scholarly journals Understanding Root Causes Contributing to Real-World Racial Disparities in Multiple Myeloma Care: Insights from a Mixed-Methods Study Utilizing Tethered Patient-Provider Surveys and Chart Reviews

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 9-10
Author(s):  
Joseph Mikhael ◽  
Anne Jacobson ◽  
Jeffrey D Carter ◽  
Tamar Sapir
Keyword(s):  
Multiple Myeloma ◽  
Racial Disparities ◽  
Small Group ◽  
Care Delivery ◽  
Cell Transplant ◽  
Novel Therapies ◽  
Optimal Care ◽  
Black Patients ◽  
Provider Surveys

Background Multiple myeloma (MM) is the most common hematologic malignancy among Black patients, who experience a 2-fold increase in MM risk and earlier age of onset compared with non-Black patients. Relative to other groups, Black patients are less likely to undergo autologous stem cell transplant (ASCT), receive timely access to novel therapies (e.g., immunomodulatory drugs, proteasome inhibitors), and enroll in clinical trials (Ailawadhi Blood Adv 2019). However, when Black patients with MM do undergo ASCT or receive novel therapies, their clinical outcomes match those observed in other patient groups, with some data suggesting a possible survival advantage (Fillmore Blood 2019). Therefore, in the absence of a clear biologic rationale for different treatment patterns, it is necessary to examine structural and other barriers to optimal care. In this ongoing quality improvement (QI) initiative, we are assessing and attempting to address the root causes of disparities in care delivery among patients with relapsed/refractory (R/R) MM in 2 large oncology systems. Methods Building on the design of our prior QI programs (Hussein ASCO 2020), this multicomponent initiative includes patient and provider surveys (n = 70), baseline and follow-up audits of electronic medical records (EMRs) (n = 400), and small-group, team-based audit-feedback (AF) sessions. Patient-Provider Surveys: 30 hematology/oncology healthcare providers (HCPs) and 40 patients with relapsed/refractory MM (20 African American [AA] and 20 non-AA patients, including Hispanic and non-Hispanic White patients) will complete 30-item and 35-item surveys, respectively. In addition to assessing MM treatment experiences, survey questions will evaluate health literacy, medication adherence, cancer beliefs, patient-HCP communication, and awareness of health disparities. With multiple shared questions, the surveys are designed to reveal alignments and discordances in attitudes, beliefs, perceptions, and practices regarding MM care (a) between patients and HCPs and (b) between AA and non-AA patient subgroups. In addition, HCPs' self-reported practice behaviors will be compared against documented practice patterns in the EMR audit. EMR Audits: Variables for the baseline EMR audit include patient/disease characteristics, treatment history, clinical practice metrics, and patient-centered measures (e.g., shared decision-making) documented for 100 AA and 100 non-AA adults with R/R MM and ≥2 clinic visits within the past year. Six months after the AF sessions, the follow-up EMR audit of 100 AA and 100 non-AA patients will assess changes in EMR documentation and practice behavior. Team-Based AF Sessions: HCP cohorts within each oncology system will participate in 1-hour live small-group AF sessions scheduled as part of each system's grand rounds series. Hematology/oncology teams will (a) assess system-specific practice gaps identified via the patient-provider surveys and baseline EMR audit, (b) prioritize areas for improvement, and (c) develop action plans for addressing root causes. Additional surveys completed before and after the AF sessions will measure changes in participants' beliefs and confidence in care delivery. Results Two large oncology systems in Chicago and Washington, DC, are enrolled. Preliminary HCP (n = 6) and patient (n = 9) survey data suggest discordant beliefs about patients' primary MM treatment concerns. HCPs overestimated how many patients are concerned about notfeeling confident that their treatment plan is the best for their cancer (83% vs 11%) and underestimated how many are concerned about lack of reliable transportation (0% vs 33%), difficulty communicating with their care team (0% vs 33%), meeting responsibilities at work and home (0% vs 11%), and treatment cost (0% vs 11%). Full findings from the baseline EMR audit (n = 200) and patient and HCP surveys (n = 70), as well as outcomes from the 2 small-group AF sessions (scheduled for September 2020), will be presented. Conclusions Factors contributing to racial disparities in MM care are complex. QI programs are critical tools for understanding and addressing system-specific barriers to optimal care for all patients with MM. Study Sponsor Statement The study reported in this abstract was funded by independent educational grants from AbbVie, Inc. and Celgene Corporation, who had no role in the study design, execution, analysis, or reporting. Disclosures Mikhael: Amgen, Celgene, GSK, Janssen, Karyopharm, Sanofi, Takeda: Honoraria.

scholarly journals Overcoming the Effect of Racial Disparities in Multiple Myeloma (MM) with Autologous Stem Cell Transplant (ASCT)

2020 ◽  
Vol 26 (3) ◽  
pp. S235-S236
Author(s):  
Naresh Bumma ◽  
Qiuhong Zhao ◽  
Abdullah Khan ◽  
Maria Chaudhry ◽  
Nidhi Sharma ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Stem Cell ◽  
Racial Disparities ◽  
Stem Cell Transplant ◽  
Autologous Stem Cell Transplant ◽  
Cell Transplant

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 < .05). Median MSS was significantly longer for African Americans (5.4 years) than whites (4.5 years; P < .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 < .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 Patterns among Patients with Recently-Diagnosed Multiple Myeloma in a National Registry

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 2374-2374
Author(s):  
Carla M. Van Bennekom ◽  
Noopur Raje ◽  
Kenneth C. Anderson ◽  
Theresa E. Anderson ◽  
Davi d W. Kaufman
Keyword(s):  
Multiple Myeloma ◽  
Prescription Drugs ◽  
National Registry ◽  
Treatment Patterns ◽  
Novel Agents ◽  
Cell Transplant ◽  
Novel Therapies ◽  
Adjunct Therapy ◽  
Baseline Questionnaire ◽  
Wide Range

Abstract Background: Patterns of treatment among patients with recently-diagnosed multiple myeloma have not been described on a population basis. This is of particular interest with the introduction of novel anti-myeloma therapies in the last several years. Methods: The “Patient Registries at Slone: Myeloma” is a national disease-based observational registry conducted by Boston University. All patients with myeloma diagnosed within 4 months of enrollment are eligible for inclusion. Subjects enroll by mail or over the internet; information on treatment, clinical events, and quality of life is obtained by questionnaire and from medical record review at baseline and at six-month intervals. We report on 314 patients with multiple myeloma residing in 43 states who were enrolled from June 2006-June 2008 and completed a baseline questionnaire (sent to them after enrollment) within six months of diagnosis (median, 68 days; range, 4–171 days). Eleven patients with smoldering myeloma or MGUS were not included. Results: A total of 231 patients (74%) had received novel therapies or other anti-myeloma agents since diagnosis. The most commonly used of the newer drugs was thalidomide alone or in combination with other agents (e.g., dexamethasone), received by 72 patients (23%), followed by lenalidomide alone or in combination, 58 (18%), bortezomib alone or in combination, 40 (13%), and a separate group who received bortezomib and either thalidomide or lenalidomide (some in combination with other agents), 24 (8%). Among patients not on novel therapies, dexamethasone alone or in combination with other medications was used by 29 (9%), while 6 (2%) received other anti-myeloma agents. There were 35 different therapeutic combinations reported at the time of completion of the baseline questionnaire. Four patients had received a stem cell transplant. The main types of adjunct therapy included bisphosphonates, 104 patients (33%); erythropoeitin stimulating agents (ESAs), 47 (15%); and myeloid growth factors, 13 (4%). Treatment patterns were examined according to sociodemographic factors. Patients receiving bortezomib were significantly younger than those who received other agents or were untreated, with a median age of 55 years vs. 62 for untreated (p=0.016), 61 for lenalidomide (p=0.009) and thalidomide (p=0.04), and 60 for dexamethasone without novel agents (p=0.04). The large majority of patients had insurance that covered prescription drugs, but those who did not received the various treatments at similar or even higher rates. African American patients had a significantly higher prevalence of thalidomide use alone or in combination (48%) than did patients in other racial/ethnic groups (21%)(p=0.02). Patients who received adjunct therapy were more likely to also be treated with novel agents or other anti-myeloma drugs: 91% among ESA-treated patients vs. 70% among other patients (p=0.002); 91% among bisphosphonates vs. 65% among others (p<0.0001). Conclusions: These results from a national registry show that the initial choice of treatments in multiple myeloma covers a wide range of therapeutic combinations. Most patients receive one or more of the newer therapies within six months of diagnosis. It is noteworthy that although fully three-fourths of patients are treated with novel or other anti-myeloma agents, only one-third report the use of bisphosphonates.

Immunologic Recovery after Autologous Transplant in Multiple Myeloma and Progression Free Survival

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 4444-4444
Author(s):  
Fernanda Maria Rodrigues Trigo-Miranda ◽  
Rui Cordeiro Bergantim ◽  
Ricardo Moreira Pinto ◽  
Patricia Guimarães ◽  
Jose E. Guimaraes
Keyword(s):  
Multiple Myeloma ◽  
Progression Free Survival ◽  
Response To Treatment ◽  
Cell Transplant ◽  
Haematopoietic Progenitor Cell ◽  
Free Survival ◽  
Post Transplant ◽  
Historical Comparison ◽  
Significant Difference

Abstract Several factors influencing disease progression and survival have been identified in multiple myeloma (MM). We analysed a series of 49 consecutive patients with MM that underwent autologous haematopoietic progenitor cell transplant (HPCT) in one center regarding the following variables: use of G-CSF for haematopoietic recovery post-transplant; recovery of normal IgM levels at day +100 post-transplant; levels of lymphocytes namely of the CD4+ and CD8+ subsets also at day +100. Before 2006, all patients had G-CSF starting 24 hours after the cell infusion until neutrophil > 500×10^9/L in two consecutive days; in the years 2006–2008, no G-CSF was given to transplanted patients. A historical comparison was done and at the time of this study no significant difference in progression free survival (Kaplan-Meyer analysis), was detected between the two groups, possibly due to the shorter follow-up of the “no G-CSF” (n=19) group; nevertheless median progression free survival (PFS) in the “G-CSF” group was 12 months while median PFS was not attained in the “no G-CSF” group (median follow-up = 7 months). Post transplant IgM levels were also determined in 39 patients. Eighteen patients recovered normal IgM levels at day +100 (46.8 %) and 21 (53.8 %) did not. Comparison of Kaplan-Meyer curves for the two groups did not show any statistically significant difference but there is a sharp difference between median PFS of the “low IgM” (10 months) and the “normal IgM” (27 months) groups. CD4/CD8 ratio was determined in 18 patients at day +100. The ratio varied between 0 and 0.63 (median – 0.305). No correlation was found between post-transplant IgM recovery and CD4/CD8 ratio. In conclusion, in our series of MM patients treated with autologous HPCT we could not find a definite relationship between immunologic recovery and response to treatment although there is a trend to a better outlook of the patients which recover normal IgM levels. It is also uncertain whether use of G-CSF in the post-transplant period would have any effect on disease behaviour.

Tandem Autologous Stem Cell Transplantation in Chemorefractory Multiple Myeloma

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 4554-4554
Author(s):  
Catherine Garnett ◽  
Chrissy Giles ◽  
Osman Ahmed ◽  
Maialen Lasa ◽  
Holger W. Auner ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Overall Survival ◽  
Stem Cell ◽  
Stem Cell Transplantation ◽  
Stem Cell Transplant ◽  
Progression Free Survival ◽  
Autologous Stem Cell Transplant ◽  
Cell Transplant ◽  
Free Survival

Abstract Abstract 4554 High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is currently standard treatment for younger patients with multiple myeloma, resulting in improved survival and response rate compared to conventional chemotherapy. Disease relapse, however, remains almost inevitable and thus the role of two successive (tandem) autologous stem cell transplants has been evaluated in chemorefractory patients as a means of prolonging duration of disease response. We retrospectively analysed the results of nine patients with chemorefractory disease treated at a single UK institution who received tandem ASCT between January 1998 and February 2009. There were six men and three women. Median age at diagnosis was 56 years (range, 42–65 years). Paraprotein isotype was IgG in eight patients and IgA in one patient. Median serum paraprotein level was 41g/L (range 12–73g/L) at presentation. At time of 1st transplant six patients were in stable disease (SD) and three had evidence of progressive disease. Conditioning melphalan dose was 140mg/m2 in all but two patients who received 110mg/m2 and 200mg/m2. Median time between transplants was 3.7 months (range 2.3–6.4 months) with PR and SD being observed in 2/9 and 7/9 patients at time of 2nd transplant. None of the patients reached complete response (CR). One patient received melphalan 140mg/m2 prior to 2nd transplant. The remaining patients received melphalan 200mg/m2. Median follow up after tandem transplant was 54.3 months (range 15.6 –143.6 months). No treatment related mortality was reported. At the time of analysis, six patients were still alive and under follow up with an overall survival (OS) figure for the group of 52% at 10 years from diagnosis (Figure 1). Median progression free survival (PFS) was 20 months from 2nd transplant (range 6.7–62.6 months) (Figure 2). Tandem autologous stem cell transplant in chemorefractory patients has resulted in overall survival similar to autologous stem cell transplant in chemosensitive patients and should be considered in patients with chemorefractory disease. Figure 1: Overall survival from diagnosis in patients receiving tandem autologous stem cell transplant for multiple myeloma Figure 1:. Overall survival from diagnosis in patients receiving tandem autologous stem cell transplant for multiple myeloma Figure 2: Progression free survival following tandem transplant Figure 2:. Progression free survival following tandem transplant Disclosures: No relevant conflicts of interest to declare.

Allogeneic Hematopoietic Stem Cell Transplant in Advanced Multiple Myeloma: Experience from a Single Center

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 5536-5536
Author(s):  
Yizel Elena Paz Nuñez ◽  
Beatriz Aguado Bueno ◽  
Isabel vicuña Andrés ◽  
Ángela Figuera Álvarez ◽  
Miriam González-Pardo ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Stem Cell ◽  
Board Of Directors ◽  
Hematopoietic Stem Cell ◽  
Hematopoietic Stem Cell Transplant ◽  
Stem Cell Transplant ◽  
Cell Transplant ◽  
Advisory Committees ◽  
Hematopoietic Stem

Abstract Introduction The prognosis of patients with multiple myeloma (MM) has improved in the last years due to the important advances in the knowledge of the biology of the disease, the implementation of new drugs and the incorporation of autologous hematopoietic stem cell transplant (autoHSCT). The allogenic hematopoietic stem cell transplant (alloHSCT) continues to be controversial: it offers a curative potential but with the cost of high toxicity, limiting the procedure to those young patients with a high-risk disease. This procedure shall be performed in expert centers and, whenever possible, in the context of a clinical trial. In the following we describe the experience of our center with alloHSCT in advance multiple myeloma patients. Patients and methods A total of 18 patients were diagnosed with multiple myeloma received an alloHSCT during a 13 year period (1996-2013), with a median age of 46 ± 5.9 years. All of our patients received an allogenic HLA matched sibling donor with reduced-intensity conditioning. The majority of patients were transplanted because of advanced disease, relapse after an autologous transplant or as part of a sequential transplant in patient with a high risk disease. One patient received, in two occasions, an alloHSCT. Around 70% of patients had received more than 3 previous lines of treatment including, in nearly 95%, an autoHSCT. Patient's characteristics can be found on table 1, characteristics of the procedure can be found in table 2.Table 1.Patient«s CharacteristicsN (%)GenderMale Female10 (55,5%) 9 (44,4%)Secreted ProteinIgGκ IgG λ IgA κ BJ Plasmocitoma8 (44,4%) 4 (22,2%) 2 (11,1%) 3 (16,7%) 1 (5,6%)Debut DS stageII-A II-B III-A III-B Plasmocitoma5 (27,8%) 1 (5,6%) 8 (44,4%) 3 (16,7%) 1 (5,6%)Cytogentics at diagnosisMissing Unfavorable Favorable10 (55,5%) 6 (33,3%) 2 (11,1%)Previous lines of treatment²2 3-4 ³56 (33,3%) 10 (55,5%) 2 (11,1%)Previous autoHSCTYes No17 (94,5%) 1 (5,6%)Previous radiotherapyYes No8 (44,4%) 10 (55,6%)Disease status at transplantComplete remission Partial remission Relapse9 (50,0%) 3 (16,7%) 6 (33,3%)Table 2.Treatment characteristicsN (%)Conditioning regimenMyeloablative Reduced-intensity6 (33,3%) 12 (66.7%)Stem cell sourceBone marrow Peripheral blood4 (22.2%) 14 (77.8%)GVHD prophylaxisCsA+MTXCsA+CSCsA+MMF10 (55.6%) 3 (16.7%) 5 (27.8%)InfectionsYes No16 (88.9%) 2 (11.1%)MucositisYes No12 (66.7%) 6 (33.3%)Acute GVHDYes II-IV III-IV No4 (22.3%) 3 (16.7%) 1 (5.6%) 14 (77.8%)Chronic GVHDNo Limited Extensive8 (44.3%) 5 (27.8%) 5 (27.8%) Results: Transplant related mortality (TRM) before day 100th was one case due to a thromboembolic event. Global TRM was 16.6% (3 cases). The incidence of acute graft versus host disease (aGVHD) was 22%, controlled on most cases when corticosteroids were initiated. More than half of the patients developed chronic graft versus host disease (cGVHD), with an equal distribution on either presentation as limited or extensive. (Table 2) The total number of patients eligible for analysis was 17 (one patient was lost on follow-up). With a median follow up of 11 years, the overall survival (OS) was of 8.06 years [IC 95% 4,33-11,78] (figure 1.) and the estimated progression free survival (PFS) was of 25.83 months [IC 95% 8.87-42.79](figure 2). A total of 5 (29,4%) patients are still alive and 2 (11,7%) of them are in complete remission, of these 1 patient did not have a previous autoHSCT with a follow up of almost 15 years. Conclusions: Our results are similar to those reflected on the literature1-2. However we have to point out that our population is homogenous with advanced MM with more than 3 previous lines of treatment including in most cases auto-HSCT. In spite of this, morbility and mortality in our cohort was acceptable with the limitation of a high rate of cGVHD. There is a need of more studies including more patients to evaluate the role of alloHSCT in the era of new drugs for MM. References 1. Rosi-ol L et al. Allogeneic hematopoietic SCT in multiple myeloma: long-term results from a single institution. Bone Marrow Transplant. 2015. 2. Beaussant Y et al. Hematopoietic Stem Cell Transplantation in Multiple Myeloma: A Retrospective Study of the Société Française de Greffe de Moelle et de Thérapie Cellulaire (SFGM-TC). Biol Blood Marrow Transplant. 2015 Disclosures Alegre: Celgene Corporation: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees.

Evaluating results from the multiple myeloma subset of patients treated with denosumab or zoledronic acid (ZA) in a randomized phase III study.

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. 8589-8589 ◽  
Author(s):  
Noopur S. Raje ◽  
Wolfgang Willenbacher ◽  
Vania Hungria ◽  
Andrew Spencer ◽  
Yulia Alexeeva ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Multiple Myeloma ◽  
Stem Cell ◽  
Solid Tumors ◽  
Primary Endpoint ◽  
Stem Cell Transplant ◽  
Phase Iii ◽  
Cell Transplant ◽  
Phase 3

8589 Background: Denosumab (dmab) is a fully human monoclonal antibody against RANKL and is superior to ZA in preventing skeletal-related events (SREs) as shown in 3 identically designed phase 3 trials (N=5723). Overall survival (OS) was balanced between treatment groups in the overall study populations of these trials. In the trial of patients (pts) with solid tumors (excluding breast and prostate) and multiple myeloma (MM), OS was longer for dmab pts with lung cancer, shorter for pts with MM, and balanced for pts with other solid tumors. This analysis further characterizes the results from the MM subset of this trial. Methods: Pts with solid tumors or MM were randomized (1:1) to receive 120 mg of SC dmab or 4 mg of IV ZA Q4W. Daily calcium and vit D supplements were strongly recommended. The primary endpoint was the time to first on-study SRE; results from the primary endpoint and lung cancer subset were previously reported. Results: Of 1776 randomized pts, 10% had MM (93 ZA, 87 dmab). OS favored ZA (hazard ratio: 2.26; 10 subject difference in deaths). 1-year OS was 83% dmab, 97% ZA. Imbalances in baseline prognostic characteristics were observed. More pts in the dmab arm had low baseline renal function (CrCl < 40 mL/min) (ZA 2 [2%], dmab 9 [10%]) and more ZA pts underwent stem cell transplant (ZA 23 [25%], dmab 15 [17%]). Additionally, more ZA pts had stage I tumors at diagnosis (ZA 13 [14%], dmab 9 [10%]) and better performance status (ECOG = 0; ZA 30 [32%], dmab 21 [24%]). Study discontinuations due to consent withdrawal or lost to follow-up were also higher in the ZA group (ZA 17 [18%], dmab 11 [13%]) and occurred earlier in the ZA arm (ZA 59%, dmab 45% within 9 months of randomization). Conclusions: In this SRE study of dmab vs ZA, pts were stratified by baseline characteristics known to affect SRE outcomes, but not by prognostic factors or concurrent anticancer therapy that may impact survival in MM. OS results in the MM cohort are difficult to interpret due to small sample size and imbalances in baseline disease characteristics, stem cell transplant therapy, and consent withdrawal or loss of follow-up that favored ZA. A phase 3 trial is currently underway, which controls for these factors in pts with MM. Clinical trial information: NCT00330759.

Prognostic significance of t(11;14) expression by FISH in patients with newly diagnosed multiple myeloma in the era of novel therapies.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e19525-e19525
Author(s):  
Miguel Gonzalez Velez ◽  
Ricardo Daniel Parrondo ◽  
Tracy Andrews ◽  
Narjust Duma ◽  
Joshua Ryan Richter ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Cox Regression ◽  
Prognostic Significance ◽  
Progression Free Survival ◽  
Autologous Stem Cell Transplant ◽  
Cell Transplant ◽  
Novel Therapies ◽  
Newly Diagnosed ◽  
Seer Data ◽  
Worse Prognosis

e19525 Background: Rearrangements of the immunoglobulin heavy chain (IGH) on chromosome 14 are identified by FISH in about 15-20% of patients (pts) with newly diagnosed multiple myeloma (MM). Historically there is variation on the significance on prognosis of these rearrangements: typically, t(4;14), t(14;16) and t(14;20) have high risk (HR), and t(11;14) have standard risk (SR). A recent study (Kaufman et al, Leukemia. 2016 30:633-9) suggests that t(11;14) may confer a worse prognosis We report the prognostic significance of t(11;14) in a single-institution MM cohort. Methods: 87 pts with t(11;14) by CD 138 selected FISH at diagnosis were identified, pts without symptomatic MM were excluded. Cox regression was used for statistical analysis. Progression free survival (PFS), and overall survivals (OS) from diagnosis and post autologous stem cell transplant (ASCT) were analyzed by Kaplan-Meier. Results: Median age at diagnosis was 62 years, 45 pts (52%) were male, and 24 pts (27%) had ISS 3. All pts received either a proteasome inhibitor or an immunomodulatory agent, and 42 (48%) received triplet treatment as induction. Sixty-nine (79%) pts had ASCT, and overall response rate (ORR, partial response or better) post ASCT was 73%. For pts with HR FISH (defined as t(14;16), p53 del, 1q21 gain or 1p del) compared to SR FISH, the ORR post ASCT was 70% vs 77% (p = 0.67). OS from diagnosis was 93% at 3 years, 74% at 4 years and 51% at 5 years. Seven patients (8%) developed plasma cell leukemia, and there was no association between HR and SR FISH (p = 0.66). In multivariate analysis, ISS stage was an independent risk factor for mortality; pts with stage 3 had 7.3 times (CI: 1.16-36.4) and 5.7 times (CI: 1.63-20.0) the risk of mortality than pts with stage 1 and 2. Having an ASCT reduced mortality by 87% (CI: 0.04-0.41). Conclusions: Despite the use of novel therapies the OS at 5 years of our pts with MM was not significantly improved compared to SEER data from 1992-2013 (51% vs 48.5%). Pts with t(11;14) who had ASCT had increased survival compared to those who did not. Our results suggest that t(11;14) may confer a worse prognosis. Further prospective studies evaluating the risk of t(11;14) are warranted.

Treatment patterns in patients with multiple myeloma (MM): A retrospective study using Medicare data.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e19506-e19506 ◽  
Author(s):  
Peggy L. Lin ◽  
Dominick Latremouille-Viau ◽  
Medha Sasane ◽  
Patrick Gagnon-Sanschagrin ◽  
Hozefa A. Divan ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Overall Survival ◽  
Stem Cell Transplant ◽  
Response Duration ◽  
Treatment Patterns ◽  
Cell Transplant ◽  
Medicare Data ◽  
Survival Table ◽  
Practice Methods

e19506 Background: MM is characterized by repeated relapses and refractoriness and is managed by successive lines of therapies (LT) each typically resulting in shorter response duration over prior LT. This study describes current MM treatment (tx) landscape in US clinical practice. Methods: Adult MM patients (pts) with continuous Medicare Part A, B, and D coverage initiated on 1st LT (1L), without stem cell transplant, were identified in the Medicare Research Identifiable Files (2012-2016). Claims for any MM tx within 60 days of the 1st tx constituted the tx regimen of an LT. End of LT was defined as a claim for a new MM tx > 60 days post LT initiation (tx augmentation or switch), discontinuation of all tx in a regimen for > 90 consecutive days, end of Medicare coverage/data or death. From 1L to 3L, overall survival (OS), LT duration (DoT), tx regimens and sequences were assessed. Results: 8374 MM pts with 1L (median [med] age = 76 years at 1L; 55% female) were analyzed. Over a med follow-up of 20 months (mos) from 1L (med 1L DoT = 5.6 mos), 2849 pts received a 2L (med 2L DoT = 5.6 mos) and 978 received a 3L (med 3L DoT = 4.7 mos). The most prominent tx regimens were bortezomib/corticosteroids (CS; VD) in 1L, and lenalidomide/CS (RD) in 2L and 3L. The most prevalent tx sequence was 1L VD, 2L RD and 3L VD. The 1- and 2-year OS rates were 81% [95% confidence interval: 81-82] and 68% [67-69] from 1L initiation, 80% [78-82] and 64% [61-66] from 2L, and 73% [69-76] and 55% [51-60] from 3L initiation, respectively. Conclusions: MM Medicare pts mainly cycle through bortezomib- or lenalidomide-based regimens in front LT; newer agents gain more usage in later LT. A better understanding of tx options and sequencing is warranted to prolong survival. [Table: see text]

scholarly journals Progressive Multifocal Leukoencephalopathy in Multiple Myeloma: A Single Institution Case Series

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4736-4736
Author(s):  
Alfredo De La Torre ◽  
Andrew Gao ◽  
Timo Krings ◽  
Donna E. Reece
Keyword(s):  
Multiple Myeloma ◽  
Stem Cell ◽  
Progressive Multifocal Leukoencephalopathy ◽  
Research Funding ◽  
Jc Virus ◽  
Brain Mri ◽  
Brain Biopsy ◽  
High Dose ◽  
Cell Transplant

Abstract Introduction Progressive multifocal leukoencephalopathy (PML), caused by the John Cunningham (JC) virus, is an infection that requires immunosuppression for its manifestations and is fatal disease in many cases. (1) After asymptomatic primary infection, which occurs in childhood, the virus remains quiescent. (1,4) The classical clinical presentation is that of a subacute symptomatology that develops over weeks or months and consists of diverse sensorimotor abnormalities depending on the site of brain involvement. Approximately 22 cases of PML amongst patients with multiple myeloma (MM) have been reported in the literature between 1965 and April 2020. (5) Methods We performed a retrospective chart review of all myeloma patients who were treated at the Princess Margaret Cancer Center from 2010-2020 to identify cases of PML. Patient and disease characteristics, responses, and survival outcomes were collected from Myeloma and Stem Cell Transplant databases and electronic patient records under REB approval. Results We identified 3 cases of PML in MM patients at our center over the past 10 years, all of which occurred in patients receiving therapy containing an immunomodulatory derivative (IMID), i.e., thalidomide, lenalidomide or pomalidomide. Patient 1 A 52-year-old male with kappa light chain MM presented in 2009 on hemodialysis and received upfront bortezomib and dexamethasone followed by melphalan 200mg/m 2 and autologous stem cell transplantation (ASCT) in March 2010; maintenance with thalidomide was given until July 2011 when he presented to the ER with left-sided weakness, facial droop, and decreased strength. CT scan showed right-sided hypodensity in keeping with demyelination. PML was confirmed by MRI, lumbar puncture with positive PCR for JC virus, and a brain biopsy (Fig 1 A-C). He was treated with mirtazapine, and also developed status epilepticus controlled with phenytoin and phenobarbital. His myeloma treatment was never resumed after the diagnosis of PML due to concerns about viral reactivation. Approximately 3 years after PML diagnosis, his serum free kappa protein levels started to increase; he remained on hemodialysis but experienced no new myeloma-related organ damage and no myeloma treatment was offered. His last follow-up in clinic was in March 2019. However, he succumbed to S. pneumonia septicemia in July 2019. Case 2 A 68-year-old female with IgG kappa MM diagnosed in 2004 was treated with high-dose dexamethasone induction followed by melphalan 200mg/m 2 and ASCT and relapsed 2 years later. She commenced cyclophosphamide and prednisone until July 2011 when treatment was changed to lenalidomide and prednisone; subsequent progression in February 2014 was treated with pomalidomide/bortezomib/prednisone. In November 2014, we noticed worsening vision. Brain MRI showed hyperintensity in T2 in the occipital lobe. Her myeloma treatment was stopped and she received corticosteroids with no improvement. LP in January 2015 was positive for JC virus and the diagnosis of PML was made. She was managed with supportive measures. Her last clinic follow-up was in 2015 and the patient died from progression in September 2015. Case 3 A 52-year-old male with IgA lambda MM diagnosed in 2015 was treated with CYBOR-D induction followed by melphalan 200mg/m 2 and ASCT. He initially received lenalidomide maintenance which was changed to bortezomib due to toxicity. On progression in January of 2019 he was placed on a clinical trial of the anti-BCMA antibody drug conjugate belantamab mafodotin in combination with pomalidomide and dexamethasone on which he achieved a VGPR. In October 2020, he developed confusion and memory problems, as well as involuntary twitching. A brain MRI showed possible demyelination Two LPs were negative for JC virus, but a targeted brain biopsy confirmed the diagnosis of PML (Fig 1 D-F). His myeloma treatment was discontinued, and he was started on mirtazapine. At his most recent clinic visit in May 2021 his speech, memory and functional status had improved considerably and there were no signs of myeloma progression. Conclusion Our current series of PML in MM showcases the potential contribution of IMIDs and other novel agents--such as the newer monoclonal antibodies like belantamab mafotidin-- to the reactivation of JC virus and subsequent PML. Our series also demonstrates that neurologic improvement and longer survival can be observed with earlier management. Figure 1 Figure 1. Disclosures Reece: BMS: Honoraria, Research Funding; Amgen: Consultancy, Honoraria; Millennium: Research Funding; GSK: Honoraria; Janssen: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Sanofi: Honoraria; Karyopharm: Consultancy, Research Funding; Takeda: Consultancy, Honoraria, Research Funding.

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