Multiple myeloma: patient outcomes in real-world practice

Abstract

With increasing number of therapies available for the treatment of multiple myeloma, it is timely to examine the course of patients' journeys. We investigated patient characteristics, treatment durations and outcomes, and symptom burden across the treatment pathway in Belgium, France, Germany, Italy, Spain, Switzerland and the UK. In total, 435 physicians retrospectively reviewed 4997 patient charts. Profiles of patients diagnosed with multiple myeloma during the last 12 months were similar across countries; bone pain was the most common presentation. Median duration of first-line therapy was 6 months, followed by a median treatment-free interval of 10 months; both these decreased with increasing lines of therapy, as did time to progression. Depth of response, as assessed by the treating physician, also decreased with each additional line of therapy: 74% of patients achieved at least a very good partial response at first line, compared with only 11% at fifth line. Deeper responses were associated with longer time to progression, although these were physician-judged. Toxicities and co-morbidities increased with later treatment lines, and were more likely to have led to discontinuation of treatment. These real-world data provide an insight into patient outcomes and treatment decisions being made in clinical practice.

Keywords: depth of response; duration of therapy; multiple myeloma; patient chart review; real-world practice.

Figure 1

Treatment distribution: (A) first line (n = 1802); (B) second line (n = 1380). CDT, cyclophosphamide + dexamethasone + thalidomide; CVD, bortezomib (Velcade) + cyclophosphamide + dexamethasone; MPT, melphalan + prednisolone + thalidomide; RVD, lenalidomide + bortezomib + dexamethasone; PAD, bortezomib + doxorubicin (Adriamycin) + dexamethasone; VM, bortezomib (Velcade) +  melphalan; VMP, bortezomib (Velcade) + melphalan + prednisone; VTD, bortezomib + thalidomide + dexamethasone.

Figure 2

Treatment duration and treatment‐free intervals. Data on the proportion of patients who had received each line are from the cross‐sectional review; data on durations of treatment and treatment‐free intervals are from the retrospective review. 1L–5L, first line–fifth line; CI, confidence interval; m, month.

Figure 3

Time to progression (A) by line of treatment, and by depth of response to (B) first‐line treatment, (C) second‐line treatment, and (D) third‐line treatment. Only patients who had progressed at the time of inclusion in the study were included in this analysis. ^aThe number of patients with a CR at third line was too small to make an accurate estimate. 1L–5L, first line–fifth line; CR, complete response; PR, partial response; VGPR, very good partial response.

Figure 4

Reasons for ending treatment. Physicians could select more than one reason. 1L–5L, first line–fifth line.

Figure 5

Reasons for ending lenalidomide treatment before progression.

Figure 6

Association of patient characteristics with the probability of receiving a further line of treatment. Associations between the probability of receiving a further line of treatment and patient and disease characteristics were calculated using logistics regression analyses. A P value of <0·05 was considered statistically significant. AE, adverse event; CI, confidence interval; CR, complete response; ECOG PS, European Cooperative Oncology Group performance status; SCT, stem cell transplant; SRE, skeletal‐related event; VGPR, very good partial response.

Figure 7

Adverse events. URI, upper respiratory infection.

Figure 8

Concomitant medications. 1L–5L, first line–fifth line; ESA, erythropoiesis‐stimulating agent; G‐CSF, granulocyte‐colony stimulating factor; Step 1 analgesic, mild – requiring non‐steroidal anti‐inflammatory drugs and, if the pain is postoperative in nature, infiltration with local anaesthetics; Step 2 analgesic, moderate – Step 1 plus opioid analgesics when required; Step 3 analgesic: severe – Step 1 and Step 2 plus local anaesthetic neural blockade with or without catheter plus sustained‐release opioid analgesic. Some patients received more than one level of analgesic in each line.