Contributions
Type: Publication Only
Background
The outcome of patients with multiple myeloma (MM) has improved significantly due to the introduction of autologous hematopoietic stem cell transplant (ASCT) and, subsequently, with the introduction of new drugs. However, the optimal sequence of treatments is unknown and, in Spain, there are no national MM treatment guidelines.
Aims
The purpose of the expert meetings was to obtain updated information about the most commonly used treatment strategies in Spain outside clinical trials.
Methods
A total of 5 expert meetings attended by 43 hematologists were held in November-December 2014. The treatment algorithms published by Ludwig et al. (The Oncologist 2014) were used as the basis for the discussions. Information was obtained on the most commonly used treatments in 3 different scenarios: 1) front line in patients who are candidates for ASCT, 2) front line in patients who are not eligible for ASCT, and 3) first relapse.
Results
Most patients are not candidates for ASCT (50-70%). The most frequently used induction regimens before transplant (4-6 cycles) are triple therapies (86%), bortezomib/thalidomide/dexamethasone (VTD) being the most common (79%), followed by bortezomib/doxorubicin/dexamethasone (PAD)(36%), bortezomib/cyclophosphamide/dexamethasone (VCD)(32%), lenalidomide/bortezomib/dexamethasone (RVD)(14%), and cyclophosphamide/thalidomide/dexamethasone (CTD)(4%). When triple therapy cannot be used due to access restrictions or patient characteristics, bortezomib/dexamethasone (VD) is generally administered. Most centers (53%) do not administer consolidation after ASCT. If consolidation is administered, the regimen is usually the same as in induction. Maintenance treatment after transplant is used only in selected cases and centers and usually consists of lenalidomide for 2 years (47%)(exceptionally until progression), thalidomide for 1 year (26%) or bortezomib (21%).
In non-transplant candidates, the front-line regimen most commonly administered is (VMP)(97%). Maintenance is not usually administered.
After the first relapse, a second transplant is considered if the remission lasted ≥18 months and if patients have good performance status. Retreatment with the same initial regimen (20-60% cases) is reserved for patients with a treatment-free interval >12-18 months or in whom the progression-free survival is greater than the median for the regimen. Otherwise, physicians prioritize inclusion in clinical trials or treatments with authorized drugs with a different mechanism of action, such as lenalidomide and dexamethasone (50-60%). If no new drugs are used in induction (8%), bortezomib-based regimens are usually administered (77%).
Summary
Although there is considerable inter-center and inter-region variability in the treatment of MM in Spain, partly explained by different patient characteristics or restrictions on access to some drugs, pre-ASCT induction and front line treatments without ASCT are quite consistent. Following the first relapse, treatment is more variable and individualized.
Keyword(s): Consolidation, Induction, Multiple myeloma, Relapse
Type: Publication Only
Background
The outcome of patients with multiple myeloma (MM) has improved significantly due to the introduction of autologous hematopoietic stem cell transplant (ASCT) and, subsequently, with the introduction of new drugs. However, the optimal sequence of treatments is unknown and, in Spain, there are no national MM treatment guidelines.
Aims
The purpose of the expert meetings was to obtain updated information about the most commonly used treatment strategies in Spain outside clinical trials.
Methods
A total of 5 expert meetings attended by 43 hematologists were held in November-December 2014. The treatment algorithms published by Ludwig et al. (The Oncologist 2014) were used as the basis for the discussions. Information was obtained on the most commonly used treatments in 3 different scenarios: 1) front line in patients who are candidates for ASCT, 2) front line in patients who are not eligible for ASCT, and 3) first relapse.
Results
Most patients are not candidates for ASCT (50-70%). The most frequently used induction regimens before transplant (4-6 cycles) are triple therapies (86%), bortezomib/thalidomide/dexamethasone (VTD) being the most common (79%), followed by bortezomib/doxorubicin/dexamethasone (PAD)(36%), bortezomib/cyclophosphamide/dexamethasone (VCD)(32%), lenalidomide/bortezomib/dexamethasone (RVD)(14%), and cyclophosphamide/thalidomide/dexamethasone (CTD)(4%). When triple therapy cannot be used due to access restrictions or patient characteristics, bortezomib/dexamethasone (VD) is generally administered. Most centers (53%) do not administer consolidation after ASCT. If consolidation is administered, the regimen is usually the same as in induction. Maintenance treatment after transplant is used only in selected cases and centers and usually consists of lenalidomide for 2 years (47%)(exceptionally until progression), thalidomide for 1 year (26%) or bortezomib (21%).
In non-transplant candidates, the front-line regimen most commonly administered is (VMP)(97%). Maintenance is not usually administered.
After the first relapse, a second transplant is considered if the remission lasted ≥18 months and if patients have good performance status. Retreatment with the same initial regimen (20-60% cases) is reserved for patients with a treatment-free interval >12-18 months or in whom the progression-free survival is greater than the median for the regimen. Otherwise, physicians prioritize inclusion in clinical trials or treatments with authorized drugs with a different mechanism of action, such as lenalidomide and dexamethasone (50-60%). If no new drugs are used in induction (8%), bortezomib-based regimens are usually administered (77%).
Summary
Although there is considerable inter-center and inter-region variability in the treatment of MM in Spain, partly explained by different patient characteristics or restrictions on access to some drugs, pre-ASCT induction and front line treatments without ASCT are quite consistent. Following the first relapse, treatment is more variable and individualized.
Keyword(s): Consolidation, Induction, Multiple myeloma, Relapse