Cyclophosphamide, Thalidomide, and Dexamethasone as Initial Therapy for Patients With Newly Diagnosed Multiple Myeloma in a Middle-Income Country: 7-Year Follow-Up

Abstract

PURPOSE Major progress has occurred in multiple myeloma (MM) treatment in recent years, but this is not seen in low- and middle-income countries. MATERIALS AND METHODS We retrospectively assessed the efficacy and safety of cyclophosphamide, thalidomide, and dexamethasone (cyclophosphamide 400 mg/m2 for 5 days, thalidomide 100 mg once daily, if tolerated, and dexamethasone 40 mg once weekly; in 28-day cycles) in patients with newly diagnosed MM treated at our institution between April 2008 and December 2012. Survival outcomes were estimated by the Kaplan-Meier method. RESULTS Fifty-nine patients were found to meet the selection criteria. Median age was 56 years (27-78). Fifty-nine percent (n = 35) were male. International Staging System three was found in 24%. The median number of treatment cycles was 11 (range 4-12). After a median of 81-month follow-up (range 5-138 months), the overall response rate was 69.5%. The complete response and very good partial response were 5% and 32%, respectively. Median progression-free survival (PFS) was 35 months (95% CI, 18 to 41). The 3-year PFS was 47.4% (95% CI, 34.5 to 59.6) and 5-year PFS was 24.9% (95% CI, 14.4 to 36.9). The median of overall survival (OS) was 81 months (95% CI, 33 to not reached). The 3-year OS was 63.4% (95% CI, 49.2 to 74.6), and 5-year OS was 57.5% (95% CI, 43.2 to 69.4). The most common adverse event was neutropenia (grade 3 and 4, 30.5%). Out of 23 patients eligible for stem-cell transplantation, 10 (43.5%) proceeded with autologous transplantation. Treatment-related deaths occurred in four patients (6.7%). CONCLUSION Cyclophosphamide, thalidomide, and dexamethasone achieves good response rates with tolerable toxicity, especially in patients age 65 years or younger representing a feasible approach for patients with MM in low-income health care settings.

Response and Survival Estimates of Patients With Plasma Cell Myeloma in a Resource-Constrained Setting Using Protocols From High-Income Countries: A Single-Center Experience From Sri Lanka

“…However, Vasquez et al reported a median OS of 81 months and a 5-year OS rate of 57.5% in a study from a middle-income country. 23 Furthermore, we did not see a survival difference between patients treated with CTD and BTD. Similar results were reported by Rosiñol et al The estimated OS rate at 4 years was 74% for patients treated with BTD, and there was no OS difference between BTD and other treatments groups.…”

“…An Iranian study has shown the median age of presentation to be 51 years, 22 and a Pakistani study has shown it to be 57 years. 20 In another study from Vasquez et al 23 from a middle-income country, the median age was 56 years and 59% were male. However, our data are similar to the data of an Asian Myeloma Network study, in which the median age of presentation was 62 years.…”

“…A study by Vasquez et al 23 from a middle-income country showed a total response rate of 69.5% using CTD. Our study showed 15.3% CR rate and 97% OR rate in the group treated with CTD, which is higher than that reported by the study by Vasquez et al The finding in our study is comparable with the results reported in the myeloma IX trial by Morgan et al 7 The OR rate and CR rate with CTD in their study were 82.5% and 13.0%, respectively.…”

“…However, Vasquez et al reported a median OS of 81 months and a 5-year OS rate of 57.5% in a study from a middle-income country. 23 …”

“… 9 In a study from South America, the incidence of VTE was 6.8%. 23 However, there are no guidelines or publications related to VTE risk in Asian people, and maintenance of low-molecular-weight heparin is relatively expensive in the local setting. Furthermore, aspirin has been used in primary and secondary thromboprophylaxis.…”