Over the past decades significant therapeutic advances have been made in the treatment of multiple myeloma (MM). A population-based study of 45,595 patients showed substantial incremental increases in myeloma-specific survival in patients younger than 80 years treated between 1973 and 2009. Depth of response to therapy has long been associated with improved long-term outcomes. Autologous stem cell transplantation (ASCT) was previously the only modality capable of inducing a very good partial response (VGPR) or complete response in a substantial proportion of patients. The introduction of 2 classes of novel agents, immunomodulatory drugs and proteasome inhibitors, resulted in induction regimens that achieve VGPR rates exceeding 60% even before transplant, thus challenging the role of ASCT. Allogeneic stem cell transplantation (allo-SCT) has also been tested in patients with MM; however, its current role remains undefined given the high rates of transplant-related mortality and chronic graft-versus-host disease. Posttransplant consolidation and maintenance strategies have further improved progression-free and overall survivals. This article discusses the current roles of ASCT, allo-SCT, and consolidation and maintenance therapies in the management of MM.
Matthew Mei and George Somlo
Zeynep Eroglu, Odicie Fielder and George Somlo
Over the past few decades, substantial progress has been made in the diagnosis and treatment of breast cancer. Early identification of relapsed and metastatic disease has been a primary focus of ongoing research. Circulating tumor cells (CTCs) are implicated as harbingers of metastases. With advances in detection technologies, CTCs offer the option for real-time liquid biopsies. Methods to identify CTCs in the bloodstream by physical or biochemical properties, although feasible, still require improvements to promote widespread, reproducible use. Sufficient data support enumeration and assessment of changes in the number of CTCs as prognostic indicators, but controversy around their predictive utility for selecting treatments remains. As the technology to detect CTCs and characterize their heterogeneous molecular profile evolves, additional information will likely be obtained to guide targeted and individualized therapies.
Rondi M. Kauffmann, Leanne Goldstein, Emily Marcinkowski, George Somlo, Yuan Yuan, Philip H.G. Ituarte, Laura Kruper, Leslie Taylor and Courtney Vito
Background: Antiestrogen (anti-e) use in estrogen receptor–positive (ER+) ductal carcinoma in situ (DCIS) has been shown to reduce the incidence of noninvasive and invasive breast cancer. Few studies have evaluated factors associated with anti-e recommendation in ER+ DCIS. Methods: The California Cancer Registry was queried for female patients diagnosed with ER+ DCIS and treated with lumpectomy or unilateral mastectomy from 2004 to 2011. Patient demographics, comorbidities, and clinical characteristics were analyzed for association with anti-e recommendation. Results: Of 5,527 patients identified, 76.4% patients underwent lumpectomy and 23.6% underwent unilateral mastectomy. Of the total cohort, 31.6% patients were recommended anti-e therapy, 60.4% were not, and the remaining 8.0% were recommended anti-e, but administration was not documented. Performance of lumpectomy predicted anti-e use compared with mastectomy (odds ratio [OR], 2.08; 95% CI, 1.77–2.43). Asian/Pacific Islanders were more often recommended anti-e therapy when compared with whites (OR, 1.28; 95% CI, 1.10–1.49). Patients younger than 70 years were more often recommended anti-e (age, 18–49 years: OR, 1.38; CI, 1.12–1.71; and age, 50–69 years: OR, 1.43; CI, 1.20–1.71). Conclusions: Despite current guidelines to consider the use of anti-e therapy, recommendation of anti-e after surgical treatment of DCIS is low, having been recommended to 40% of patients, and used by fewer than one-third. Significant predictors include lumpectomy compared with unilateral mastectomy, Asian/Pacific Islander race, younger age, and number of comorbidities. Further work is merited to understand patterns of anti-e therapy recommendation by providers in patients with DCIS.
Laura Bourdeanu, Thehang Luu, Norma Baker, Suzanne Swain-Cabriales, Cathie T. Chung, Joanne Mortimer, Arti Hurria, Sandra Helton, David Smith, Betty Ferrell, Gloria Juarez and George Somlo
Delays between presentation and treatment could have a significant effect on breast cancer mortality. The authors hypothesized that patient, physician, and system barriers are all responsible for treatment delays. Therefore, a study was conducted to define prevalent barriers to treatment from the patient’s perspective. A modified 43-item Likert-scale questionnaire was administered to patients with clinical stage III locally advanced breast cancer (LABC) who had experienced a delay in treatment of 3 months or more. Between October 2008 and January 2010, 153 patients presented with LABC; 43 patients (28.1%) met eligibility, and 40 completed the questionnaire. Among the patient barriers reported, 38% of patients delayed care for fear of losing their breast and 47% awaited previously scheduled routine appointments instead of seeking care. Among the physician barriers reported, 20% of physicians of initial contact did not believe the breast lump/symptom was related to cancer and 15% did not believe it needed a biopsy. Among the system barriers reported, the most prevalent were delays in performing diagnostic tests and obtaining insurance authorization for tests, treatment, or physician visits. Substantial delays were seen in 28.1% of patients from presentation to when they sought therapy at City of Hope Comprehensive Cancer Center. The high prevalence of patient barriers versus physician/system barriers suggests that increased educational efforts for patients and health care professionals are needed.
Kenneth C. Anderson, Melissa Alsina, William Bensinger, J. Sybil Biermann, Asher Chanan-Khan, Adam D. Cohen, Steven Devine, Benjamin Djulbegovic, Cristina Gasparetto, Carol Ann Huff, Madan Jagasia, Bruno C. Medeiros, Ruby Meredith, Noopur Raje, Jeffrey Schriber, Seema Singhal, George Somlo, Keith Stockerl-Goldstein, Guido Tricot, Julie M. Vose, Donna Weber, Joachim Yahalom and Furhan Yunus
Kenneth C. Anderson, Melissa Alsina, Djordje Atanackovic, J. Sybil Biermann, Jason C. Chandler, Caitlin Costello, Benjamin Djulbegovic, Henry C. Fung, Cristina Gasparetto, Kelly Godby, Craig Hofmeister, Leona Holmberg, Sarah Holstein, Carol Ann Huff, Adetola Kassim, Amrita Y. Krishnan, Shaji K. Kumar, Michaela Liedtke, Matthew Lunning, Noopur Raje, Seema Singhal, Clayton Smith, George Somlo, Keith Stockerl-Goldstein, Steven P. Treon, Donna Weber, Joachim Yahalom, Dorothy A. Shead and Rashmi Kumar
Multiple myeloma (MM) is a malignant neoplasm of plasma cells that accumulate in bone marrow, leading to bone destruction and marrow failure. Recent statistics from the American Cancer Society indicate that the incidence of MM is increasing. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) included in this issue address management of patients with solitary plasmacytoma and newly diagnosed MM.
Shaji K. Kumar, Natalie S. Callander, Melissa Alsina, Djordje Atanackovic, J. Sybil Biermann, Jason C. Chandler, Caitlin Costello, Matthew Faiman, Henry C. Fung, Cristina Gasparetto, Kelly Godby, Craig Hofmeister, Leona Holmberg, Sarah Holstein, Carol Ann Huff, Adetola Kassim, Michaela Liedtke, Thomas Martin, James Omel, Noopur Raje, Frederic J. Reu, Seema Singhal, George Somlo, Keith Stockerl-Goldstein, Steven P. Treon, Donna Weber, Joachim Yahalom, Dorothy A. Shead and Rashmi Kumar
Multiple myeloma (MM) is caused by the neoplastic proliferation of plasma cells. These neoplastic plasma cells proliferate and produce monoclonal immunoglobulin in the bone marrow causing skeletal damage, a hallmark of multiple myeloma. Other MM-related complications include hypercalcemia, renal insufficiency, anemia, and infections. The NCCN Multiple Myeloma Panel members have developed guidelines for the management of patients with various plasma cell dyscrasias, including solitary plasmacytoma, smoldering myeloma, multiple myeloma, systemic light chain amyloidosis, and Waldenström's macroglobulinemia. The recommendations specific to the diagnosis and treatment of patients with newly diagnosed MM are discussed in this article.