Treatment of Persons with Multiple Myeloma in Underprivileged Circumstances: Real-World Data from a Single Institution

Abstract

Background: The treatment of patients with multiple myeloma (MM) has evolved in recent years, and the disease-associated prognosis has improved substantially. This improvement has been driven largely by the approval of novel agents, many of which are expensive and not universally available. Less expensive but effective approaches would be of value globally. Patients and Methods: All consecutive MM patients diagnosed in the Centro de Hematología y Medicina Interna de Puebla after 1993 were included in this study. Patients were given oral thalidomide (100 mg/day), oral dexamethasone (36–40 mg/week), and aspirin 100 mg/day. Bor­tezomib (1.75 mg s.c. every week) was administered to those who could afford it. After 4–6 weeks of treatment, patients were offered an outpatient-based hematopoietic cell transplant (HCT). After the recovery of granulocytes following HCT, patients continued indefinitely on thalidomide; those who failed to tolerate thalidomide were switched to lenalidomide (25 mg/day). Results: The median overall survival (OS) for all patients has not been reached and is >157 months. Median follow-up of the patients lasted 14 months (range 1.3–157). The median OS of patients with and without HCT was similar. The response rate (complete remission or very good partial remission) was 72% for those given thalidomide plus dexamethasone versus 88% for those given bortezomib, thalidomide, and dexamethasone before HCT, but OS was not different. As post-HCT maintenance, 37 patients received thalidomide; 26 of those (70%) could be maintained indefinitely on thalidomide, whereas 11 were switched to lenalidomide after a median of 7 months; median OS of patients maintained on thalidomide or lenalidomide after HCT was not different. Conclusion: In this series, a regimen incorporating low-cost novel agents and outpatient HCT was associated with excellent long-term survival in the treatment of MM patients. This approach may be a model for MM treatment in underprivileged circumstances.

Up to half of patients diagnosed with chronic lymphocytic leukemia in México may not require treatment

“…The diminished aggressiveness of CLL in México may stem from several facts: (a) Most patients (80%) presented in this study in early stages of the disease (Rai stages 0-2); (b) 89% of patients were ZAP-70 negative, whereas in Caucasians the negativity of ZAP-70 is around 60% [12]; (c) There were no cases of T-CLL; (d) Genetic factors may be involved as has been shown in multiple myeloma [4,[9][10][11], and (e) Other unknown reasons.…”

“…As far as the age of the patients is concerned, the median age was found to be lower than that informed in Caucasian populations (65 versus 70 years) [8]. We have previously shown that multiple myeloma, in addition to being less frequent in Mexican mestizos, is also less aggressive [9,10]. In this study, despite the use of medications that were not especially expensive, we observed good patient outcomes in patients with newly diagnosed CLL, with an OS of more than 20 years (median not yet reached): these data suggest that the clinical course of CLL patients in México is less aggressive than in Caucasian populations, as it has been shown in multiple myeloma [9][10][11].…”

“…We have previously shown that multiple myeloma, in addition to being less frequent in Mexican mestizos, is also less aggressive [9,10]. In this study, despite the use of medications that were not especially expensive, we observed good patient outcomes in patients with newly diagnosed CLL, with an OS of more than 20 years (median not yet reached): these data suggest that the clinical course of CLL patients in México is less aggressive than in Caucasian populations, as it has been shown in multiple myeloma [9][10][11]. Genetic differences have been suggested to explain the differences in the prevalence of CLL in México [4], but the precise explanation has not been found.…”

Mantle cell lymphoma may have a different clinical course in Mexican Mestizos: Real-world data from a single center

“…Jean Bernard, an icon in the world's hematology, presented in 1963 the concept of "geographic hematology" distinguishing two major branches; the so-called "ethnic hematology" that dealt with differences between populations and a second branch about environmental factors such as food habits, infections, and its implication with the hematological diseases referred as "environmental hematology" 4,7 . Along this line, we have analyzed the salient features of several hematological diseases, making comparisons with the features of some conditions in other populations 4 : we have shown that two B-cell malignancies, both CLL and multiple myeloma, are less frequent and less aggressive in México than in Caucasian populations 4,8,9 .…”

Treating Plasma Cell Myeloma in Developing Countries: Does Everyone Need the Newest Drugs?

“…In this issue of Acta Haematologica, Murrieta-Alvarez et al [1] report on the results of plasma cell myeloma (PCM) therapy at an advanced cancer centre in Puebla Mexico where many anti-myeloma drugs, including dexamethasone, thalidomide, bortezomib, and lenalidomide, were available but many newer therapies such as pomalidomide, carfilzomib, xiazomib, and daratumu­mab were not. Moreover, not everyone had access to bor­tezomib and lenalidomide because the costs of these drugs are not covered by Mexico’s national health insurance.…”