Analysis of Final Data from the Multinational, Non-Interventional, Observational Emmos Study (NCT01241396) in Patients (Pts) with Multiple Myeloma (MM) in Real-World Clinical Practice
Authors: Mohty Mohamad , Terpos Evangelos , Mateos Maria-Victoria , Palumbo Antonio , Lejniece Sandra , Beksac Meral , Bekadja Mohamed Amine , Legiec Wojciech , Dimopoulos Meletios , Stankovic Svetlana , Durán Maria Soledad , De Stefano Valerio , Corso Alessandro , Kochkareva Yulia , Laane Edward , Berthou Christian , Salwender Hans-Juergen , Masliak Zvenyslava , Pečeliūnas Valdas , Willenbacher Wolfgang , Da Silva João , Louw Vernon , Nemet Damir , Borbényi Zita , Abadi Uri , Pedersen Robert Schou , Cernelc Peter , Potamianou Anna , Couturier Catherine , Olie Robert , Feys Caroline , Thoret-Bauchet Florence , Boccadoro Mario 
Published: October 2019

Abstract
Background
A lack of objective data exists on differences in treatment practices and outcomes for MM between countries. The EMMOS study aimed to document and describe current treatment regimens and disease progression patterns of MM pts at different stages of the disease in real-world medical practice.
Methods
Adult pts initiating any new MM therapy, irrespective of treatment line at study entry or therapy type received, were eligible for inclusion in the EMMOS registry. A multi-staged pt/site recruitment model was applied to minimize selection bias; enrollment was stratified by country, region, and practice type. Pts' medical/disease features, treatment history, and remission status were recorded at baseline. Prospective data on treatment, efficacy, and safety were collected electronically every 3 mos until 2 yrs after the last pt enrolled. Responses were investigator-assessed (no predefined criteria). Here we report data from the final analysis of EMMOS. Pts were grouped according to receipt of high-dose chemotherapy/stem cell transplantation in any treatment line (SCT pts, non-SCT pts). Within a given line, pts may have received induction, SCT, consolidation, and/or maintenance therapy; if multiple drug combinations were used within a line, the line grouping was based on the combination received in cycle 1.
Results
2358 pts were enrolled between Oct 2010-Oct 2012 in 22 countries in Europe and Africa; the last pt completed follow-up in Oct 2014. Of these, 775 pts had undergone SCT in any treatment line. Baseline characteristics in the prospective phase by starting line are shown in the Table. As expected, there was a higher proportion of younger pts (≤65 yrs) in the SCT vs non-SCT group across all treatment lines, and in both groups a higher proportion of pts in 4th + vs earlier lines with ISS stage III disease. While cytogenetics were evaluated in a small number of pts overall (670/2358 [28%]), these assessments were performed significantly more frequently in SCT vs non-SCT pts (p<0.0001). In 380 prospective 1st line (L1) SCT pts, 299 (79%) underwent SCT-based treatment in L1; induction was with a bortezomib (btz)-based combination in 83% (47% btz without immunomodulatory drug [IMiD]; 36% btz + IMiD), IMiD in 11%, and other (ie. no btz/IMiD) in 6%. In 81 SCT pts who received non-SCT-based treatment in L1 (21%), 36% received btz without IMiD, 40% other, and 17% IMiD-based combinations. In 345 pts receiving L2, most frequent therapies were btz without IMiD (45% of pts), IMiD without btz (30%), other (13%), and btz + IMiD (12%); non-btz/IMiD combinations were increasingly prevalent in pts receiving L3 or L4 (24% and 40%, respectively). In the non-SCT population, 58% of pts received a btz-based combination in L1, most frequently btz without IMiDs (54%). In pts receiving L2, btz or IMID were equally represented (39%); in L3, non-SCT pts were most likely to receive other therapies (39%) versus 27% btz without IMiD and 32% IMiD without btz. Based on preliminary data, mean EQ5D score at baseline was 0.316 (range -0.594, 0.731) in the overall pt population, which increased slightly to 0.410 (-0.429, 0.731) at 12 mos and was largely comparable between countries. Resource utilization (hospitalization, ICU, ER visit, outpatient visit, full-time care) appeared highest in Germany (67.6 records per pt) and lowest in Croatia (7.5 per pt), with those in Germany spending a mean of 12.1 days in hospital per stay. Efficacy/safety data will be presented at the meeting.
Conclusion
This large, real-world, observational study provides for the first time a comprehensive picture of the baseline characteristics and therapy of MM pts treated in Europe, the Middle-East, and Africa. These data provide a framework towards the design of future protocols aiming to improve outcomes in MM.
Table. Baseline characteristics by starting line Non-SCT pts SCT pts L1 (n=897) L2 (n=319) L3 (n=184) L4+ (n=166) Total* (N=1566) L1 (n=378) L2 (n=161) L3 (n=107) L4+ (n=120) Total* (N=775) Age ≤65 yrs, % 36 34 35 39 36 87 76 72 71 80 ISS Stage II/III, % 36/44 34/47 43/38 22/52 35/44 33/35 44/27 34/26 23/48 34/34 Salmon-Durie Stage 2/3, % 28/64 25/66 24/71 29/62 27/65 22/68 25/67 20/65 11/81 20/69 Bone lesion history, % 64 72 75 70 68 66 74 77 80 71 Cytogenetics assessed, % 24 19 19 14 21 51 35 43 33 44 Del 17p 8 8 9 13 8 10 7 4 13 9 t(4,14) 6 7 9 4 6 7 14 13 8 9 ISS, International staging system; L, line *17 non-SCT and 9 SCT pts were enrolled but did not receive a line of therapy within 75 days of baseline

Disclosures
Mohty: Celgene: Honoraria; Janssen: Honoraria. Terpos:Amgen: Honoraria, Research Funding; Janssen: Honoraria; Celgene: Honoraria; Novartis: Honoraria. Mateos:Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees. Palumbo:Array BioPharma: Consultancy; Onyx Pharmaceuticals: Consultancy; Millennium Pharmaceuticals Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited: Consultancy, Honoraria; Janssen-Cilag: Consultancy, Honoraria; Genmab A/S: Consultancy; Bristol-Myers Squibb: Consultancy; Amgen: Consultancy; Sanofi Aventis: Consultancy. Lejniece:Amgen: Honoraria; Sandoz: Honoraria. Beksac:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen-Cilag: Speakers Bureau; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene: Speakers Bureau; Amgen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Dimopoulos:Novartis: Honoraria; Janssen: Honoraria; Amgen: Honoraria; Onyx: Honoraria; Celgene: Honoraria; Genesis Pharma: Research Funding. De Stefano:Shire: Speakers Bureau; Roche: Research Funding; Bruno Farmaceutici: Research Funding; Janssen Cilag: Research Funding; Amgen: Speakers Bureau; GlaxoSmithKline: Speakers Bureau; Novartis: Research Funding, Speakers Bureau; Celgene: Speakers Bureau. Salwender:Celgene: Honoraria; Janssen Cilag: Honoraria; Bristol Meyer Sqibb: Honoraria; Amgen: Honoraria; Novartis: Honoraria. Pečeliūnas:Johnson & Johnson: Honoraria, Research Funding. Willenbacher:CTI: Consultancy, Other: Travel, Accommodations, Expenses; Gilead: Consultancy, Other: Travel, Accommodations, Expenses, Speakers Bureau; Amgen: Consultancy, Other: Travel, Accommodations, Expenses, Research Funding; Janssen: Consultancy, Other: Travel, Accommodations, Expenses, Research Funding; Roche: Consultancy, Other: Travel, Accommodations, Expenses, Research Funding; Celgene: Consultancy, Honoraria, Other: Travel, Accommodations, Expenses, Research Funding; Novartis: Consultancy, Honoraria, Other: Travel, Accommodations, Expenses, Research Funding. Da Silva:Janssen Pharmaceuticals: Research Funding. Louw:Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis Oncology: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Nemet:Sanofi: Honoraria; Pliva: Honoraria; Pfizer: Honoraria; Amgen: Honoraria; Janssen: Honoraria; Celgene: Honoraria. Potamianou:Janssen: Employment. Couturier:Janssen-Cilag: Employment. Olie:Johnson & Johnson: Equity Ownership; Janssen-Cilag: Employment. Feys:Janssen Pharmaceutica N.V.: Employment, Equity Ownership. Thoret-Bauchet:Janssen-Cilag: Employment.