Lenalidomide-Based Treatment for Newly Diagnosed Multiple Myeloma Patients, Ineligible for Transplant: A Healthcare Cost-Impact Analysis in Europe

Abstract Background: Multiple myeloma remains an incurable and relapsing haematological cancer. The FIRST study showed that lenalidomide, an immunomodulatory agent, plus dexamethasone improved overall survival of newly diagnosed multiple myeloma (ndMM) patients who are not eligible for transplants by 10.4 months when it was used continuously compared with fixed treatment duration (72 weeks) with melphalan, prednisone and thalidomide(Facon et al, EHA 2015). Compared with alternative intravenous agents, lenalidomide as an oral therapy has also been associated with fewer hospital visits(Gualtney et al, J Clin Pharm Ther, 2013; Armoiry et al, J Clin Pharm Ther, 2011; Arikian et al, Curr Med Res Opin, 2015). In an era of increasing cost conscious health systems, additional economic information is playing an important role in access decisions on innovative medicines. This analysis examines the cost impact of lenalidomide when used in the first-line setting for patients with ndMM in the EU5. Methods: A healthcare cost impact model was developed to estimate total costs associated with the treatment of ndMM over 5 years in the EU5 (France, Germany, Italy, Spain and the UK). The model included drug costs and hospitalisation costs of first-line treatment and up to four additional lines of post-progression treatment for lenalidomide-, thalidomide-, bortezomib as well as costs of pomalidomide-based regimens in later lines. The expected rate of lenalidomide uptake in the first-line setting was based on its observed uptake in the US over the last 5 years. Care pathway costs were calculated for the EU5 according to treatment duration and time to progression. Hospitalisation costs from a retrospective medical chart review in Dutch patients with relapse/refractory MM (Gualtney et al, J Clin Pharm Ther, 2013) were adapted to the first-line setting by adjusting for the duration of treatment and the time to progression for each regimen in each line. Results: Baseline yearly costs per patient were €48,032 ($53,066). In year 1, first-line lenalidomide use resulted in a cost increase by 1.9% (€923 [$1,020] per MM patient, on average). In year 5, annual costs were expected to increase by 7.7% (€3,732 [$4,123] per MM patient). The monthly drug cost per patient was greater in lenalidomide treated patients compared with those receiving bortezomib or thalidomide (€6,548 [$7,234] vs. €5,151 [$5,691] and €1,742 [$1,925], respectively). However, lenalidomide use was associated with the lowest monthly hospitalisation cost per patient (€641 [$708]) compared with bortezomib and thalidomide (€925 [$1,022] and €1,209 [$1,336] respectively). Conclusion: Lenalidomide as a treatment option for newly diagnosed patients is a significant development in the management of MM. Use of lenalidomide in this setting is expected to result in an overall MM care pathway cost impact of under 10% over 5 years. Whilst the drug acquisition cost of lenalidomide is relatively higher than currently used options for ndMM, this is partially offset by savings from displaced use of bortezomib and lenalidomide in the first and second lines, respectively. Additionally there are potential savings from lower resource use. Further studies should be undertaken to evaluate full real life healthcare costs. Disclosures Schey: Celgene Corporation: Honoraria. Montero:Celgene Corporation: Honoraria. Stengel-Tosetti:Celgene Corporation: Consultancy. Gibson:Celgene Corporation: Employment, Equity Ownership. Dhanasiri:Celgene Corporation: Employment, Equity Ownership.

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A Phase III Study to Determine the Efficacy and Safety of Lenalidomide in Combination with Melphalan and Prednisone (MPR) in Elderly Patients with Newly Diagnosed Multiple Myeloma.

Blood ◽

10.1182/blood.v114.22.613.613 ◽

2009 ◽

Vol 114 (22) ◽

pp. 613-613 ◽

Cited By ~ 17

Author(s):

Antonio Palumbo ◽

Meletios A. Dimopoulos ◽

Michel Delforge ◽

Martin Kropff ◽

Robin Foa ◽

...

Keyword(s):

Multiple Myeloma ◽

Maintenance Therapy ◽

Board Of Directors ◽

Primary Endpoint ◽

Interim Analysis ◽

Newly Diagnosed ◽

Efficacy And Safety ◽

Time To Progression ◽

First Line ◽

Advisory Committees

Abstract Abstract 613 Background: Lenalidomide (Revlimid®) is an oral immunomodulatory agent with clinical efficacy in patients with multiple myeloma (MM). In patients with relapsed/refractory MM, lenalidomide plus dexamethasone improved time to progression (TTP) and overall survival (OS) in comparison with dexamethasone alone. In newly diagnosed MM patients, the current study compares the efficacy and safety of melphalan, prednisone and lenalidomide (MPR) with that of MP alone. Methods: Key inclusion criteria were: ≥65 years of age, newly diagnosed and symptomatic MM. 459 patients were randomly assigned to receive MPR followed by lenalidomide maintenance therapy or MPR followed by placebo maintenance therapy or MP followed by placebo maintenance therapy (Figure 1). The study induction and maintenance phases were followed by an open label lenalidomide extension and a follow-up phase. All patients received aspirin 100 mg/day as thrombo-prophylaxis. The primary endpoint of the study is progression free survival (PFS). The secondary endpoints are OS, time-to-progression, response rate, time to response, response duration, time-to-next anti-myeloma therapy, safety, quality of life and exploratory assessment of cytogenetic abnormalities. Primary comparison is based on the intent-to-treat population comparing PFS between MPR followed by lenalidomide with MP followed by placebo; secondary comparisons are between MPR followed by lenalidomide and MPR followed by placebo, and between MPR followed by placebo and MP followed by placebo. Results: The first patient was enrolled in February 2007. A pre-planned interim analysis to evaluate the efficacy and safety was performed at 50% information. An independent central adjudication committee determined the assessment and timing of progressive disease prior to the interim analysis. At the interim analysis, it was determined by the Data Monitoring Committee (DMC) that the study had crossed the O'Brien Fleming superiority boundary for the primary endpoint, demonstrating a highly statistically significant improvement in PFS for patients treated with MPR compared with MP as first-line treatment for MM patients. The topline results will be availabel at the time of the meeting. Conclusions: MPR is an effective and safe regimen for front-line use in MM. PFS was significantly improved in patients who received MPR followed by lenalidomide maintenance compared with those who received MP followed by placebo maintenance. MPR followed by lenalidomide maintenance is a new therapeutic option and can be considered a new standard for patients older than 65 years old. Disclosures: Palumbo: Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen Cilag: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pharmion: Honoraria, Membership on an entity's Board of Directors or advisory committees. Off Label Use: Lenalidomide is not approved for first line use in multiple myeloma. Dimopoulos:Celgene: Honoraria. Delforge:Janssen-Cilag: Consultancy, Honoraria; Celgene: Honoraria, Speakers Bureau. Kropff:Ortho Biotech: Consultancy, Honoraria, Speakers Bureau; Celgene: Consultancy, Honoraria, Speakers Bureau. Foa:Celgene: Membership on an entity's Board of Directors or advisory committees. Yu:Celgene: Employment. Herbein:Celgene: Employment. Mei:Celgene: Employment. Jacques:Celgene: Employment. Catalano:Celgene: Research Funding.

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Carfilzomib, Lenalidomide, and Dexamethasone In Newly Diagnosed Multiple Myeloma: Initial Results of Phase I/II MMRC Trial

Blood ◽

10.1182/blood.v116.21.862.862 ◽

2010 ◽

Vol 116 (21) ◽

pp. 862-862 ◽

Cited By ~ 5

Author(s):

Andrzej J Jakubowiak ◽

Dominik Dytfeld ◽

Sundar Jagannath ◽

David H. Vesole ◽

Tara B. Anderson ◽

...

Keyword(s):

Multiple Myeloma ◽

Phase I ◽

Board Of Directors ◽

Newly Diagnosed ◽

Employment Equity ◽

Advisory Committees ◽

Level 3 ◽

Equity Ownership ◽

Level 1 ◽

Level 2

Abstract Abstract 862 Background: Carfilzomib (Cfz) is a novel, irreversible proteasome inhibitor that has demonstrated promising single-agent activity and favorable toxicity profile, including very low rates of peripheral neuropathy and neutropenia in relapsed/refractory multiple myeloma (MM). Combining Cfz with Lenalidomide (Revlimid®, Len), and Dexamethasone (Dex) into CRd shows an additive anti-MM effect in preclinical studies and lack of overlapping toxicity allowing for the use of these agents at full doses and for extended duration of time in relapsed/refractory MM (Niesvizky et al, ASH, 2009). This Phase I/II study was designed to determine the maximum tolerated dose (MTD) of CRd and to assess safety and evaluate efficacy of this combination in newly diagnosed MM. Methods: In Phase I, dose escalation follows the TITE-CRM algorithm, with Cfz as the only escalating agent starting at 20 mg/m2 (level 1), maximal planned dose 27 mg/m2 (level 2), and 15 mg/m2, if needed (level -1), given IV on days 1, 2, 8, 9, 15, 16 in 28-day cycles. Len is used at 25 mg PO (days 1–21), and Dex at 40/20 mg PO weekly (cycles 1–4/5-8) for all dose levels. Based on toxicity assessment, the study was amended to add dose level 3 with Cfz at 36 mg/m2 and the number of pts in the Phase I was increased to 35. A total of 36 pts are planned to be treated at the MTD in Phase I/II. Pts who achieve ≥ PR can proceed to stem cell collection (SCC) and autologous stem cell transplant (ASCT) after ≥ 4 cycles, although per protocol design, ASCT candidates are offered to continue CRd treatment after SCC. After completion of 8 cycles, pts receive 28-day maintenance cycles with Cfz (days 1, 2 15, 16), Len days 1–21, and Dex weekly at the doses tolerated at the end of 8 cycles. Responses are assessed by IMWG criteria with the addition of nCR. Results: The study has enrolled 24 pts to date, 4 pts at level 1 (Cfz 20), 14 at level 2 (Cfz 27) and at 6 at level 3 (Cfz 36). Toxicity data are available for 21 pts, of which 19 have completed at least the first cycle required for DLT assessment; 2 pts were removed during the first cycle for events unrelated to study therapy (1 at level 1 and 1 at level 2), and 3 are currently within their first cycle of treatment. There was a single DLT event at dose level 2 (non-febrile neutropenia requiring dose reduction of Len per protocol) and the MTD has not been reached. Hematologic toxicities were reversible and included Grade (G) 3/4 neutropenia in 3 pts, G3/4 thrombocytopenia in 3, and G3 anemia in 2. There have been additional G3 non-hematologic AEs including 1 case of DVT while on ASA prophylaxis, 1 fatigue, 1 mood alteration, and 5 glucose elevations; the last 2 AEs were related to Dex. There was no emergence of peripheral neuropathy (PN), even after prolonged treatment, except in 2 pts who developed G1 sensory PN. Twenty-three pts continue on treatment, most (20 pts) without need for any dose modifications. After a median of 4 (range 1–8) months of treatment, preliminary response rates by IMWG in 19 evaluable pts who completed at least 1 cycle are: 100% ≥ PR, 63% ≥ VGPR, 37% CR/nCR, including 3 pts with sCR. Responses were rapid with 17 of 19 pts achieving PR after 1 cycle and improving responses with continuing therapy in all pts. To date, 7 pts proceeded to SCC using growth factors only, with a median 6.3 × 106 CD34+ cells/kg collected (range 4.1–8.2), after a median of 4 cycles of CRd (range 4–8); all resumed CRd treatment after SCC. After a median of 4 months of follow-up, none of evaluable pts progressed and all are alive. Conclusion: CRd is well tolerated and highly active in newly diagnosed MM with ≥ PR of 100%, including 63% ≥VGPR and 37% CR/nCR. Accrual is ongoing, with updated toxicity and efficacy data to be presented at the meeting. The results of this study represent the first report of treatment of frontline myeloma with Cfz to date, and provide additional support to recently initiated Phase 3 trial of CRd vs. Rd in relapsed MM. Disclosures: Jakubowiak: Bristol-Myers Squibb: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Exelixis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Centocor OrthoBiotech: Consultancy, Honoraria, Speakers Bureau; Celgene: Consultancy, Honoraria, Speakers Bureau; Millennium: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Off Label Use: Lenalidomide for newly diagnosed multiple myeloma. Jagannath:Millennium: Honoraria; OrthoBiotech (Canada): Honoraria; Celgene: Honoraria; Merck: Honoraria; Onyx Pharmaceuticals: Honoraria; Proteolix, Inc: Honoraria; Imedex: Speakers Bureau; Medicom World Wide: Speakers Bureau; Optum Health Education: Speakers Bureau; PER Group: Speakers Bureau. Vesole:Celgene: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Anderson:Millennium: Honoraria, Speakers Bureau; Celgene: Honoraria, Speakers Bureau. Stockerl-Goldstein:Celgene: Speakers Bureau; Millennium: Speakers Bureau. Barrickman:Celgene: Employment, Equity Ownership. Kauffman:Onyx Pharmaceuticals: Employment, Equity Ownership. Vij:Proteolix: Consultancy; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Onyx: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

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Melphalan, Prednisone and Lenalidomide Followed by Lenalidomide Maintenance Displays Treatment Characteristics Favourable to Global Quality of Life in Newly Diagnosed Multiple Myeloma (NDMM) Patients ≥ 65 Years,

Blood ◽

10.1182/blood.v118.21.3988.3988 ◽

2011 ◽

Vol 118 (21) ◽

pp. 3988-3988 ◽

Cited By ~ 2

Author(s):

Meletios Athanasios Dimopoulos ◽

Antonio Palumbo ◽

Roman Hajek ◽

Martin Kropff ◽

Maria Teresa Petrucci ◽

...

Keyword(s):

Quality Of Life ◽

Multiple Myeloma ◽

Partial Response ◽

Progressive Disease ◽

Newly Diagnosed ◽

Employment Equity ◽

Risk Of Disease ◽

Equity Ownership ◽

Grade 3

Abstract Abstract 3988 Background: Melphalan, prednisone and lenalidomide followed by lenalidomide maintenance (MPR-R) demonstrated higher response rates (ORR; 77% vs. 50%, p <.001; VGPR or better: 32% vs. 12%, p <.001) and significantly reduced the risk of disease progression (hazard ratio [HR] = 0.423, p <.001) vs. MP alone [Palumbo, 2010]. Alongside efficacy considerations, analyses on health-related quality of life (HRQoL) may help more fully establish a regimen's overall treatment profile. HRQoL improvements with MPR-R were observed during MPR induction as well as lenalidomide maintenance, documenting a well-balanced profile in terms of efficacy, tolerability and HRQoL [Dimopoulos, 2011]. Alternative findings on novel NDMM treatment have shown efficacy of melphalan, prednisone and bortezomib (VMP) treatment to be associated with an intermittent deterioration in patients' HRQoL [Dhawan, 2009]. Methods: A mixed effects model was developed based on parameters pre-selected as potentially clinically relevant in impacting HRQoL. Models were run on six domains pre-selected based on clinical relevance: Global QoL, Physical Functioning, Fatigue and Pain (from EORTC QLQ-C30), and Disease Symptoms and Side Effects of Treatment (from EORTC MY20). Cycle 16 was determined as the last observation time point with a statistically meaningful sample size at time of follow-up (May 2010). Following explanatory variables were included: time-dependant covariates at individual HRQoL measurement time points (i.e. cycle 4, 7, 10, 13 and 16), treatment group (MPR-R vs. MP), gender (Female vs. Male), age, baseline QoL, Partial Response (PR) vs. Stable Disease (SD) and Very Good Partial Response or better (≥VGPR) vs. SD, Progressive Disease (PD) and Discontinuation (DC). Neutropenia and anemia, both Grade 3 or 4, were considered the clinically most relevant safety parameters. Main results for Global QoL are reported, with results from other domains found to be comparable. Results: Across all time-dependant covariates, a statistically significant reduction on Global QoL (−4.63; p=.004) was observed at Cycle 4. Being female vs. male significantly reduced Global QoL by -−.07 (p=.026). Each additional life year was found to lower Global QoL b− −0.40 points (p=.034). Baseline Global QoL was also significant, each additional score point leading to +0.30 (p <.001). A response level of ≥VGPR vs. SD increased Global QoL by 9.11 (p=.023); Progressive Disease (PD) reduced Global QoL by -−.34 score points (p <.001). All other pre-defined variables did not significantly impact Global QoL. Clinically meaningful changes for Global QoL in the underlying patient population have been determined to constitute at least a 7-point change [Dimopoulos, 2011]. Progressive disease (reducing Global QoL), respectively ≥VGPR (increasing Global QoL) exerted clinically meaningful changes, as did anemia grade 3–4, which had a clinically meaningful, but not statistically significant negative impact (−9.85; p=.057). Although no significant direct effect of MPR-R over MP on Global QoL was detected in the underlying model, MPR-R displays properties which favor an improved HRQoL profile, including a stronger delay in PD and higher % of VGPR vs. MP patients. Furthermore, certain properties more frequently observed with MPR-R than MP (neutropenia grade 3 or 4 and discontinuation, DC) were shown not to have a significant impact on HRQoL. Anemia grade 3 or 4, exerted a clinically meaningful negative effect but was not significantly more often observed with MPR-R compared to MP (24% vs. 17%, p= 0.091). Conclusions: More patients achieved ≥VGPR when receiving continuous MPR-R treatment than those receiving MP. In the above pooled analysis, ≥VGPR was shown to improve Global QoL in a clinically meaningful and statistically significant way. Furthermore, progression was also shown to negatively impact Global QoL (−8.34; p <.001), with MPR-R significantly reducing the risk of disease progression over MP. Delaying progression with continuous MPR-R therefore helps to maintain a high Global QoL. Disclosures: Dimopoulos: Celgene: Consultancy, Honoraria. Off Label Use: Lenalidomide in newly diagnosed multiple myeloma. Palumbo:Celgene: Consultancy, Honoraria; Janssen-Cilag: Consultancy, Honoraria; Ortho-Biotech: Honoraria. Hajek:Celgene: Honoraria; Janssen-Cilag: Honoraria; Merck: Honoraria. Petrucci:Celgene: Honoraria. Lewis:Celgene: Employment, Equity Ownership. Millar:Celgene: Consultancy. Zhang:Celgene: Employment, Equity Ownership. Mei:Celgene: Employment, Equity Ownership. Delforge:Celgene: Consultancy, Honoraria, Speakers Bureau; Janssen-Cilag: Consultancy, Honoraria, Speakers Bureau.

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Patterns of Total Costs of Care for Newly Diagnosed Multiple Myeloma (MM) Patients

Blood ◽

10.1182/blood.v124.21.2656.2656 ◽

2014 ◽

Vol 124 (21) ◽

pp. 2656-2656

Author(s):

Steven R. Arikian ◽

Dejan Milentijevic ◽

Gary Binder ◽

Mara Silvia Monzini ◽

X Henry Hu ◽

...

Keyword(s):

Multiple Myeloma ◽

Research Funding ◽

Direct Costs ◽

Drug Costs ◽

Newly Diagnosed ◽

Employment Equity ◽

Monthly Total ◽

Equity Ownership ◽

The Cost ◽

Over Time

Abstract Introduction: As clinical evidence has mounted in support of novel agents and longer treatment (Tx) durations for patients (pts) with newly diagnosed multiple myeloma (NDMM), questions have arisen regarding the economic impact of extending time to progression (TTP) in these pts, and the cost consequences once pts relapse and move to a second line of Tx. Previous analysis showed that relapsed myeloma pts incurred higher monthly costs once they advanced to later lines of Tx (Gaultney, 2013). There is limited information on the cost patterns of MM pts before and after their first relapse. A claims analysis was performed to evaluate the patterns of total direct costs of care, from Tx initiation until progression, for NDMM patients and for newly relapsed patients treated with novel agents, utilizing time to next therapy (TTNT) as a proxy measure for progression. Methods: A retrospective study was conducted using a large US medical and pharmacy claims database, covering > 25 million lives annually. NDMM patients were identified with at least 2 outpatient claims or 1 inpatient medical claim associated with a diagnosis of MM (ICD-9-CM] code 203.0X), with the first such claim used to define the index date. Inclusion criteria required a minimum of 12 months' pre-index enrollment and 6 months' post-index continuous enrollment between 2006 and 2012. Pts with claims for stem cell transplantation (SCT) were excluded, to avoid confounding results from various factors based on timing, costs, and site of care of SCT. The analysis focused on NDMM and relapsed MM pts receiving lenalidomide (LEN)- or bortezomib (BORT)- based Tx, where complete claim history was available from Tx onset to initiation of subsequent Tx. Using methods similar to those described by Gaultney, patients' average monthly costs were determined, including medical (inpatient, ambulatory, and emergency room) and pharmacy (index and other drugs) costs, and total cost patterns over quarterly time periods were calculated. Average Charlson comorbidity scores were determined to compare baseline measures between pt groups. Results: 897 NDMM pts and 280 relapsed MM pts were identified with complete data through initiation of subsequent Tx. Monthly total direct costs for NDMM pts were $15,400 in the first 3 months (mos) of Tx, and declined each quarter, reaching approximately $5,000/mo at 18+ mos. At relapse, monthly costs increased to over $12,000 for the first 3 mos and followed a quarterly pattern of reduction similar to that seen for NDMM pts (Fig 1). Quarterly cost reduction patterns were consistent for patients treated with LEN or BORT for both NDMM and relapsed pts. Pts' total monthly NDMM costs over the full TTNT period averaged $8,942 with LEN vs. $11,139 for BORT (due to 54% higher monthly medical costs for BORT), while monthly drug costs were nearly identical (Table 1). The baseline Charlson comorbidity index was similar between Tx groups in both lines of Tx. Figure 1: Direct monthly costs (medical and pharmacy) for LEN- and BORT-based treatments Figure 1:. Direct monthly costs (medical and pharmacy) for LEN- and BORT-based treatments Table 1: Direct monthly costs for NDMM pts Table 1 Table 1. Conclusions: For a population of NDMM pts receiving either LEN- or BORT-based Tx without SCT, followed until TTNT, total direct monthly costs per pt declined steadily over time, decreasing by 68% from the initial quarter to the period post 18 mos. Costs spiked when pts began 2nd-line therapy, then followed a similar pattern of decline over time. This pattern may suggest that further extending the TTP for NDMM pts may also yield economic benefits for each month extended before relapse. Patterns of cost decline were similar between the LEN and BORT groups, for NDMM and for relapsed patients, although mean monthly total costs were lower for NDMM pts receiving LEN-based Tx due to lower medical costs and similar drug costs. Disclosures Arikian: Genesis Research: Consultancy. Off Label Use: Lenalidomide in newly diagnosed multiple myeloma patients . Milentijevic:Celgene Corporation: Consultancy. Binder:Celgene Corporation: Employment, Equity Ownership. Monzini:Celgene Corporation: Employment, Equity Ownership. Hu:Celgene Corporation: Employment. Nagarwala:Celgene Corporation: Employment. Hussein:Celgene Corporation: Employment. Corvino:Genesis Research LLC: Consultancy. Surinach:Genesis Research LLC: Consultancy. Usmani:Celgene Corporation: Consultancy, Honoraria, Research Funding; Millennium: Consultancy, Honoraria; Onyx: Consultancy, Honoraria, Research Funding; Sanofi: Consultancy; Array BioPharma: Research Funding; Janssen: Research Funding; Pharmacyclics: Research Funding.

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Clinical Outcomes of Patients with Newly Diagnosed Multiple Myeloma Receiving Triplet Therapy in the Connect MM® Disease Registry

Blood ◽

10.1182/blood.v126.23.4229.4229 ◽

2015 ◽

Vol 126 (23) ◽

pp. 4229-4229

Author(s):

Jatin J. Shah ◽

Rafat Abonour ◽

Mohit Narang ◽

Jayesh Mehta ◽

Howard R. Terebelo ◽

...

Keyword(s):

Multiple Myeloma ◽

Board Of Directors ◽

Research Funding ◽

Newly Diagnosed ◽

Employment Equity ◽

Advisory Committees ◽

Risk Of Death ◽

Equity Ownership ◽

Triplet Regimen

Abstract Introduction: Triplet therapies are used for treatment (Tx) of both transplant-eligible and -ineligible patients (pts) with newly diagnosed multiple myeloma (NDMM). Actual patterns and outcomes of Tx are not fully understood. Connect MM® is the first and largest multicenter, US-based, prospective observational cohort study designed to characterize Tx patterns and outcomes for pts with NDMM. This analysis describes demographic and disease characteristics of pts who received triplet Tx as an induction regimen and for whom transplant was or was not intended. The analysis explores the relationship of these factors with overall survival (OS) and other efficacy endpoints. Patients and Methods: Pts aged ≥ 18 y with NDMM within 60 days of diagnosis were eligible for enrollment regardless of disease severity, medical history, or comorbidities. Data including transplant intent (yes/no) was collected at baseline; follow-up data was collected quarterly thereafter. Based on the initial intent, 2 groups were identified: patients with intent to transplant who received transplant (TT) and pts with no intent to transplant who did not receive a transplant (NT). Triplet Tx was defined as the combination of ≥ 3 concurrent therapeutic agents in the first course of Tx (within 56 days of study entry). KM analysis adjusted for age was conducted for OS. Because decisions on use of transplant and triplet therapy are influenced by multiple factors, a multivariable Cox regression analysis was performed to evaluate the contribution of the triplet therapy (yes/no) to OS and was adjusted for other variables, including age, comorbidities, and ISS staging. Results: Between September 2009 and December 2011, 1493 pts were enrolled. This analysis was on 1436 pts: 650 pts with transplant intent and 786 pts without transplant intent. The data cutoff date was November 30, 2014, and the median follow-up for overall survival (OS) was 33.8 mos. Of pts with transplant intent, 451 (69%) received transplant (TT) and 199 (31%) did not. Of pts without transplant intent, 62 (8%) received transplant and 724 (92%) did not (NT). The abstract focuses on TT and NT groups only. NT pts tended to be older and have more advanced ISS staging and higher β2-microglobulin levels than TT pts (Table). The most common triplet regimen given during the first course treatment (within 56 days) was lenalidomide, bortezomib, and dexamethasone (RVd). RVd was administered to 34% of the NT pts (76/225) and 59% of the TT pts (152/257). The most common non-triplet regimen was bortezomib and dexamethasone (Vd), which was given to 31% of NT pts (156/499) and 38% of TT pts (73/194). Within the NT group, pts given triplet Tx had a lower risk of death than those who did not receive triplet Tx (P = .0013). The multivariable analysis found triplet Tx to be associated with a 36% reduced risk of death (hazard ratio [HR] = 0.64 [95% CI, 0.50-0.82]; P = .001). ISS disease stage (HR = 1.43 [95% CI, 1.21-1.69]; P < .001) and history of diabetes (HR = 1.38 [95% CI, 1.08-1.78]; P = .012) were negative prognostic factors for OS. Within the TT group, pts who received triplet Tx did not attain an OS benefit (P = .8993), and no baseline characteristics were significantly associated with OS. These results may be limited by other factors not considered that may have influenced physicians' choice of treatment, including the use of maintenance therapy and a short follow-up period of 33.8 months. Conclusions: Triplet Tx as a first regimen is associated with longer OS in pts without transplant intent who did not receive a transplant. RVd and Vd were the most common first Tx regimens, respectively. Continued follow-up of these pts and enrollment of an additional cohort will provide additional data with mature follow-up. Table 1. Table 1. Disclosures Shah: Bristol-Myers Squibb: Research Funding; Array: Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees, Research Funding; Onyx: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Millenium: Research Funding; Merck: Membership on an entity's Board of Directors or advisory committees. Abonour:Celgene: Research Funding, Speakers Bureau. Narang:Celgene: Speakers Bureau. Mehta:Celgene Corporation: Speakers Bureau. Terebelo:Millenium: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Pharmacylics: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Gasparetto:Celgene Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Millennium: Honoraria, Other: Export Board Committee, Speakers Bureau. Toomey:Celgene: Consultancy. Hardin:Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees. Srinivasan:Celgene Corporation: Employment, Equity Ownership. Larkins:Celgene Corporation: Employment, Equity Ownership. Nagarwala:Celgene Corporation: Employment, Equity Ownership. Rifkin:Onyx Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees; Millennium Pharmaceuticals, Inc., Cambridge, MA, USA, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees.

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Management of Patients with Relapsed/Refractory Multiple Myeloma (RRMM) Treated with Proteasome Inhibitor Based Therapy at First Relapse in Routine Clinical Practice in Germany

Blood ◽

10.1182/blood-2018-99-110937 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 1953-1953 ◽

Cited By ~ 1

Author(s):

H. Tilman Steinmetz ◽

Moushmi Singh ◽

Andrea Lebioda ◽

Aurelien Mantonnier ◽

Leah Fink ◽

...

Keyword(s):

Multiple Myeloma ◽

Clinical Practice ◽

Treatment Duration ◽

Employment Equity ◽

Available N ◽

Median Treatment ◽

Median Treatment Duration ◽

Refractory Multiple Myeloma ◽

Equity Ownership ◽

Patient Profiles

Abstract Background: Proteasome inhibitors (PI) represent an important therapeutic advance in the treatment of patients with relapsed/refractory multiple myeloma (RRMM). In 2017, three distinct PIs (bortezomib [BTZ], carfilzomib [CFZ] and ixazomib [IXA]) were available in Germany but real-world data describing their usage was scarce. Aim: To describe characteristics and treatment experience of PI-treated patients with RRMM in Germany. Methods: A national retrospective medical chart review included consecutive patients treated with at least one dose of PI-based regimen in participating hospitals/centers across Germany between January and June 2017. The following data were extracted until April 2018 or death of patient, whichever occurred first: patient demographics, disease characteristics and treatment history at diagnosis and at initiation of PI-based therapy. Physician assessed treatment response were also collected. Results: Physicians from 44 participating centers extracted 302 patient charts, including 219 patients in 2nd line (2L) and 83 in 3rd line treatment (3L), as shown in Figure 1. Results for 2L patients are described below (Table 1, Figure 2): BTZ-treated patients represented 42% of patients (n=92) with a PI-based therapy in 2L. BTZ was often combined with dexamethasone (dex) alone (77%). Median age was 74 years and 56.5% had an ECOG status ≥2 at 2L initiation. Most patients (86%) did not receive a prior transplant. Median treatment duration was 6 months among 40 patients who completed 2L; based on 38 narratives, 2L was ended as planned (47.4%). Where response was available (n=83), 25% of patients achieved a complete response/very good partial response [CR/VGPR]. Median time to next treatment (TTnT) was 7.5 months for 12 patients who moved to 3L. Patient profiles differed in terms of prior treatment exposure: 22% of patients had been treated with a BTZ-based therapy in both 1L and 2L and 62% switched therapies from 1L lenalidomide (len) to BTZ. None of the patients receiving len in 1L were transplanted. A CR/VGPR was achieved by 65% of prior BTZ-treated patients (13/20) and 30% of patients with prior len therapy (17/57). CFZ-treated patients: 48% (n=106) of patients received CFZ-based therapy in 2L. Of those, 56% (n=59) received CFZ in combination with len/dex (KRd) and 44% (n=47) with dex alone (Kd). Median age was 68 years, 60.4% had an ECOG status of 0-1 at 2L initiation and 49% had received a transplant. In 1L, 82% had received a BTZ-based regimen. Where response was mentioned (n=89), a CR/VGPR was reached in 53% of CFZ-treated patients. Median treatment duration was 6.5 months (24/106). Based on 21 narratives, the main reason for discontinuing CFZ in 2L was disease progression (47.6%). Median TTnT was 9.5 months for 10 patients who moved to 3L. The patient profiles by KRd or Kd combination were as follows: at KRd initiation, median age was 65 years, 10.2% of patients had an ECOG status ≥2 and 72.9% were transplanted. At Kd initiation, median age was 71 years, 76.6% of patients had an ECOG ≥2 and 19.1% were transplanted. IXA-treated patients (n=21) represented only 10% of PI-treated patients in 2L. Median age was 66 years, 71.4% had an ECOG status of 0-1 at 2L initiation, 33% were transplanted, and 72% had received a BTZ combination in 1L. Information on response was premature as it was only available for 13 patients with no CR reached (VGPR 77%). Median treatment duration was 4 months (n=9) and median TTnT was 10 months for 4 patients who moved into 3L. Limitation: The main limitation of the study was the sample size of IXA-treated patients due to open inclusion criteria to select patient charts. This analysis was not powered to compare between PIs. Hence, results are descriptive of the clinical experience with PI-based therapy to date and reflect current treatment practices in Germany in 2017. Conclusion: In Germany, distinct patient characteristics are observed in clinical practice by selected PI-based therapy. Patients treated with novel PI agents in 2L are generally younger and more transplanted than bortezomib-treated patients; these appear to be important considerations when tailoring therapy in RRMM. In addition, the choice between triplet or doublet therapy for CFZ-based combinations seems to reflect prior transplant status and patients' overall functional performance. Evidence suggests that use of novel PI agents such as CFZ can translate into deeper response in 2L. Disclosures Steinmetz: Amgen, Celgene, Novartis, Vifor: Research Funding; Amgen; BMS, Celgene, Hexal-Sandoz, Medice, Novartis; Janssen-Cilag; Pharmacosmos; Pfizer, Vifor; Ariad: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Alexion, Amgen, Bayer, Celgene, Janssen-Cilag, Novartis: Other: Travel grants. Singh:Amgen: Employment, Equity Ownership. Lebioda:Amgen: Employment, Equity Ownership. Mantonnier:Kantar Health: Employment, Other: Received funding to conduct this research. Fink:Kantar Health: Employment, Other: Received funding to conduct this research. Rieth:Amgen: Employment, Equity Ownership. Suzan:Amgen: Employment, Equity Ownership. Gonzalez-McQuire:Amgen: Employment, Equity Ownership.

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Gene Expression and Genomic Markers Identify a Subpopulation of Poor Prognosis t(4;14) Patients in Newly Diagnosed Multiple Myeloma

Blood ◽

10.1182/blood-2019-128907 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 366-366

Author(s):

Maria Ortiz ◽

Fadi Towfic ◽

Erin Flynt ◽

Nicholas Stong ◽

Sneh Lata ◽

...

Keyword(s):

Gene Expression ◽

Multiple Myeloma ◽

High Risk ◽

Poor Prognosis ◽

Newly Diagnosed ◽

Employment Equity ◽

Gene Set ◽

Combining Data ◽

Genomic Markers ◽

Equity Ownership

Cytogenetics is an important prognostic marker in multiple myeloma (MM). Patients with t(4;14) (~15% of newly diagnosed MM patients) are known to have short progression free survival (PFS) and overall survival (OS). This feature, measured by FISH, is used in combination with ISS=3 as a selection marker for patients with high risk (HR) of progression. Only a subset of patients grouped by t(4;14) and ISS=3 display genuinely poor survival, however, with ~25% dying within 24 months after diagnosis (similar to the Double Hit subgroup defined by Walker et al1). To elucidate this observation, we created the largest dataset of MM t(4;14) patients to date by combining data from the Myeloma Genome Project (MGP, n=73) and data from TOUL (n=100, patients analyzed in routine practice) to identify transcriptomic and/or genomic markers associated with HR t(4;14). Gene expression (GE), copy number aberration (CNA), single nucleotide variant (SNV) and translocations were derived from RNAseq and WGS/WES profiling of biopsies from patients aged less than 75 years who received transplant, and integrated with clinical information (including Age, PFS and OS). Demographics: MGP median age=61; 30% female; median PFS (mPFS)=26.2months (m) and median OS (mOS) not reached. TOUL median age=60; 35% female, mPFS=23.7m and mOS = 86.1m. Our previous work (Ortiz ASH 2018, Ortiz EHA 2018) identified a molecularly-defined HR MM patient subgroup (MDMS8, mPFS<20m, m0S<35m) defined by GE patterns related to cell cycle dysregulation. In that analysis, 24% of t(4;14) patients were identified as MDMS8 (mPFS<13m, mOS<30m), the rest (76%) were grouped in other lower risk molecular segments (mPFS<30m, mOS NR). A GE classifier for t(4;14) in MDMS8 vs the rest of t(4;14) patients was created on the MGP dataset and applied to identify similar patients in the TOUL data, obtaining a significant difference between MDMS8-like t(4;14) patients (20% prevalence, mPFS<15m, mOS<26m) in the TOUL dataset and non-HR t(4;14) (mPFS<26m, mOS<103m) in both PFS (p.value<1e-3) and OS (p.value<1e-5). Although there are some conventional t(4;14) gene expression surrogates, they do not identify the HR t(4:14) subgroup. Comparison of known t(4;14) gene expression markers MMSET and FGFR3 in HR t(4;14) (OS < 24ms & not_alive, N=34) versus non-HR t(4;14) patients (N=94) across both datasets combined did not yield significant differential expression of either gene (p.value>0.10). MMSET was over-expressed in all t(4;14) patients, while FGFR3 displayed a binomial distribution (two groups of patients with high (N=37, median value=10 log2CPM) and low (N=91, median value=2 log2CPM) FGFR3 expression) within t(4;14) patients (p.value<0.05) without association with outcome (p.value>0.10). GE analysis of HR t(4;14) vs non-HR t(4;14) patients aligned with MDMS8 biology, but identified new pathways also including DNA repair, MYC targets and Oxidative Phosphorylation being up-regulated in the HR t(4;14) group. A gene-set variation analysis based on the MSigDb C1 gene-set, wherein genes are grouped based on their genomic location, was performed to identify GE changes of potentially epigenomic origin. Results highlighted chr9q22, chr9q33, and chr13q13 as down-regulated in the HR t(4;14) group, while genes in 16q24 were significantly up-regulated. CNA analysis identified amplifications in chromosomes 3 and 19 and deletions in chr12p as significantly associated with the HR t(4;14) population (p.value < 0.05); while deletions in chr14q (preceding the translocated region) occurred more frequently in the non-HR t(4;14) group. Our results provide new insights into identification of these patients and underlying biology that could drive poor prognosis in t(4;14) patients. Molecular identification of HR t(4;14) patients would enable proper risk classification for this MM patient group and understanding differences in HR t(4;14) biology could provide the basis for identification of a specific therapeutic target for this HR subpopulation. An ongoing aim of this work is development of a clinically applicable classifier that accurately identifies this subpopulation of MM patients and the biological drivers of their high-risk disease. Disclosures Ortiz: Celgene Corporation: Employment, Equity Ownership. Towfic:Celgene Corporation: Employment, Equity Ownership. Flynt:Celgene Corporation: Employment, Equity Ownership. Stong:Celgene Corporation: Employment, Equity Ownership. Lata:Celgene Corporation: Employment, Equity Ownership. Sampath:Celgene Corporation: Employment, Equity Ownership. Rozelle:Celgene Corporation: Other: Contractor for Celgene. Trotter:Celgene Corporation: Employment, Equity Ownership. Thakurta:Celgene: Employment, Equity Ownership.

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Asian Subgroup Analysis - Denosumab Vs Zoledronic Acid in Bone Disease Treatment of Newly Diagnosed Multiple Myeloma: An International, Double-Blind, Double-Dummy, Randomized Controlled Phase 3 Study

Blood ◽

10.1182/blood-2018-99-113132 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 3251-3251

Author(s):

Chang-Ki Min ◽

Sung-Soo Yoon ◽

Wee Joo Chng ◽

Shang-Yi Huang ◽

Cheng-Shyong Chang ◽

...

Keyword(s):

Multiple Myeloma ◽

Zoledronic Acid ◽

Research Funding ◽

Acid Group ◽

Newly Diagnosed ◽

Primary Analysis ◽

Employment Equity ◽

Double Blind ◽

Asian Patients ◽

Equity Ownership

Abstract Introduction: Denosumab is a monoclonal antibody targeting receptor activator of nuclear factor-kappa B ligand (RANKL) that has been shown to reduce skeletal-related events (SREs) associated with bone lesions in patients with multiple myeloma. Results from the full primary analysis of an international, double-blind, double-dummy, randomized controlled phase 3 (20090482) study that assessed the efficacy and safety of denosumab vs zoledronic acid for preventing SREs in patients with multiple myeloma (MM) indicated that denosumab was non-inferior to zoledronic acid for time to SREs. Here we present a sub-analysis to evaluate efficacy and safety outcomes in a subgroup of Asian patients enrolled in the 20090482 study. Methods: Adult patients from Asian countries with newly diagnosed MM and ≥1 documented lytic bone lesion were included in this analysis. Patients received subcutaneous denosumab (120 mg) plus intravenous placebo or intravenous zoledronic acid (4 mg) plus subcutaneous placebo in 4-week cycles. The primary endpoint was time to first on-study SRE; the incidence of adverse events (AEs) by preferred term was also examined. Results: Overall, 196 Asian patients (denosumab, n=103; zoledronic acid, n=93) were included in this analysis. Patient demographics were generally well balanced between groups. Median (interquartile range [IQR]) number of months on study was 17.5 (9.8-30.2) for the denosumab group and 20.2 (13.1-29.2) for the zoledronic acid group. Median (IQR) cumulative drug exposure was 15.9 (8.5-24.0) months for denosumab and 17.4 (9.1-26.7) months for zoledronic acid. Fewer patients in the denosumab group developed first on-study SRE compared with the zoledronic acid group; the crude incidence of SREs at the primary analysis cutoff was 38.8% in the denosumab group and 50.5% in the zoledronic acid group. Median (95% CI) time in months to first on-study SRE was not reached (11.2-not reached) for the denosumab group and 12.3 (3.1-not reached) for the zoledronic acid group (hazard ratio [HR], 0.77; 95% CI, 0.48-1.26; Figure 1). Overall, all patients (100%) experienced ≥1 treatment-emergent AE; the AEs reported in ≥20% of patients in either treatment arm are presented in Table 1. The most common AEs reported in either subgroup (denosumab, zoledronic acid) were diarrhea (51.0%, 51.1%), nausea (42.2%, 46.7%), pyrexia (38.2%, 41.3%), upper respiratory tract infection (37.3%, 40.2%), and constipation (33.3%, 31.5%). Renal toxicity (preferred terms of blood creatinine increased, renal failure, urine output decreased, acute kidney injury, renal impairment, and blood urea decreased) occurred in 9 of 102 (8.8%) patients in the denosumab group and 20 of 92 (21.7%) patients in the zoledronic acid group. Adjudicated osteonecrosis of the jaw was reported in 7 (6.9%) patients in the denosumab group and 5 (5.4%) patients in the zoledronic acid group. Hypocalcemia was reported in 19 (18.6%) patients in the denosumab group and 17 (18.5%) patients in the zoledronic acid group. Conclusion: Results from this Asian subgroup analysis were comparable to those of the full analysis set. In addition, in this analysis there were numerically fewer patients in the denosumab arm that developed a first on-study SRE compared with those in the zoledronic acid arm, and the time to first on-study SRE had a trend favoring the denosumab-treated patients. The AE profiles for denosumab and zoledronic acid in the Asian subgroup were comparable to those observed in the full primary analysis, with renal toxicity similarly reported to be higher in the zoledronic acid group. Overall, this analysis supports that denosumab may be an additional treatment option for the standard of care for Asian patients with newly diagnosed MM with bone disease. Disclosures Chng: Merck: Research Funding; Aslan: Research Funding; Celgene: Consultancy, Honoraria, Other: Travel, accommodation, expenses, Research Funding; Janssen: Consultancy, Honoraria, Other: Travel, accommodation, expenses, Research Funding; Takeda: Consultancy, Honoraria, Other: Travel, accommodation, expenses; Amgen: Consultancy, Honoraria, Other: Travel, accommodation, expenses. Chang:BMS: Consultancy, Speakers Bureau; AbbVie: Consultancy; Janssen: Consultancy, Speakers Bureau; Celgene: Consultancy; Takeda: Consultancy; Roche: Consultancy, Speakers Bureau; Novarits: Consultancy, Speakers Bureau. Wong:Amgen: Consultancy, Research Funding, Speakers Bureau; Bayer: Research Funding, Speakers Bureau; Novartis: Research Funding, Speakers Bureau; Archigen: Research Funding; Baxalta: Research Funding; Pfizer: Research Funding; Apellis: Research Funding; Roche: Research Funding; Boehringer: Research Funding; Ingelheim: Research Funding; AbbVie: Research Funding; Alexion: Consultancy; Astellas: Speakers Bureau. Shimizu:Amgen Inc.: Other: Non-remunerative Position of Influence, Denosumab 20090482 Global Steering Committee Member; Fujimoto Pharmacuetical Corp: Consultancy; Daiichi-Sankyo, Co., Ltd: Consultancy. Gao:Amgen Asia Holding Limited: Employment, Equity Ownership. Glennane:Amgen: Employment, Equity Ownership. Guan:Amgen: Employment, Equity Ownership.

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Genomic and Immunologic Analysis of Cmaf and Hypermutated Multiple Myeloma: Implications for Immunologic Therapy

Blood ◽

10.1182/blood-2019-131274 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3093-3093

Author(s):

Hearn Jay Cho ◽

Deepak Perumal ◽

Adeeb H Rahman ◽

Donald Jackson ◽

Michael Robbins ◽

...

Keyword(s):

Multiple Myeloma ◽

Research Funding ◽

Mononuclear Cells ◽

Checkpoint Inhibitors ◽

Clonal Evolution ◽

Control Group ◽

Newly Diagnosed ◽

Employment Equity ◽

Mutation Burden ◽

Equity Ownership

The advent of therapeutic monoclonal antibodies (elotuzumab, daratumumab) for multiple myeloma (MM) heralded a new era of immunologic therapy for this disease. Laboratory and clinical data suggest that immune checkpoint inhibitors (ICI) targeting the PD-1/PD-L1 axis are a promising novel strategy, as PD-L1 is commonly expressed on MM cells and a phase 2 clinical trial demonstrated encouraging responses to pembrolizumab (anti-PD-1) in combination with pomalidomide and dexamethasone. However, two late stage MM clinical trials of ICI combined with either lenalidomide or pomalidomide were halted due to safety concerns and lack of efficacy, although subgroup analysis suggested that the overall response rate in subjects with immune related adverse events was higher in subjects who received pembrolizumab + pomalidomide and dexamethasone vs the control group. As a result, further investigation of ICI in MM has largely discontinued. This discrepancy with the positive findings in the early phase trial suggests that genetic or immunologic features of the tumors or immune microenvironment of the patients may influence outcome to ICI, but these factors are as yet undefined. In solid tumors, high mutation burden as assessed by microsatellite sequence instability-high (MSI-high) or mismatch repair genes deficiency (dMMR) was correlated to response to anti-PD-1 ICI, and is now an indication for these agents. Newly diagnosed MM is considered an intermediate-low mutation burden disease (<10 muts/Mb), but a subset of newly diagnosed subjects, often characterized by overexpression of cMAF, have two-to-ten-fold higher average mutation burden. In addition, clonal evolution, characterized by accumulation of somatic mutations, is a common feature of MM and increases the mutation burden through its natural history. We hypothesized that cMAF/hyper-mutated (HM) MM patients may be more likely to have a tumor microenvironment (TME) that is amenable to ICI therapy, analogous to MSI-high/dMMR solid tumor patients. To investigate this, we identified cMAF/HM (n=25) and standard mutation burden (n=20) subjects from the CoMMPass database of newly-diagnosed MM patients. We performed bulk RNA sequencing and mass cytometry (CyTOF) analysis of CD138- bone marrow mononuclear cells, representing the TME, and proteomic (O-link) and grand serology (ELISA-based) analysis of peripheral blood plasma. CyTOF analysis of the TME demonstrated that cMAF/HM subjects had relatively decreased cycling myeloid cells and increased CD4+, CD73low T cells compared to standard. cMAF/HM subjects had significantly higher frequencies of antibody titers against the MM-associated autologous antigens SOX2 and NY-ESO-1. These results suggest that cMAF/HM patients are more likely to feature immune activation in the TME and generate adaptive immune responses to MM-associated antigens, but these responses are not sufficient to control the disease, possibly due to inhibition by checkpoint ligands such as PD-L1. These results support further investigation of ICI-based combination therapies in cMAF/HM MM patients. Disclosures Cho: The Multiple Myeloma Research Foundation: Employment; Celgene: Honoraria, Research Funding; Takeda: Research Funding; Agenus: Research Funding; Genentech: Honoraria, Research Funding; BMS: Consultancy; GSK: Consultancy. Jackson:Bristol-Myers Squibb: Employment, Equity Ownership. Robbins:Bristol-Myers Squibb: Employment, Equity Ownership. Parekh:Karyopharm Inc.: Research Funding; Foundation Medicine Inc.: Consultancy; Celgene Corporation: Research Funding.

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Melphalan, Prednisone and Lenalidomide Followed by Lenalidomide Maintenance Improves Health-Related Quality of Life (HRQoL), with Newly Diagnosed Multiple Myeloma (NDMM) Patients ≥ 65 Years Benefiting From Delays in Disease Progression

Blood ◽

10.1182/blood.v118.21.3157.3157 ◽

2011 ◽

Vol 118 (21) ◽

pp. 3157-3157 ◽

Cited By ~ 1

Author(s):

Meletios Athanasios Dimopoulos ◽

Michel Delforge ◽

Roman Hajek ◽

Martin Kropff ◽

Maria Teresa Petrucci ◽

...

Keyword(s):

Multiple Myeloma ◽

Side Effects ◽

Disease Progression ◽

Physical Functioning ◽

The Other ◽

Newly Diagnosed ◽

Employment Equity ◽

Disease Symptoms ◽

End Of Treatment ◽

Equity Ownership

Abstract Abstract 3157 Background: Lenalidomide maintenance following induction with melphalan, prednisone, and lenalidomide has been shown to provide sustained disease control by significantly decreasing the relative risk of progression in NDMM patients [Palumbo, 2010]. HRQoL analyses, alongside efficacy and safety considerations, may help establish a more complete picture of an overall treatment profile. Initial findings on HRQOL have shown a well-balanced profile of MPR-R in terms of efficacy, safety and tolerability, with HRQoL improving both during MPR induction and lenalidomide maintenance [Dimopoulos, 2011]. Alternative findings on novel NDMM treatment have shown efficacy of melphalan, prednisone and bortezomib (VMP) treatment to be associated with an intermittent deterioration in patients' HRQoL [Dhawan, 2009]. Methods: This analysis considers the impact on HRQoL of ending treatment due to progressive disease (PD) or discontinuation due to other reasons (DC) for both MPR-R and MP patients. HRQoL scores were assessed for six domains, pre-selected based on clinical relevance: Global QoL, Physical Functioning, Fatigue and Pain (from EORTC QLQ-C30), and Disease Symptoms and Side Effects of Treatment (from EORTC MY20). Mean HRQoL scores measured at PD/DC, PD alone and DC alone were compared to mean HRQoL scores at baseline. In a second analysis, HRQoL observations during treatment (excluding baseline) were compared to HRQoL at end of treatment, analyzing observations for patients experiencing PD/DC, PD and DC via a mixed effects model that adjusted for time of observation as a fixed effect and patient as a random effect. Results: With a May 2010 follow-up, mean HRQoL at PD/DC had significantly improved from baseline for 3 of 6 domains with MPR-R - Global QoL (55.9 vs. 46.8; p=.021), Pain (30.4 vs. 42.6; p=.044) and Disease Symptoms (21.6 vs. 28.6; p=.031)(a) with non-significant changes in the other 3 domains. When assessing MPR-R patients experiencing PD, Global QoL (48.0 vs. 37.3; p=.029) and Pain (38.9 vs. 54.6; p=.046) also significantly improved from baseline, with no significant changes in the other 4 scales. MPR-R patients with DC experienced one significant improvement for Disease Symptoms (16.0 vs. 26.9; p=.007), with non-significant changes in the other domains. No significant HRQoL changes at end of treatment vs. baseline were observed for MP in any comparisons of the six domains considered. HRQoL during treatment was better in 33 of 36 comparisons when compared to HRQoL at end of treatment (assessment for six HRQoL domains; MPR-R and MP; PD/DC, PD and DC, i.e. 6×2×3), with significantly better HRQoL during treatment in 14 out of 36 observations. PD/DC significantly reduced HRQoL in terms of Physical Functioning (56.9 vs. 67.5, p =.003) and Fatigue (46.4 vs. 37.8, p=.026) for MPR-R and Global QoL (48.7 vs. 59.4, p <.001), Physical Functioning (61.6 vs. 70.3, p =.001) and Fatigue (46.7 vs. 39.3, p =.021) for MP. All significant differences involved PD, with no significant differences observed for DC. 9 of 12 (=6×2) HRQoL comparisons (see Figure 1) showed significantly higher HRQoL during treatment vs. PD; 2 of 3 non-significant HRQoL differences related to Side Effects of Treatment. HRQoL was clinically meaningfully higher during treatment than at progression in all 5 statistically significant MPR-R comparisons, but only in two MP comparisons (Global QoL and Physical Functioning), as determined by Minimal Important Differences (MIDs) [Dimopoulos, 2011]. The results indicate that delaying progression through continued MPR-R treatment is of key importance in strengthening NDMM patients' HRQoL. Conclusions: Continuous lenalidomide significantly prolongs progression-free survival in NDMM patients. The underlying analysis documented higher HRQoL especially during MPR-R treatment compared to HRQoL at disease progression. Patients continuing on lenalidomide treatment experienced an elevated level of HRQoL, often reporting higher HRQoL levels at the end of MPR-R treatment vs. baseline. These findings further highlight the favourable balance between efficacy, tolerability and HRQoL with MPR-R. Disclosures: Dimopoulos: Celgene: Consultancy, Honoraria. Off Label Use: Lenalidomide in newly diagnosed multiple myeloma. Delforge:Celgene: Consultancy, Honoraria, Speakers Bureau; Janssen-Cilag: Consultancy, Honoraria, Speakers Bureau. Hajek:Celgene: Honoraria; Janssen-Cilag: Honoraria; Merck: Honoraria. Petrucci:Celgene: Honoraria. Lewis:Celgene: Employment, Equity Ownership. Millar:Celgene: Consultancy. Zhang:Celgene: Employment, Equity Ownership. Mei:Celgene: Employment, Equity Ownership. Palumbo:Celgene: Consultancy, Honoraria; Janssen-Cilag: Consultancy, Honoraria; Ortho-Biotech: Honoraria.

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