Cherepanov, Dasha

AbstractBackgroundExtended first‐line therapy (1LT) has improved clinical outcomes in newly diagnosed multiple myeloma (NDMM). This retrospective study of NDMM patients evaluated the relationship between dose‐attenuation of 1LT and duration of therapy (DOT) and DOT on outcomes.MethodsAdults with NDMM not undergoing stem cell transplant (SCT) from January 1, 2012 toMarch 31, 2018 from the Integrated Oncology Network were included; 300 were randomly selected for chart review. 1LT DOT, time to next treatment (TTNT), progression‐free survival (PFS), and overall survival (OS) were estimated using Kaplan–Meier analysis. Marginal structural models evaluated relationships between DOT and TTNT, PFS, and OS at 2 years accounting for confounders and survival bias from the time‐dependent nature of DOT.ResultsOf 300 chart‐reviewed patients, 93 were excluded for incomplete data or meeting exclusion criteria. Among 207 NDMM patients, median age was 74 years; 146 (70.5%) did not receive dose‐attenuation during 1LT. Patients with short DOT were older, frailer, with a higher comorbidity burden, and a significantly lower proportion had an Eastern Cooperative Oncology Group PS = 0. As DOT increased, more patients underwent dose‐attenuation (p < 0.0001). The median 1LT DOT was 20.9 (95% confidence interval [CI]: 13.9, 26.4) versus 4.2 months (95% CI: 3.2, 4.9) for patients receiving versus not receiving dose‐attenuation, respectively (p < 0.0001). After accounting for survival bias, confounder‐adjusted TTNT was prolonged with each additional month of 1LT (odds ratio [OR]: 0.76 [95% CI: 0.75, 0.78]); likelihoods of risks of disease progression (OR: 0.87 [95% CI: 0.86, 0.88]) and death at 2 years (OR: 0.72 [95% CI: 0.70, 0.74]) were reduced with each month of 1LT (p < 0.0001 for all outcomes).ConclusionsDose‐attenuated 1LT was associated with longer DOT among patients with non‐SCT NDMM. Each additional month of 1LT was associated with a reduced adjusted likelihood of disease progression and death at 2 years. Dose‐attenuation of 1LT can extend DOT; longer DOT may improve clinical outcomes.

BACKGROUND: PIs combined with an Rd backbone are the most commonly used triplet combination regimens in patients (pts) with RRMM in the US. The hallmark trials supporting the efficacy of these regimens were predominantly in pts without prior exposure to lenalidomide (R).1,2 Real-world analyses have shown that R-based regimens are increasingly used in the front-line setting.3-5 Thus, real-world treatment patterns in pts with prior R exposure and the real-world comparative effectiveness of PI-Rd triplets in this population with RRMM needs further elucidation. METHODS: A retrospective cohort of RRMM pts initiating IRd, KRd, or VRd in line of therapy (LOT) ≥2 were followed between 7/2007-9/2018 in Optum's deidentified national electronic health records database. RRMM pts were defined as those initiating LOT ≥2 between 1/2014 and 9/2018 and were categorized as having or not having prior exposure to R (R-exposed; no-prior-R) in any prior LOT. Index regimen was the first use of I-/K-/or V-Rd. LOTs were defined via an algorithm developed with MM specialists to proxy the definition of a LOT in RCTs & in accordance with NCCN MM Guidelines.6 Baseline data included: CRAB (hyperCalcemia, Renal insufficiency, Anemia, and Bone lesions); high risk cytogenetics (defined as del[17p], 1q21 gain, t[4;14], or t[14;16]); Charlson Comorbidity Index (CCI) score; and modified frailty score using age and CCI score. Median duration of therapy (DOT) and time-to-next-treatment (TTNT) (a proxy for PFS; defined as time from index regimen start to subsequent LOT or death) were estimated using Kaplan-Meier methods and compared using covariate-adjusted Cox proportional hazard models (FIGURE). Observations were censored at time of loss to follow-up (f/u)/end of study period (9/30/2018). RESULTS: Of 650 pts included, 397 were R-exposed (IRd, n=112; KRd, n=115; VRd, n=170); 253 had no-prior-R (IRd, n=29; KRd, n=62; VRd, n=162). R-exposed pts, overall, were treated in later LOTs (LOT2: 55% v 78%) and had a longer median time from diagnosis to index LOT (26.7 v 13.4 months) than no-prior-R pts; this differed between treatment cohorts (TABLE). In R-exposed pts, more pts with symptomatic relapse (≥1 CRAB symptom, 87%) or high-risk cytogenetics (30%) received KRd than IRd (75% & 23%) or VRd (74% & 16%) (TABLE). More pts treated with IRd were ≥75 years old: 42% (IRd) v 36% (VRd) / 21% (KRd). In R-exposed pts, 35.3% of those receiving VRd in LOT ≥2 had prior V-IMID-based and 53.5% had IMID-based therapy (ie, IMID with no PI nor monoclonal antibody) in LOT1; &gt;98% of LOT1 IMID use was R, across groups. In R-exposed pts, 56.5% of those receiving KRd had prior V-IMID-based and 16.5% had IMID-based therapy in LOT1; in IRd pts in LOT ≥2, 29.5% and 43.8% had prior V-IMID-based and IMID-based therapy in LOT1. In unadjusted analysis, at a median f/u of 11, 11.9, and 14.8 months for I-, K-, and V-Rd, median TTNT for R-exposed pts: 12.3 months (IRd), 7.8 months (KRd), and 13.9 months (VRd) (P=0.50); HRs for TTNTLOT stratified: 0.84 (IRd v KRd), 0.96 (IRd v VRd), 1.15 (KRd v VRd), and median regimen DOTs: 8.4 months (IRd), 7.5 months (KRd), and 9.5 months (VRd) (P=0.75). In no-prior-R pts, HRs for TTNTLOT stratified were significant for IRd v KRd (HR=0.33) and KRd v VRd (HR=1.62) (P&lt;0.01, both); IRd v VRd (HR=0.53; P=0.11). In adjusted analysis, there were no significant differences for R-exposed pts by PI-Rd regimens for TTNT (FIGURE), nor for regimen DOT. For no-prior-R pts, adjusted HR for TTNT was significant for I- v K-Rd (HR=0.36; P=0.03) and for regimen DOT was significant for I- v V-Rd (HR=0.34; P=0.03). CONCLUSIONS: In this real-world study, the majority of pts received a PI-Rd combination after prior VRd or Rd in front-line. After controlling for baseline characteristics, including prior PI-exposure, PI-Rd triplets were comparable in TTNT in R-exposed pts treated in LOTs ≥2. TTNT was significantly longer for I- v K-Rd in pts with no-prior-R, although this is limited by small sample size. Published studies indicate that individualized treatment recommendations may improve real-world outcomes, such as IRd v KRd in frail pts which was associated with significantly longer TTNT.6 Prior-R exposure, in our analysis, does not appear to influence the relative PI-triplet regimen effectiveness in LOTs ≥2. With increasing use of R in earlier LOTs, understanding real-world treatment patterns and subsequent PI-Rd effectiveness in consequent LOTs is key for optimizing RRMM pt management. Disclosures Cherepanov: Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited: Current Employment. Romanus:Takeda: Current Employment. Raju:Xcenda: Current Employment, Other: Xcenda received research funding from Takeda. Blazer:Xcenda: Current Employment, Other: Xcenda received research funding from Takeda. Farrelly:Xcenda: Current Employment, Other: Xcenda received research funding from Takeda. Stull:Takeda: Current Employment. Ailawadhi:Phosplatin: Research Funding; Celgene: Honoraria; Amgen: Research Funding; Takeda: Honoraria; Janssen: Research Funding; Pharmacyclics: Research Funding; Cellectar: Research Funding; BMS: Research Funding; Medimmune: Research Funding.

Background Maintenance therapy improves PFS in NDMM pts. Additional active, well-tolerated treatment options that are suitable for long-term administration are required. The international, multicenter, double-blind, placebo-controlled, phase 3 TOURMALINE-MM4 trial (NCT02312258) of the oral PI ixazomib as maintenance therapy post-induction in non-transplant NDMM pts met its primary endpoint of PFS. Ixazomib demonstrated a significant and clinically meaningful benefit vs placebo, with a manageable and well-tolerated toxicity profile. Feasible, tolerable options for long-term therapy are particularly important in this setting, as pts are often elderly and/or frail. We report herein a subgroup analysis of TOURMALINE-MM4 according to age and frailty status. Methods Pts who achieved ≥partial response (PR) after 6-12 months of standard-of-care induction therapy were randomized 3:2 to ixazomib or placebo maintenance for up to 24 months. The sum of 4 components - age (&lt;75 vs 75-80 vs &gt;80 years; score 0 vs 1 vs 2), the Katz Index of Independence in Activities of Daily Living (ADL; &gt;4 vs ≤4, score 0 vs 1), the Lawton Instrumental ADL Scale (&gt;5 vs ≤5, score 0 vs 1), and the Charlson Comorbidity Index (≤1 vs ≥2, score 0 vs 1) - was used to classify pts as fit (total score: 0), unfit (score: 1), or frail (score: ≥2). Analyses of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and MY20 modules were conducted to evaluate the effects of treatment on QoL within subgroups defined by frailty status and age. Results In the ixazomib (n=425) vs placebo (n=281) arms, there were similar proportions of pts aged &lt;65, 65-74, and ≥75 years and of pts classified as fit, unfit, and frail (Table 1). Baseline disease and treatment characteristics were generally balanced in ixazomib vs placebo pts across the different age and frailty groups, with some numerical differences observed. In pts aged &lt;65 years, higher rates of International Staging System (ISS) stage III disease and fit pts and a lower rate of complete (CR) or very good partial (VGPR) response post-induction were seen (Table 1). Across frailty groups, a higher rate of CR or VGPR was seen in fit pts, a lower rate of ISS stage III disease was seen in unfit pts, and a higher rate of ISS stage III disease and a lower rate of CR or VGPR were seen in frail pts (Table 1). PFS benefit with ixazomib vs placebo was seen across age groups, with hazard ratios (HRs) of 0.576 (95% confidence interval [CI] 0.299-1.108, p=0.095, median 11.0 vs 9.3 months) in pts aged &lt;65 years, 0.615 (95% CI 0.467-0.810, p&lt;0.001, median 17.9 vs 9.3 months) in pts aged 65-74, and 0.740 (95% CI 0.537-1.019, p=0.064, median 16.7 vs 10.2 months) in pts aged ≥75 years. HRs for time to progression (TTP) were similar to those for PFS. PFS benefit with ixazomib vs placebo was also seen across frailty groups (Figure), with similar HRs for TTP. Rates of grade ≥3 treatment-emergent adverse events (TEAEs), serious TEAEs, and discontinuation due to TEAEs were higher or similar with ixazomib vs placebo across age and frailty subgroups (Table 2). Rates were generally somewhat higher in older age groups and in unfit/frail pts in both arms; nevertheless, rates of discontinuation due to TEAEs across groups were &lt;20%, even in pts aged ≥75 years and frail pts (Table 2). With ixazomib, rates of common gastrointestinal TEAEs were similar across age groups; rash and liver impairment appeared less common and peripheral neuropathy more common in older pts (Table 2). Covariate-adjusted changes in QoL subscales from baseline were estimated at each cycle using repeated measures linear mixed models stratified by frailty status. In all frailty groups, the mean changes in each treatment arm were small over time (&lt;10 points on a 0-100 scale) and similar between arms, indicating that continued treatment with ixazomib vs placebo maintenance did not adversely affect pts' QoL. Analyses by age were generally consistent with the results by frailty. Conclusions Ixazomib as post-induction maintenance therapy in non-transplant NDMM pts results in PFS benefits vs placebo regardless of age or frailty status. Ixazomib appeared generally well tolerated across groups, with TEAE rates in both arms generally elevated in elderly/frail vs younger/fit pts. Ixazomib is a feasible and effective maintenance option for prolonging PFS across this heterogeneous pt population. Disclosures Bringhen: Takeda: Consultancy; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Honoraria; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Karyopharm: Membership on an entity's Board of Directors or advisory committees. Vorog:Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited: Current Employment. Labotka:Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited: Current Employment. Wang:Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited: Current Employment. Cherepanov:Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited: Current Employment. Cain:Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited: Current Employment. Manne:Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited: Current Employment. Dimopoulos:Celgene: Honoraria; Janssen: Honoraria; Takeda: Honoraria; Bristol-Myers Squibb: Honoraria; Beigene: Honoraria; Amgen: Honoraria. OffLabel Disclosure: Use of the oral proteasome inhibitor ixazomib as maintenance therapy in patients with newly diagnosed multiple myeloma not undergoing stem cell transplantation

Background Multiple myeloma (MM), a malignant neoplasm of plasma cells in the bone marrow, accounts for up to 1.8% of all cancers in the U.S., most frequently affecting people 65-74 years old. A variety of therapies are available to manage MM, including stem cell transplantation (SCT), immunomodulatory drugs (IMiD), proteasome inhibitors (PI), monoclonal antibodies (mAB), and alkylating agents (alk). Given the heterogeneity of MM and the rapidly evolving therapeutic landscape, MM contemporaneous real-world treatment patterns are not well described. We examined the patient characteristics and first-line (LT1) treatment patterns in NDMM patients. Methods MM patients (≥18 years), diagnosed in April 30, 2015 - April 29, 2017 (early cohort) or in April 30, 2017 - April 30, 2019 (recent cohort), were followed retrospectively from MM diagnosis to last patient activity in the Flatiron Health database - a geographically-diverse, longitudinal electronic health record spanning over 280 community and academic cancer clinics in the U.S. LT1 regimens were described as: 1) containing an IMiD (thalidomide, lenalidomide [R], or pomalidomide), PI (bortezomib [V], carfilzomib, or ixazomib), alk (melphalan, cyclophosphamide [C], bendamustine), mAB (daratumumab, elotuzumab), or combinations of these; and 2) doublet/monotherapy (doublets-) vs. triplet or greater agent (triplets+) combinations. Treatment patterns were examined by SCT status and by cytogenetic risk (high: del17p, t(4;14) and/or t(14;16); standard: ≥1 cytogenetic tests without high cytogenetic risk) and age groups (<65, 65-74, ≥75). Duration of therapy (DOT) and time to next therapy (TTNT) were estimated using Kaplan-Meier methods in the early cohort with longer follow-up. Results Of 4,070 NDMM patients, 3,433 were non-SCT (nSCT: early cohort: n=1,736; recent cohort: n=1,697) and 637 had SCT (early cohort: n=407; recent cohort: n=230). In nSCT patients, mean age at diagnosis was 70 years (SD: 10); 46% were female; 36% had stage III (699/1916, among non-missing), and 15% (392/2574, among non-missing) had high risk MM (25% had unknown cytogenetics). SCT patients were younger at diagnosis (mean [SD]: 61 years [9]); 44% were female; 25% (117/470, in non-missing) had stage III, and 19% (102/547, in non-missing) had high risk MM (14% had unknown cytogenetics). Overall, proportions with known cytogenetic risk were similar within SCT status cohorts over time but were lower in the SCT group (nSCT early vs. recent cohort: 26% vs. 24% had unknown cytogenetics; and in SCT: 15% vs. 13%, respectively). In nSCT and SCT patients, respectively, most common regimens were VRd (d: dexamethasone; 44% and 58%), Rd (16% and 7%), Vd (13% and 1%), and VCd (12% and 4%). In nSCT patients, the use of VRd increased over time (37% [early cohort] to 51% [recent cohort]), while frontline therapy with Rd/Vd doublets (19% to 14%/16% to 9%) and with VCd (13% to 11%) decreased. In the nSCT recent cohort, VRd (51%) frontline therapy dominated, with a slightly higher proportion of patients in the high-risk group vs. standard and unknown risk receiving VRd (56% vs. 53% and 46%); use of doublet therapy with Rd/Vd was lower in the high risk (12%/5%) vs. standard risk group (14%/9%). Irrespective of age, VRd was the most common frontline regimen in the nSCT recent cohort, albeit its use was lower among patients 75+ years of age (43%) vs. younger patients (54% [<65 years] and 59% [65-74 years]); 75+ year old patients had a higher use of Rd/Vd doublets (19%/15%) vs. <65 (10%/5%) or 65-74 (10%/6%) years of age. Triplets+ were more commonly used than doublets- across all cohorts: 59% vs. 41% (nSCT early cohort); 74% vs. 26% (nSCT recent cohort); and 89% vs. 11% (SCT early cohort); 95% vs. 5% (SCT recent cohort). mAB use in the recent cohort was low: 1.4% nSCT and 2.2% SCT patients. In the nSCT early cohort, the median (95% CI) LT1 DOT was 10 months (9-11) and for TTNT was 14 months (13-16). Conclusions PI/IMiD treatment combinations were most commonly observed in both nSCT and SCT patients, with an increase in use from early (40%) to recent (56%) cohort in nSCT patients. Use of triplets, generally, is on the rise from early (60%) to recent cohorts (74%). LT1 TTNT was lower than has been shown in clinical trials. These findings indicate a notable change in treatment patterns over time in nSCT NDMM patients, highlighting the changing landscape of MM management. Disclosures Ailawadhi: Celgene: Consultancy; Takeda: Consultancy; Cellectar: Research Funding; Amgen: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Pharmacyclics: Research Funding. Romanus:Takeda: Employment. Cherepanov:Takeda: Employment. Yin:Takeda: Employment. Cheng:Takeda: Employment. Hari:Celgene: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria, Research Funding; BMS: Consultancy, Research Funding; Janssen: Consultancy, Honoraria; Kite: Consultancy, Honoraria; Amgen: Research Funding; Spectrum: Consultancy, Research Funding; Sanofi: Honoraria, Research Funding; Cell Vault: Equity Ownership; AbbVie: Consultancy, Honoraria.