Real-world epidemiology, treatment patterns and survival of multiple myeloma patients in a large nationwide health plan.

BACKGROUND: Survival of patients with multiple myeloma (MM) has improved significantly with access to autologous stem cell transplant (SCT) and new treatments. This study aims to describe epidemiology, treatment patterns, and outcomes of MM in Israel. METHODS: A retrospective observational study was conducted in Maccabi Healthcare Services, a 2-million-member nationwide health plan in Israel. MM was defined by cross-linking data on MM diagnoses, dispensed treatments, and serum free light-chain assays. Point prevalence (31/12/2016) and incidence (2012-2016) rates were age-standardized. Newly diagnosed and treated patients (2009-2015) were followed through 31/12/2016 for progression to second-line (L2), with death as a competing risk. RESULTS: MM prevalence and incidence rates were 26.2 and 4.6 per 100,000 population, respectively. In the treatment cohort (N = 552), mean ±â€¯SD) age was 65.6 ±â€¯11.3) years (60.1% male) and median (95% CI) OS in years was 5.2 (4.3-6.1) overall and 6.5 (4.9-8.1) for first-line (L1) bortezomib (N = 421). In a multivariable analysis, OS was significantly higher among patients starting L1 in 2012-2015 vs. 2009-2011. Within a year, 38.4% underwent SCT. Cumulative incidence of L2 was 38.2% and 51.4% within 1 and 2 years, respectively, and was associated with older age (≥65y; P < 0.001). CONCLUSION: These results from a large heterogeneous population demonstrate MM incidence and survival rates that are in line with the literature, together with a significant improvement in overall survival over time. Approximately half of newly treated patients progressed to L2 within two years. These results will serve as a baseline for further research to evaluate the clinical impact of new interventions.

[Bone marrow transplantation--new developments in the last decade].

The last decade has witnessed very significant developments in the field of bone marrow transplantation (BMT), resulting in the improved safety and availability of this procedure. The expansion of international registries of voluntary, unrelated donors, the establishment of banks of fetal cord blood stem cells, as well as improved technology for transplantation of stem cells derived from partially matched family members, offer this treatment to patients hitherto not eligible for BMT. In addition to better donor availability, there has been a change in the concept regarding the role of BMT in the treatment of cancer: the understanding that the transplanted donor cells are capable of mounting an immunological assault against the host malignant cells. This goal can be achieved without fully destroying the patient's bone marrow stem cells and thus prepare the patient for transplantation with a reduced dose intensity of the myelotoxic drugs. Such nonmyeloablative conditioning increases the safety of the procedure. These developments have resulted in a vast expansion of the patient population eligible for BMT, including patients older than those who could have benefited from conventional allogeneic BMT with its associated high mortality in the older age groups, and those lacking fully matched family donors. This article surveys these developments and reviews the clinical indications for BMT in selected malignancies that are evidence-based. The role of BMT and its timing, in the light of new alternative solutions already in the market, is also discussed. Such critical evaluation is particularly warranted in view of the vastly higher rate of BMT per capita in Israel, as compared to other western countries, and given the late side effects inherent in the procedure.

Monitoring oral anticoagulant therapy by telephone communication.

The number of patients who need supervision during oral anticoagulant treatment is growing constantly. We have presently enrolled 156 patients who were referred to our anticoagulant clinic and who were taking sodium warfarin with target International Normalized Ratios (INR) of low (2-3), intermediate (2.5-3.5) and high (3-4) range. Patients performed the tests in laboratories situated in locations at their convenience and received further instructions from a specialist via telephone communication. A total of 8758 prothrombin times (5214, 1947 and 1597 tests for individuals in the low, intermediate and high range, respectively) were performed over the period of 3.16 +/- 2.6 years (range, 6 months-9.5 years) and reported to the specialist. It was found that in the aforementioned three groups of intensity 63.3, 57.0 and 47.7% of the INRs were within the target range, the respective percentages for the expanded (+/- 0.5) target INR being 92.8, 87.8 and 78.5%. The INTERDAY software was used to calculate the number and proportion of days within the target INR range, the respective results being 71.0, 64.0 and 51.6% and 96.2, 93.2, 86.4% for the expanded range. The number and percentage of bleeding and embolic complications' referrals to the emergency room and hospitalizations were similar to those reported for anticoagulant clinics in which patients have to actually pay a personal visit in order to receive instructions. Our study is significant in that it documents that trans-telephonic communication is feasible safe and cost-effective and that the clinical results are at least as good as those obtained by traditional consultation.

Aleukemic monocytic leukemia cutis.

Aleukemic leukemia cutis is a rare condition in which leukemic cells invade the skin before they appear in peripheral blood or bone marrow specimens. The condition frequently is misdiagnosed as atypical lymphoma. Generally, the diagnosis is made retrospectively, after the leukemic cells appear in peripheral blood or bone marrow samples. Immunohistochemical studies are the primary methods for diagnosis. Prognosis is usually poor. We describe the case of a 75-year-old woman with acute aleukemic monocytic leukemia cutis who developed systemic disease 1 1/2 years after skin involvement.

Prevalence of hepatitis C virus infection in patients with lymphoproliferative disorders.

BACKGROUND: Epidemiologic studies in different parts of the world have revealed controversial results on the association between hepatitis C virus infection and non-Hodgkin's lymphoma. This discrepancy suggests that HCV lymphotropism or its effect on host lymphocytes may be influenced by regional and racial factors, as well as by genomic variations. OBJECTIVE: To determine the prevalence of HCV infection in patients with lymphoproliferative disorders diagnosed and treated in our institute in Israel. METHODS: A total of 212 consecutive patients (95 males and 117 females) treated in our hematology outpatient clinic between August 1997 and September 1999 was screened for anti-HCV antibodies and hepatitis B surface antigen. HCV infection was confirmed by the presence of HCV RNA in the serum. The prevalence of HCV in patients with lymphoproliferative disorders was compared to that in a control group of patients with myeloproliferative disorders and myelodysplastic syndromes. RESULTS: HCV infection was more prevalent in the group of LPD patients than in the control group, but this finding was not statistically significant. The prevalence of HCV among LPD patients was 7.8%, while that in the group with myeloproliferative and myelodysplastic disorders was 1.19% and in the general population 0.64%. Among the different classes of LPD, a significant association with HCV infection was established only in patients with diffuse large B cell lymphoma. Furthermore, HCV infection was significantly more prevalent than HBV infection in the LPD group, but not in the myeloproliferative and myelodysplastic disorders group. CONCLUSIONS: Our finding of a significant association between HCV infection and diffuse large B cell lymphoma leads us to suggest that anti-HCV antibodies be performed routinely in such subjects.