Navigating the Changing Multiple Myeloma (MM) Treatment Landscape: Real-World Data on Clinical Practice Patterns in 287 MM Patients Treated in and Outside German DSMM (Deutsche Studiengruppe Multiples Myelom) Study Group Trials

Introduction: Over the last decade MM diagnosis and therapy have greatly improved; notably due to an increasing number of "novel agents" (NA; e.g. PIs, IMiDs, mAbs, HDAC-, PD1/PD-L1-inhibitors). Anti-MM-therapy has gained complexity; orientation towards "state of the art" chemotherapy (CTx) protocols and international guidelines, as well as their continuous evaluation is highly important. According to the international literature, analyses of CTx management and particularly the use of novel substances have mainly been performed in the context of clinical trials (CT), therefore in a selected minority of patients (pts). In order to determine, whether guideline recommendations on MM therapy are thoroughly implemented in- and outside CT settings, we performed a real-world data analysis on clinical MM practice patterns. Substance use was analyzed in view of treatment lines and evaluated for "MM-pathway conformity".

Methods: We performed a detailed analysis of 287 myeloma pts treated at our University Medical Center, part of the DSMM study group in 2014/15. The pt cohort was defined using the hospital pharmacy and tumor documentation (TBD) databases. TBD analysis enabled the detailed acquisition of pt characteristics, such as age at initial diagnosis (ID), gender, Durie and Salmon (D&S) and International Staging System stage (ISS). Status of transplantation (Tx), comorbidity (via Revised Myeloma Comorbidity Index [R-MCI]), CT data, treatment line/cycle and the year of CTx application were collected using electronic medical records, TBD and CTx management tools. Basic data on therapy composition was collected for the years 2005 to 2017, separating two treatment periods for 1st, 2nd and 3rd-line therapy of 2005-2012 and 2013-2017. This cut-off was carefully chosen to discriminate best between NA- and non-NA-based regimens, and between first generation PI- (bortezomib (BOR) and IMiD-use (thalidomide (THAL), lenalidomide (LEN)) and second generation NA.

Results: Pt characteristics were representative for tertiary centers with a median age of 63 years (27-89), 54% were 60-79 and 14% >80 years old. The male:female gender ratio was 58%:42% and ISS predominantly advanced (II/III:62%). Pts showed substantial comorbidities and were classified as fit, intermediate-fit and frail according to R-MCI in 33%, 56% and 11%, respectively. Of interest, 33% of pts could be enrolled in CTs and 88% received 1st line treatment at our center. 275 pts received 1st-line, 149 pts 2nd-line and 97 pts 3rd-line treatment (Fig.1). As expected, numbers of pts decreased with subsequent lines of treatment, albeit the median time to 2nd line therapy due to progression amounted to 2 years. As depicted in Fig.1, 1st line conventional CTx (cCTx) alone was rare and substantially declined over time from 12% 2005-2012 to 1% in 2013-2017. 200 pts (73%) were treated with BOR in 1st line, 63 of 106 reinduced pts received BOR in 2nd or 3rd line. IMiD 2nd and 3rd line treatment was also common within different regimens and the combination of 2 NA of both PI+IMiD increased over time (BOR+THAL, BOR+LEN). The use of second generation NA in 2nd and 3rd line treatment notably increased in 2013 to 2017 in line with their approval. Our analysis revealed that 44% of second generation NA protocols were administered outside CT settings, mainly due to tight inclusion and wide CT exclusion criteria. Maintenance was performed in 57% of pts, predominantly with LEN (60%) and within DSMM CT protocols.

Conclusion: Our analyses demonstrate that NA combinations are used predominantly today, whereas the use of cCTx alone is substantially declining. While BOR plays an important role in induction, LEN was subsequently used for maintenance and in outpatient-regimens. BOR-reinduction as a validated treatment option is also reflecting the substantial amount of BOR-based protocols worldwide. A significant percentage of second generation NA are administered outside CT settings, representing the fast and effective implementation of guideline recommendations into the real-world clinical practice at our and other MM centers. Currently, we are assessing the percentage of pts discussed in our weekly MM tumorboard, the evidence level of therapeutic interventions, PFS and OS. Results will be shown at the meeting, including the comparison of our data with others in a detailed review of the literature.

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