Trends in First Line Prescribing Preferences Among US-Based Hematology-Oncology Physicians for Patients with Multiple Myeloma Who Are Not Candidates for or Elect Not to Undergo Stem Cell Transplant
Authors: Schwartz Joel H , Willey Joanne , Buettner Arden , Scharf Mitch , Lankford Maria , Green Mark R. , Puto Katarzyna 
Published: October 2019

Abstract
Background: Doublet therapy or melphalan containing regimens have been the standard of care for the 1st line treatment of patients with multiple myeloma (MM) who are not transplant candidates due to advanced age, poor PS, comorbidities or a desire not to undergo transplant. However, recently there has been an increase in the preference for non-melphalan containing triplet therapy among this population. Prescribing preferences (PPrefs) may be influenced by multiple considerations such as randomized efficacy data, cross trial comparisons of efficacy and toxicities, co-morbid conditions, ease of access to and administration/management of specific agents, cumulative patient out of pocket costs, patient compliance, and physician familiarity with available agents.
Methods: PPrefs were assessed through a validated, proprietary, live, case-based market research tool (Challenging Cases®). Assessments of 1348 US based hematology-oncology physicians (HOPs) were conducted from 2011-2014. Data were acquired using blinded, audience-response technology. All responses were obtained contemporaneously prior to any display of respondent selections. The case scenario involved a 74 year old male with total globulin level 9.2 gms, 40% plasma cells in bone marrow, no cytogenetic abnormalities on FISH analysis. White blood cell count (WBC) 5,700; Hemoglobin (Hgb) 9.7 gms; Platelets (Plts) 214K; 500 mg kappa light chains/24 hours via 24 hour urine. The patient did not wish to consider transplant. U.S. HOPs were asked what they would prescribe as 1st line therapy for the patient in this scenario.
Results: 1st line PPrefs by yearAbstract 5776. Table 11st line preference74 yo, newly diagnosed patient2011 N=3542012 N=3712013 N=3672014 N=256Bortezomib IV* ± dexamethasone24%8%5%3%Bortezomib SC** ± dexamethasonen/a16%21%23%Lenalidomide + dexamethasone26%20%24%26%RVd (lenalidomide, bortezomib, dexamethasone)20%31%30%33%CyBorD (cyclophosphamide, bortezomib, dexamethasone)2%2%4%8%Melphalan-based regimen22%20%16%6%Other6%3%2%1%
* Intravenous ** Subcutaneous
Use of doublets remains at about 50%, albeit with a shift away from IV bortezomib to the SQ route.Use of non melphalan triplets almost doubles from 2011 to 2014 (22% to 41%). This is accompanied by a decline in the use of a melphalan based regimen, from 22% to 6%.
Conclusions: Although approximately 50% of US-based HOPs still use a non melphalan doublet in non-SCT eligible pts presenting with a new diagnosis of multiple myeloma, the remaining 50% of physicians appear to be progressively shifting towards use of non-melphalan containing triplet combinations, such as RVd and CyBorD, as initial therapy. During the same time period, a corresponding decline in the PPref for melphalan is seen in this patient population. Additionally, bortezomib administration via the IV route has been replaced almost entirely by preference for the SC route in those treating with a bortezomib doublet.

Disclosures
Off Label Use: Clofarabine is not FDA-approved for non-Hodgkin lymphoma.