PRINCIPLES: Chronic obstructive pulmonary disease (COPD) is a major burden on patients and healthcare systems. Diagnosis and the management of COPD are often administered by general practitioners (GPs). This analysis investigated the adherence of GPs in Switzerland to the Global Initiative for Chronic Obstructive Lung Diseases (GOLD) guidelines. METHODS: As part of an ongoing investigation into the effect of GPs prescriptions on the clinical course of COPD, 139 GPs submitted a standardised questionnaire for each COPD patient recruited. Information requested included spirometric parameters, management and demographic data. Participating GPs were provided with and received instruction on a spirometer with automatic feedback on quality. Patients were grouped by the investigators into the GOLD COPD severity classifications, based on spirometric data provided. Data from the questionnaires were compared between the groups and management was compared with the recommendations of GOLD. RESULTS: Of the 615 patients recruited, 44% did not fulfil GOLD criteria for COPD. Pulmonary rehabilitation was prescribed to 5% of all patients and less than one-third of patients exercised regularly. Less than half the patients in all groups used short-acting bronchodilators. Prescribing long-acting bronchodilators or inhaled corticosteroids conformed to GOLD guidelines in two-thirds of patients with GOLD stage III or IV disease, and approximately half of the less severe patients. Systemic steroids were inappropriately prescribed during stable disease in 6% of patients. CONCLUSIONS: Adherence to GOLD (COPD) guidelines is low among GPs in Switzerland and COPD is often misdiagnosed or treated inappropriately. This is probably due to poor knowledge of disease definitions.
For patients with relapsed or refractory multiple myeloma (MM) treated with a prior high-dose therapy (HDT) followed by autologous peripheral blood stem cell transplantation (PBSCT), the reapplication of HDT is a widely used salvage strategy. In this retrospective study, we report on 55 patients who were treated with salvage HDT at our institution. The conditioning regimen consisted of melphalan 200 mg/m(2) (27%), melphalan 140 mg/m(2) and busulfan 12 mg/kg body weight (40%), or melphalan 200 mg/m(2) and bortezomib 1.3 mg/m(2) (33%). Treatment-related mortality was 5% and response rates were as follows: 9% complete remission, 9% very good partial remission, 56% partial remission, 11% minimal response + stable disease, and 4% progressive disease (5% not assessable). Toxicity was moderate and the median event-free (EFS) and overall survival (OS) were 14 months and 52 months, respectively. The different conditioning regimens did not result in differences in terms of remission rates, EFS and OS, or toxicity. In multivariate analysis a duration of remission of more than 12 months after the first transplant was the only predictive factor for both EFS (p < 0.0001) and OS (p = 0.0001). In conclusion, salvage HDT followed by autologous PBSCT is an effective treatment option for patients with relapsed or refractory MM, while patients with an early relapse after their first transplant do not benefit from this treatment modality.
4087 Introduction: Secondary primary malignancies (SPM) are an emerging issue in patients with multiple myeloma (MM) since the French IFM 99–02 trial has been closed as a consequence of a higher incidence of SPM in patients who had received lenalidomide as maintenance treatment compared to the patients in the placebo arm. Methods: To evaluate the incidence of SPM in the group of patients, who were treated with high-dose therapy (HDT) followed by autologous peripheral blood stem cell transplantation (PBSCT), we retrospectively looked at a homogeneous group of 313 consecutive patients, who were diagnosed with MM and had received HDT and autologous PBSCT at our hospital between December 1994 and January 2009. Induction treatment consisted of conventional chemotherapy without novel agents in 95% of patients and maintenance treatment was given with interferon or thalidomide in 37% und 35% of patients, respectively. Results: Within 313 patients with a median age of 55 (range: 31–74) years at diagnosis, we observed 18 (5.8%) patients who developed a SPM at various time points during the course of their disease. The number of patients who developed a solid neoplasm or a hematologic malignancy was identical. While the types of solid tumor observed varied greatly, we noted 8 patients with MDS/AML and only one patient with Hodgkins Disease. The median time from diagnosis of MM to the occurrence of SPM was 56 months (range: 14–127). The cumulative incidence of SPM was 19.7% with a rate of 0.7%, 5.8% and 15.7% at 2, 5 and 10 years after diagnosis without statistical differences between the group of patients with solid tumors (0.3%, 4.4%, 7.5%) and those with hematologic malignancies (0.4%, 1.8%, 9.3%). OS from the time of diagnosis in our group of 18 patients with SPM was not significantly different from that of patients without SPM with in median 70 and 83 months (p=0.7, HR 0.9 (0.5–1.7)), respectively. The same was true, when a landmark analysis was performed for patients alive after 2, 5 and 8 years with hazard ratios of 0.9 (95%CI 0.5–1.7, p=0.8), 0.6 (95%CI 0.3–1.4, p=0.2) and 1.0 (95%CI 0.2–4.3, p=1.0), respectively. In line with this finding, we found that survival time of more than 5 years from the time of diagnosis was the only prognostic parameter indicating a greater risk for the development of SPM (HR 4.7 (95%CI 1.1–19.8), p=0.04). In particular, we did not find any relationship to the incidence of SPM and the treatment with novel agents. The incidence rate of 206 patients, who were exposed to thalidomide was 6% (n=13, HR1.4 (95%CI 0.5–4.0), p=0.5), while of the 123 patients exposed to bortezomib 5 developed a SPM (4%, HR 0.4 (95%CI 0.1–1.1), p=0.1). There were two cases of SPM among the 71 patients following lenalidomide treatment (3%, HR 0.4 (95%CI 0.1–1.5), p=0.2). Having a closer look at the maintenance setting, which is associated with a longer duration of drug exposure, we did not find a higher incidence of SPM in patients treated with thalidomide maintenance after HDT in comparison to patients who had received interferon or no maintenance therapy (HR 1.0, 95%CI 0.3 – 3.2, p=1.0). Conclusions: In conclusion, the incidence of SPM in patients with MM treated with HDT is increased, especially for patients with a prolonged life span. SPM were not related to various treatment modalities including maintenance treatment with thalidomide. As a consequence on the available data, physicians should be aware of the risk of SPM and diagnostic measures to detect SPM should be included in the daily clinical workup of patients with MM. Disclosures: Fenk: Celgene: Consultancy, Research Funding; Ortho Biotec: Consultancy. Germing:Celgene: Consultancy, Research Funding. Gattermann:Celgene: Consultancy, Research Funding. Kobbe:Celgene: Consultancy, Research Funding; Ortho Biotec: Consultancy.
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