regimen (0.69, 0.49-0.96, p=0.027). No difference was seen for MEL100 versus MP (0.86, 0.65-1.15, p=0.32). INTERPRETATION The results of our trial provide strong evidence to indicate that the use of thalidomide in combination with melphalan and prednisone should, at present, be the reference treatment for previously untreated elderly patients with multiple myeloma.
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Affiliation(s)
- Thierry Facon
- Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France.
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