scholarly journals Treatment Disparities in Minority Groups with Multiple Myeloma at a Large Safety-Net Hospital

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4864-4864
Author(s):  
Michael Dennis ◽  
Diana Cirstea ◽  
Asaf Maoz ◽  
Adam Lerner ◽  
Ami K. Patel ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Ethnic Groups ◽  
Induction Therapy ◽  
Minority Groups ◽  
Safety Net ◽  
First Year ◽  
Cell Transplant ◽  
Induction Regimen ◽  
Drug Induction ◽  
Racial Ethnic

Abstract Background: Outcomes in multiple myeloma (MM) have improved in recent years, but disparities among racial-ethnic groups persist (Costa, 2017; Ailawadhi, 2012; Waxman, 2010). Differences in disease biology, treatment modalities, and access to care are likely explanations for these disparities. Currently the preferred induction therapy for MM is a three-drug regimen, such as bortezomib/cyclophosphamide/dexamethasone (VCD), bortezomib/lenalidomide/dexamethasone (VRD) or carfilzomib/pomalidomide/dexamethasone (KPd). This is often followed by high-dose melphalan with autologous stem cell transplant (HDM/SCT) and maintenance therapy. Older or frail adults may not tolerate this three-drug approach or HDM/SCT. Two-drug regimens without HDM/SCT are acceptable options in these groups. This retrospective study was designed to explore the utilization of preferred induction therapy and HDM/SCT across racial-ethnic groups at Boston Medical Center. Results: One hundred sixty-eight patients with MM were treated at our institution between 2004 and 2017. Sixty-six percent were non-Hispanic Black (NHB), 20% were non-Hispanic White (NHW), and 14% were Hispanic. The average age was 63 years and 56% of the population was male. There was no significant difference in age or sex between the NHB, NHW, and Hispanic groups. Only 83 patients (49%) received a three-drug induction regimen. Forty-six (51%) were < 65 years old, while 37 (48%) were ≥ 65 years old. The utilization of standard induction therapy was significantly different among racial-ethnic groups < 65 years old. Thirteen NHW patients (76%) received triplet induction therapy, compared to only 10 Hispanics (63%) and 23 NHB patients (40%) (p=0.02). A similar trend was observed in regards to treatment with HDM/SCT within the first year after diagnosis for patients age < 65 years and triplet therapy in patients undergoing HDM/SCT (any age), although these trends did not reach statistical significance (47% NHWs, 31% Hispanics, and 28% NHBs, p=0.31 and 91% NHWs, 78% Hispanics, and 58% NHBs, p=0.11 respectively). There were no significant differences among groups age ≥ 65 years in regards to triplet induction therapy, HDM/SCT within the first year, or HDM/SCT any time after diagnosis. The median time to HDM/SCT and overall survival were not significantly different between racial-ethnic groups, regardless of age above or below 65 years. Conclusion: NHB and Hispanic patients less than 65 years old are less likely to receive a standard three-drug induction regimen. There is also a trend towards fewer patients receiving HDM/SCT in the first year after diagnosis among these groups compared to NHW patients. Our study did not confirm a survival benefit in NHB patients under age 65, which has been reported in prior studies (Fillmore, 2018; Waxman, 2010). The lack of benefit seen in this study could be related to lower rates of three-drug induction therapy and HDM/SCT in the NHB group. Further research is needed to explore patient co-morbidities, socioeconomic factors, and physician biases to determine why minority groups have less utilization of standard therapies. Table. Table. Disclosures No relevant conflicts of interest to declare.

scholarly journals The Impact of RVD or VCD Induction on Response 3 Months after First Line Autologous Transplant in Multiple Myeloma. a Single-Center Retrospective Analysis

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3445-3445
Author(s):  
Magnus Moksnes ◽  
Fredrik H. Schjesvold
Keyword(s):  
Multiple Myeloma ◽  
Partial Response ◽  
Induction Therapy ◽  
Research Funding ◽  
Response Analysis ◽  
Cell Transplant ◽  
First Line ◽  
Induction Regimen ◽  
Final Response ◽  
Group 1

Abstract Introduction: The use of triple agent induction therapy before first line high-dose therapy (HDT) and autologous stem cell transplant (ASCT) in multiple myeloma is now considered standard of care. While thalidomide/bortezomib/dexamethasone (VTD) is the only induction regimen approved by EMA, both cyclophosphamide/bortezomib/dexamethasone (VCD) and lenalidomide/bortezomib/dexamethasone (RVD) are recommended in the most recent ESMO guidelines (Moreau et al., Annals of Oncology, 2017). Prospective comparisons of VCD and RVD are lacking. Cross-study comparisons show that the combinations of proteasome inhibitors (PIs) and immunomodulatory drugs (IMIDs) have the highest response rates (Malankody Nat Rev Clin Onc 2015). In recent years there has been a shift in choice of induction therapy from the VCD to the RVD regimen in our region. We have evaluated how this shift has affected depth of response 3 months after ASCT in all patients receiving first line HDT with ASCT in our region from January 1st, 2015, and how frequently our patients needed to change induction regimen, based on choice of first line therapy. Methods: All patients receiving first line HDT with ASCT for multiple myeloma in our institution in the period from January 1st, 2015 to March 16th, 2018 were evaluated for the final analysis of response 3 months post-ASCT. The induction regimen was chosen at their local physician´s discretion. The patients received 3-5 cycles of induction therapy before leukapheresis, HDT (melphalan 200mg/m2) and ASCT. All patients received a follow-up consultation in our institution 3 months post-ASCT, where response was evaluated and recorded according to the IMWG 2016 response criteria. No patients had started maintenance therapy at the time of evaluation. Age, sex, date of ASCT, the presence of high-risk cytogenetics, ISS stage at diagnosis, choice of induction regimen and response 3 months post-ASCT was recorded by the primary investigator (Table 1). In case of change of regimen during induction treatment, the reason was recorded. Patients receiving either VCD or RVD as induction therapy, who did not change regimen during induction, were included in the final response analysis. Results: 212 patients received HDT with ASCT in the period. 209 patients were evaluated 3 months after ASCT as of June 21st, 2018. 57.5% (122 patients) received VCD as first-line induction therapy, while 25.9% (55 patients) received RVD. 11.5% (14 patients) in the VCD group changed induction therapy vs 3.6% (2 patients) in the RVD group. Reasons for changing regimen were: not achieving at least a partial response (PR) (n=10), unacceptable toxicity (n=4), lack of documented reason (n=2). In the RVD group, 1 patient died from sepsis 2 weeks post-ASCT, and 1 patient refused to attend the post-ASCT evaluation. Therefore, 108 patients in the VCD group and 51 patients in the RVD group were included in the final response analysis. 29 patients could not confirm a complete response (CR) due to lack of bone marrow and/or serum immunofixation at response evaluation. For that reason, patients achieving CR, unconfirmed CR and very good partial response (VGPR) were compounded to a ≥VGPR response grade. In the RVD group 94,1% (48 patients) achieved ≥VGPR vs 85,2% (92 patients) in the VCD group. Similar differences were also present for confirmed CR (25% vs 18%) and unconfirmed CR (44% vs 35%). In addition, 2% in the RVD group (1 patient) achieved PR, while 3.9% (2 patients) had disease progression (PD) 3 months after ASCT. In the VCD group, 13.0% (14 patients) achieved PR, while 1.8% (2 patients) had PD 3 months after ASCT (Table 2, Figure 1). Discussion: RVD induction therapy before HDT with ASCT yielded higher rates of at least VGPR compared to VCD induction (85,2% s 94,1%). The choice of RVD as first line induction therapy necessitated fewer changes of induction regimen due to insufficient response or unacceptable toxicities compared to VCD induction (3,6% vs 11,5%). The differences were not statistically significant, possibly because of too few patients. Still, our results support the trend in our region of choosing RVD as first-line induction for transplant-eligible patients. These results should be confirmed in larger patient materials, and in prospective studies. Updated data with approximately 35 additional patients, mainly receiving RVD induction, will be presented at the ASH annual meeting if our abstract is selected for presentation. Disclosures Moksnes: Shire: Consultancy. Schjesvold:Amgen: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria; Takeda: Consultancy, Honoraria; Bristol Myers Squibb: Consultancy; Bayer: Consultancy; Janssen: Consultancy, Honoraria, Research Funding; Oncopeptides: Consultancy; Abbvie: Honoraria; Adaptive: Consultancy; Novartis: Honoraria.

Racial Disparity in Drug Utilization Among Multiple Myeloma Patients: A SEER Medicare Analysis

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 3542-3542
Author(s):  
Sikander Ailawadhi ◽  
Ryan D Frank ◽  
Richa Menghani ◽  
Mayank Sharma ◽  
M'hamed Temkit ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Drug Use ◽  
Drug Utilization ◽  
Time Dependent ◽  
First Year ◽  
Cell Transplant ◽  
Medicare Claims ◽  
Significant Difference ◽  
Racial Ethnic ◽  
Novel Agent

Abstract Background: Patient (Pt) outcomes have improved significantly in multiple myeloma (MM) due to widespread use of novel therapeutic agents and stem cell transplant (SCT) butoutcome disparities among racial/ethnic groups exist. Differences in access to and utilization of novel therapeutics are likely contributing factors. We performed an analysis of the SEER-Medicare database to explore such differences. Methods: Pts with a confirmed MM diagnosis between 2007-2009 and continuous Medicare coverage from 1 year prior to diagnosis through end of 2012 were included. Medicare Part D data (oral medications) is not available prior to 2007 so utilization analysis of lenalidomide (LEN), thalidomide (THAL) and bortezomib (BORT) was performed from 2007-2009. Demographic/survival data (PEDSAF files) and drug/SCT utilization (NCH, OUTSAF, PDESAF files) were obtained (HCPCS/NCH codes). Categorical and continuous variables were compared using /Fisher tests and Wilcoxon tests, respectively. Gender, age, and year-adjusted p-values were calculated using logistic regression. A proportional odds model was used to detect time-dependent trends in drug usage within 12 months of MM diagnosis across year of diagnosis by race. Separate multivariate models were fit for each drug adjusting for gender, age, drug use and race. Associations between drug use and overall survival (OS) were examined using a time dependent proportional hazards model. Results: A total of 5358 MM pts were included (any Medicare claims) with 2733 (51%) males. Mutually exclusive race categories were White (W; 67%), African-American (AA; 18%), Hispanic (H; 10%) and Asian (A; 5%). Median follow up was 2.4 yrs. Baseline pt characteristics were significantly different for age with AA being the youngest at diagnosis (p<0.001) and for gender (p<0.001) with W having the largest (53.4%) and AA the smallest (45.2%) proportion of males. Medicare claims capture only pts without any supplemental insurance and so drug utilization in this database was much lower than expected for all subgroups. Year-wise comparison showed that LEN use within the first year of MM diagnosis increased from 2007 to 2009 (16.5% to 27.7%; p<0.001) and there was a significant decrease in median days to first dose (p=0.002). Over the same period, use of THAL decreased (26.6% to 14.6%; p<0.001) while use of BORT (7.8% to 15.4%; p<0.001), SCT (3.3% to 6.2%; p<0.001) and more than 1 novel agent (2.5% to 5.7%; p<0.001) increased significantly. Utilization patterns within first year of MM diagnosis were significantly different among racial subgroups for LEN, THAL, BORT, SCT and >1 novel agent use. (Figure 1) No significant difference was seen for days to first dose of LEN/THAL for any race but for BORT, H got first dose in median 117 days after diagnosis as compared to median 46-51 days for other races (p=0.025). During the first year after diagnosis, W and AA had higher BORT only usage while H and A had a higher LEN/THAL only usage (p<0.001). For drug use by year and race, a significant increase in LEN use was seen from 2007 to 2009 in W (p<0.001), AA (p=0.001) and A (p<0.001) but not H (p=0.26) while THAL use decreased significantly for all races. BORT use increased significantly for all except A (p=0.602) and SCT use increased significantly for all except AA (p=0.068). Inferior OS was significantly associated with older age (p<0.001) and males (p<0.001). LEN/THAL use within the first year of diagnosis did not affect OS while BORT use within the first year of diagnosis increased mortality risk (HR 1.18, p=0.021). SCT use improved OS (HR 0.52, p<0.001). Conclusions: In this comprehensive analysis of MM therapeutics utilization, we noted significant variability among different racial groups. The use of LEN, BORT and SCT has increased while THAL has decreased over time but disparities exist in utilization among different races, with lower use of LEN in AA, lower use of BORT in A and significantly delayed use of BORT in H, which are all notable since racial/ethnic minorities are fast growing in the US population mix and seem to have inequitable utilization and/or access. Inferior survival with early BORT use may represent selection bias of pts with more advanced/aggressive disease. These trends need to be examined in larger sample sizes especially from commercial payers to eliminate drug access and utilization disparities and achieve equitable benefit of therapeutic advances across all racial subgroups. Figure 1 Figure 1. Figure 2 Figure 2. Disclosures Ailawadhi: Pharmacyclics: Consultancy; Novartis: Consultancy; Amgen Inc: Consultancy; Takeda Oncology: Consultancy.

scholarly journals Novel Insight into Multi-Hit Multiple Myeloma Based on "Two-Hit" Theory of Cancer Causation

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 47-48
Author(s):  
Chenxing Du ◽  
Xue-Han Mao ◽  
Jiahui Liu ◽  
Huishou Fan ◽  
Weiwei Sui ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Induction Therapy ◽  
Conflicts Of Interest ◽  
Prognostic Significance ◽  
Staging System ◽  
Hazard Ratio ◽  
Drug Induction ◽  
Double Hit ◽  
Definition Of ◽  
Standard Risk

Background: Current definition of multi-hit multiple myeloma (MM) is based upon the number of high-risk cytogenetic abnormalities (CA). But we may overlook the influence of standard-risk CA and different concurrent patterns. In fact, standard-risk t(11;14) and del(13q) may bring extra danger when concurrent with other CA. And the concurrency of two secondary CA may do more harm to patients than that of one secondary CA with one primary CA. This study is to answer whether CA number or pattern exert an impact on outcomes of MM patients. Methods: This study was carried out based on the prospective, non-randomized clinical trial BDH 2008/02. 537 MM patients with complete cytogenetic data were enrolled, of whom 64% (341/537) patients were treated with bortezomib-based three-drug induction therapy, and the remaining patients with thalidomide-based therapy. Autologous stem cell transplantation (ASCT) was recommended post induction therapy in transplant-eligible patients, and all patients received maintenance therapy for two years. CA were divided into primary CA [pCA: any type of IgH breakage], and secondary CA [sCA: del(17p), del(13q), gain(1q) (≥3 copies)] Results: In the era of novel agents, patients with pCA only did not have outcomes different from those patients without any FISH abnormality. Patients with s1 CA or s1+p CA had hazard ratio for PFS or OS of 1.5-2.0. Patients with s2 CA or s2+p CA had hazard ratio for PFS or OS of 2.0-3.0. Patients with concurrent del(13q), del(17p) and gain(1q) (s3 CA) had hazard ratio for PFS of 3.11 and for OS of 3.00. Patients with s3+p CA had hazard ratio for PFS of 4.65 and for OS of 6.16. Based on these results, we divided patients into four subgroups: no CA or only pCA, s1 CA in the presence or absence of pCA, s2 CA in the presence or absence of pCA, and s3 CA in the presence or absence of pCA. Both the PFS and OS decreased in a stepwise fashion with the accumulation of CA (Figure 1). Therefore, we defined double-hit MM as any one sCA in the presence or absence of pCA. Triple-hit MM referred to two sCA plus pCA or not, and quadra-hit MM referred to three sCA plus pCA or not. Furthermore, we confirmed the prognostic independence of CA pattern in the multivariant analysis with International Staging System (ISS) and LDH (Table 1). Conclusion: In this study, we found that the primary CA as a whole lost its adverse effect when treated by bortezomib-based regimens. CA subtype conferred a prognostic value. In details, secondary CA imposed an accumulative risk to patients. For the first time, we indicated that double-hit or triple-hit MM should be defined upon the number of secondary CA. This definition coincides with the "Two-Hit" theory of cancer causation and fits well with MM evolution model. The prognostic significance of CA pattern needs validation in further prospective trials. Disclosures No relevant conflicts of interest to declare.

Three-drug versus two-drug induction therapy regimens for patients with transplant-eligible multiple myeloma

2013 ◽  
Author(s):  
Mohamed Kharfan-Dabaja ◽  
Taiga Nishihori ◽  
Tea Reljic ◽  
Mehdi Hamadani ◽  
Rachid Baz ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Induction Therapy ◽  
Drug Induction

scholarly journals Three-drug versus two-drug induction therapy regimens for patients with transplant-eligible multiple myeloma

2016 ◽  
Author(s):  
Mohamed Kharfan-Dabaja ◽  
Taiga Nishihori ◽  
Tea Reljic ◽  
Mehdi Hamadani ◽  
Rachid Baz ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Induction Therapy ◽  
Drug Induction

scholarly journals Racial disparities in treatment patterns and outcomes among patients with multiple myeloma: a SEER-Medicare analysis

2019 ◽  
Vol 3 (20) ◽  
pp. 2986-2994 ◽  
Author(s):  
Sikander Ailawadhi ◽  
Kejal Parikh ◽  
Safiya Abouzaid ◽  
Zhou Zhou ◽  
Wenxi Tang ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
African Americans ◽  
Racial Disparities ◽  
Autologous Stem Cell Transplant ◽  
Cell Transplant ◽  
Linear Regression Models ◽  
Novel Therapy ◽  
Therapy Initiation ◽  
Hispanic Patients ◽  
Racial Ethnic

Abstract The objective of the study was to assess racial disparities in the treatment and outcomes among white, African American, and Hispanic patients with multiple myeloma (MM). Patients with an MM diagnosis from the Surveillance Epidemiology and End Results (SEER)–Medicare (2007-2013) database were included. Continuous Medicare enrollment for 6 months before (baseline) and after MM diagnosis was required unless death occurred. Time from MM diagnosis to novel therapy initiation and autologous stem cell transplant (ASCT), overall survival (OS), and MM-specific survival (MSS) was evaluated. Unadjusted and multivariable regressions compared African Americans and Hispanics vs whites. Trends of novel therapy and ASCT use across MM diagnosis years were assessed using linear regression models. The study included 3504 whites, 858 African Americans, and 468 Hispanics. African Americans and Hispanics had a longer time from MM diagnosis to novel therapy initiation vs whites (median: 5.2 and 4.6 vs 2.7 months, respectively). All cohorts had an increasing trend of novel therapy initiation within 6 months of MM diagnosis, particularly whites (all P &lt; .05). Median MSS was significantly longer for African Americans (5.4 years) than whites (4.5 years; P &lt; .05), and was comparable for Hispanics and whites. Median OS was similar overall (2.6-2.8 years). ASCT rate within 1 year of MM diagnosis rose among whites and African Americans (P &lt; .05), but not Hispanics, who were less likely to receive ASCT vs whites. Significant variations in novel therapy and ASCT use were observed among different racial/ethnic groups with MM. Although OS was similar, both African Americans and Hispanics may not be fully benefitting from the introduction of novel therapies, as they receive them later than whites.

Treatment disparities in minority groups with multiple myeloma at a safety-net hospital

2020 ◽  
Vol 61 (10) ◽  
pp. 2507-2510
Author(s):  
Michael Dennis ◽  
Asaf Maoz ◽  
Diana Cirstea ◽  
Ami Patel ◽  
Adam Lerner ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Minority Groups ◽  
Safety Net ◽  
Safety Net Hospital ◽  
Treatment Disparities

Characteristics Of Multiple Myeloma Patients With 6-Year Or Longer Progression-Free Survival After a Single Autologous Transplant

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 3366-3366 ◽  
Author(s):  
Kehinde U.A. Adekola ◽  
Qaiser Bashir ◽  
Nina Shah ◽  
Sai Ravi Pingali ◽  
Simrit Parmar ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Board Of Directors ◽  
Induction Therapy ◽  
Progression Free Survival ◽  
High Dose ◽  
Cell Transplant ◽  
Advisory Committees ◽  
Free Survival ◽  
Autologous Transplant ◽  
Preparative Regimen

Background High dose chemotherapy followed by an autologous stem cell transplant (auto-HCT) is considered standard of care in patients with newly diagnosed multiple myeloma (MM). In a recent randomized trial, median progression free survival (PFS) after auto-HCT, with or without maintenance therapy was 46 and 27 months, respectively (McCarthy P et al. NEJM 2012). However, about 15% of patients are reported to have much longer PFS (Pineda-Roman M et al. Cancer 2008). Here we tried to identify the factors that may predict a long PFS after auto-HCT. Methods We performed a retrospective chart review of patients who received an auto-HCT for MM between January 2000 and March 2007. A total of 1135 patients underwent an auto-HCT during this period, and 194 patients (17%) had a minimum PFS of 72 months or longer after a single auto-HCT. The primary objective was to determine the variables associated with a long PFS and overall survival (OS). Results Patient characteristics and outcomes are shown in the attached Table. The median age at auto-HCT was 56 years, and the median time from diagnosis to auto-HCT was 7.5 months. Twenty-three (13%) patients had ≥ 10% plasma cells in the bone marrow at auto-HCT and only 9 patients (4.8%) had high-risk cytogenetic abnormalities. One-hundred and fifty (77%) patients received induction therapy containing either an immunomodulatory (IMiD) agent or a proteasome inhibitor (PI). At the time of the auto-HSCT, only 13 (6.7%) patients were in CR and 38 (19.6%) were CR or VGPR after induction therapy (Table). One-hundred and sixty three (84%) patients received mephalan alone as conditioning regimen. Eighty-one (42%) patients received post auto-HCT maintenance. Eighty (41%) patients achieved a CR, while 104 (54%) achieved CR + VGPR after auto-HCT. Six patients (3.1%) developed a second primary malignancy post- autologous transplant. After a median follow-up of 95.4 months, median PFS was 97.3 months and median OS has not been reached. The 10-year PFS and OS were 41% and 73% respectively. Use of melphalan alone as preparative regimen was associated with a longer PFS and OS (p=0.004 and 0.004, respectively). Achievement of CR after auto-HCT was associated with a longer PFS only (p=0.001), and the use of IMiD or a PI as induction was associated with a longer OS (p=0.01). Conclusion Approximately 17% patients achieved a median PFS of 6 years or longer after a single auto-HCT. The long PFS in this cohort may be associated with younger age, low incidence of HR cytogenetics, use of an IMiD or PI as induction therapy, relatively low disease burden at auto-HCT, transplant from the year 2000 onwards, achievement of CR in >40% and the use of melphalan alone as preparative regimen. Disclosures: Shah: Celgene: Membership on an entity’s Board of Directors or advisory committees, Research Funding. Qazilbash:Celgene: Membership on an entity’s Board of Directors or advisory committees.

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