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What Predicts Early Mortality in Myeloma?

Value-Based Care in Myeloma - Front-line Therapy, Maintenance Therapy, Multiple Myeloma
Caroline Helwick

Despite advances in the treatment of multiple myeloma, survival time is short for many newly diagnosed patients, often because of treatment complications.

“It’s not clear if newer agents have impacted this early mortality, and whether we can identify patients at the highest risk of early death based on the clinical and laboratory features with which they present,” said Vishal Rana, MBBS, of the Mayo Clinic in Rochester, MN, who led a study that looked for factors that predict early death from myeloma (Rana V, et al. Blood (ASH Meeting Abstracts). 2011;118:Abstract 3981).

The study was based on 1545 patients seen within 90 days of diagnosis at the Mayo Clinic from January 1999 to December 2008. The investigators identified 265 patients who died within 12 months of follow-up. For each patient, they identified 2 control subjects who were alive at 12 months and were closest to the case in terms of the time of diagnosis.

“We examined the impact of age, performance status, hemoglobin, platelets, serum creatinine, calcium, lactose dehydrogenase, albumin, B2M (beta2 microglobulin), free light chain difference, plasma cell labeling index, risk category, ISS [International Staging System] stage, and exposure to novel agents,” Dr Rana said.

The multivariate analysis showed that advanced age (>72 years), poor performance status (Eastern Cooperative Oncology Group score >2), high calcium level (>11.3 mg/dL), and ISS stage 3 at diagnosis best predicted mortality within 12 months of diagnosis.

More Risk Factors, Greater Risk of Early Death

The researchers then developed a risk score using 1 point for each risk factor. The odds ratio for patients dying in the first year was 2.7 in the presence of 1 risk factor, 9.2 in the presence of 2 risk factors, and 37.0 in the presence of ≥3 risk factors compared with patients lacking these risk factors.  

They then looked at the impact of initial therapy on outcome. Among the 279 patients (35%) who received a novel agent (ie, thalidomide, lenalidomide, or bortezomib) as initial therapy, the odds ratio for dying in the first year was 0.35 compared with patients who did not receive a novel agent.

“Despite improvements in treating multiple myeloma, early mortality continues to be a limitation. We have identified factors that help predict the risk of early death,” Dr Rana said. “The difference in mortality based on the risk factors holds true for patients whether they received novel agents up front or not; however, patients who received novel agents up front had 65% less chance of death in the first year.”

Because novel agents are much better tolerated than older therapies, patients should be offered the benefit of these drugs up front, the investigators concluded.

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Last modified: May 20, 2015
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