Conditions: Myeloma
Keywords: Myeloma Multiple Myeloma Light chain Multiple Myeloma MM Autologous Hematopoietic Stem Cell Transplantation Busulfan Busulfex Myleran Melphalan Alkeran G-CSF Filgrastim NeupogenTM Questionnaire Survey Quality of Life QOL
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 205
Healthy volunteers: no

Brief summary:
The goal of this clinical research study is to compare Busulfex (busulfan) with or without Alkeran (melphalan) to learn which study therapy may be better at helping to control MM in patients who will receive an autologous stem cell transplant. The safety of this combination therapy will also be studied.

Melphalan and busulfan are designed to damage the DNA (genetic material) of cells, which may cause cancer cells to die.

Detailed description:
Study Groups:

If you are found to be eligible to take part in this study, you will be randomly assigned (as in the flip of a coin) to 1 of 2 study groups.

* Group 1 will receive melphalan and busulfan.
* Group 2 will receive melphalan.

Both groups will have a stem cell transplant.

Study Drug Administration:

If you are in Group 1, you will first receive an additional low-level "test" dose of busulfan given by vein to check how your blood levels change over time. This information will be used to decide the next dose that is needed to reach a target blood level of busulfan. Blood (about 1 teaspoon each time) will be drawn up to 11 times during the next 11 hours after the test dose and the first high-dose busulfan treatment.

A heparin lock line will be placed in a vein to lower the number of needle sticks needed for these draws.

This test dose of busulfan can be given as an outpatient before you are admitted to the hospital, or you will be admitted on Day -10 (10 days before your transplant) and will receive the test dose on Day -9. If it is not possible for these blood level tests to be performed for technical or scheduling reasons, you will receive the standard, fixed (unchanging) dose of busulfan.

Eight (8) or 10 days before the transplant, you will be admitted to the hospital and given hydration fluids by vein.

On Days -7, -6, -5, and -4, you will receive busulfan by vein over 3 hours. You will receive melphalan on Days -2 and -1 by vein over 30 minutes. You will receive the stem cell transplant through the CVC on Day 0.

If you are in Group 2, you may be admitted to the hospital 3 days before the transplant. You will receive hydration fluids by vein. Two (2) days before the transplant, you will receive melphalan by vein over 30 minutes. You will not receive melphalan the day before the transplant.

Stem Cell Transplant:

The day that you receive the stem cell transplant is called Day 0. The stem cells will be given by vein through the CVC. The cells will travel to your bone marrow where they are designed to start making healthy, new blood cells after several weeks. You will sign a separate consent for the collection of your stem cells.

Beginning 5 days after the transplant, you will receive filgrastim (G-CSF) through a needle under your skin 1 time each day until your blood cell levels return to normal. Filgrastim is designed to help with the growth of white blood cells.

You will be in the hospital after the transplant for about 2-4 weeks.

Questionnaire:

You will be asked to complete a quality-of-life questionnaire before starting the study drugs and then once a week during Weeks 1, 2, and 4 after the stem cell transplant. The questionnaire will take about 15 minutes to complete.

Follow-Up Visits:

About 3 months after the transplant, you will have a bone marrow aspiration and biopsy to check the status of the disease. To collect a bone marrow aspiration and biopsy, an area of the hip is numbed with anesthetic, and a small amount of bone marrow and bone is withdrawn through a large needle.

Every 3 months during the first year after the transplant, blood (about 1-2 tablespoons) will be drawn to check your immune response and status of the disease.

About 1 year after the transplant, you will have a bone scan if the doctor thinks it is needed.

Length of Study:

One (1) year after the transplant, your participation in this study will be over.

If intolerable side effects from the chemotherapy occur or there is sign of disease after the transplant, you will be taken off study. If you have intolerable side effects after you receive chemotherapy, then you will still have the transplant. If you are taken off study early, you still may need to return for routine post-transplant follow-up visits, if your transplant doctor decides it is needed.

This is an investigational study. Busulfan and melphalan are commercially available and FDA approved for the treatment of myeloma. The use of melphalan alone before an autologous stem cell transplant is considered standard of care. Using busulfan with melphalan is investigational.

Up to 205 patients will take part in this study. All will be enrolled at MD Anderson.

Arms:
arm 1: Busulfan test dose (32 mg/m\^2) on day -9 then 130 mg/m\^2 intravenous (IV) Days -7, -6, -5, and -4 + Melphalan 70 mg/m2 IV on Days -2 and -1. Stem Cell Transplant (SCT) Day 0. arm 2: High-dose Melphalan 200 mg/m2/day IV over 30 minutes on day -2. SCT Day 0.

Interventions: intervention 1: Busulfan intervention 2: Melphalan intervention 3: Questionnaire intervention 4: G-CSF intervention 5: High Dose Melphalan intervention 6: Stem cell transplant
Intervention descriptions: intervention 1: Test dose (32 mg/m\^2) on day -9 then 130 mg/m\^2 by vein or adjusted dose on Days -7, -6, -5, and -4. intervention 2: 70 mg/m2 by vein over 30 minutes minutes on Days -2 and -1. intervention 3: Quality of Life (QOL) questionnaire before starting the study drugs and then once every 4 weeks after the stem cell transplant, taking about 15 minutes to complete. intervention 4: Approximately 5 mcg/kg/day subcutaneously beginning on Day +5. intervention 5: 200 mg/m2 by vein over 30 minutes on Day -2. intervention 6: Stem cell infusion on Day 0.

Protocol document:
Prot_SAP_000.pdf: 
2010-0071
December 14, 2015
Page 1
Protocol Page
A Randomized Trial to Compare Busulfan + Melphalan 140 mg/m2 with Melphalan 
200 mg/m2 as Preparative Regimen for Autologous Hematopoietic Stem Cell 
Transplantation for Multiple Myeloma
2010-0071
Core Protocol Information
Short Title 
Bu-Mel vs. Mel 200
Study Chair: 
Muzaffar H. Qazilbash
Additional Contact:
Glenda Woodworth
Peggy S. LeCompte
Sofia R. Qureshi
Department:
Stem Cell Transplantation and Cellular Therapy
Phone:
713-792-8750
Unit:
423
Full Title: 
A Randomized Trial to Compare Busulfan + Melphalan 140 mg/m2 with Melphalan 200 mg/m2 
as Preparative Regimen for Autologous Hematopoietic Stem Cell Transplantation for Multiple 
Myeloma
Protocol Type:
Standard Protocol
Protocol Phase:
Phase III
Version Status:
Terminated 03/19/2019
Version:
26
Submitted by:
Peggy S. LeCompte--5/10/2017 3:51:46 PM
OPR Action:
Accepted by:  Rosheta McCray -- 5/24/2017 1:03:46 PM
Which Committee will review this protocol?
 The Clinical Research Committee - (CRC)


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Protocol Body
1.0 Objectives
Primary Objective
To compare the progression-free survival (PFS) rates of Busulfan + Melphalan 
(Bu-Mel) with Melphalan alone in patients with multiple myeloma (MM).
Secondary Objectives
To compare rates of complete responses at day 90 (CR) between the two arms.
1.
To compare rates of complete responses + very good partial responses 
2.
(CR+VGPR) between the two arms.
To compare overall survival (OS) between the two treatment arms. 
3.
To compare the outcome (CR, PFS and OS) between the 2 arms in high-risk 
4.
patients. 
To compare Grade 3-4 toxicities, graded according to CTCAE between the 2 
5.
arms. 
To compare treatment-related mortality (TRM) between the 2 arms.
6.
To compare quality of life between the 2 arms by measuring the symptom burden 
7.
using the MD Anderson Symptom Inventory (MDASI).
2.0 Background
The Role for Busulfan in Marrow Transplantation for Advanced 
Hematologic Malignancies
Busulfan [1, 4-bis-(methanesolfonoxyl) butane] is a bifunctional alkylating 
agent, and its use for a long period (~1954-1975) was limited to low dose oral 
therapy with palliative intent, requiring frequent blood count monitoring 
(Canellos 1985, Hughes 1991).  In 1974, however, Santos and Tutschka 
investigated the use of busulfan to create a murine model of aplastic anemia 
(Santos 1974).  Subsequently, the experience gained in this model system 
was used to introduce high-dose combination chemotherapy based on oral 
busulfan for pretransplant conditioning of non-human primates and, 
thereafter, for patients undergoing both autologous and allogeneic marrow 
transplantation (Santos 1983, Lu 1984, Yeager 1986, Tutschka 1987, Peters 
1987, Geller 1989, Grochow 1989, Dix 1996, Sheridan 1989, Clift 1994, 
Schwertfeger 1992, Vaughan 1991).  Since then, high-dose busulfan, most 
commonly in combination with cyclophosphamide (BuCY), has proven to be 
an effective antileukemic regimen when used in conjunction with autologous 
or allogeneic hematopoietic stem cell support.
Rationale for the Combination of Busulfan and Melphalan
Several series have demonstrated the potent antitumor effects of melphalan in 
advanced hematologic malignancies (Maraninchi, 1986).   Furthermore, because 
it has tolerable non-overlapping, non-hematologic toxicities with busulfan, it has 
been combined with busulfan to provide an effective, myelosuppressive 


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preparative regimen prior to autologous and allogeneic HSCT (Vey 1996, 
Cony-Makhoul 1995, Meloni 2001).  However, the majority of these studies used 
oral busulfan, and extensive mucositis and veno-occlusive disease (VOD) were 
documented.  Trials from our insitution and others (Andersson 2003, De Lima 
2004, Shimoni 2003, Callander 2003, Schuler 2001) have shown that the i.v. 
preparation of busulfan is more effective and less toxic. 
However, some experience has already accumulated from a phase I study of 
escalating doses of i.v. busulfan with fixed dose melphalan in multiple myeloma 
patients receiving autologous HSCT at the University of Texas Health Science 
Center in San Antonio. Engraftment and toxicity data were recorded for patients 
receiving busulfan, with doses ranging from 10-13.5 mg/kg i.v., combined with 
melphalan at 140 mg/m
2.  Thus far, 25 patients have received this regimen: 
neutrophil engraftment occurred at 9.5 + 0.9 days, platelet engraftent occurred at 
11.3 + 1.5 days, no grade IV mucositis or diarrhea occurred, and notably, no 
patients developed VOD (Callander 2003).    
We will use fixed doses of i.v. busulfan, derived from the pharamcokinetic (PK) 
data from a previous phase II study (see below), and melphalan in this phase II 
study.  
The main cytotoxic actions of busulfan and melphalan are through DNA 
alkylation.  To investigate whether these biochemical events can be correlated 
with treatment outcome, we intend to collect cells from consenting patients with 
circulating myeloma cells (>2,000 cells/µL), or bone marrow cells and study the 
in vitro alkylating effects of busulfan and melphalan and, if possible, in relation to 
cytokine activation.  Correlative samples will also be collected after the i.v. 
administration of busulfan and melphalan during the conditioning treatment. All of 
these correlative studies will be conducted under separate IRB-approved studies 
and will require separate consent.
2.2  Rationale for Busulfan Dose and Schedule 
The IV dose to be administered in this study was derived from the PK data from  
the previous phase II study of i.v. high-dose busulfan with cyclophosphamide as 
pretransplant conditioning therapy, and from information obtained from Dr J. 
Russell (Calgary), who has used i.v. busulfan with fludarabine, as pretransplant 
conditioning therapy for approximately 250 patients undergoing allogeneic 
hematopoietic stem cell transplant (HSCT) for hematologic malignancies (J 
Russell, MD, personal communication, December, 2000). His dose of 3.2 mg/kg 
body weight was extrapolated from our previous experience of using 0.8 mg/kg 
IV every six hours for a total of 16 doses.  The 0.8 mg/kg dose has previously 
been demonstrated to be pharmacokinetically similar to what was achieved with 
an oral dose of 1.0 mg/kg.  The 3.2 mg/kg body weight is equivalent to a dose of 
130 mg/m2 dose.  This dose can be anticipated to yield a median target AUC of 
5 – 6,500 µM-min, and it should be considered safe, affording a low risk for 
hepatic VOD.  The careful PK analysis of i.v. busulfan in relationship to dosing 


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weight, actual weight vs. adjusted ideal weight vs. ideal weight, yielded the 
information that dosing based on body surface area (BSA) derived from actual 
weight would give the most consistent dosing of i.v. busulfan for adults (Vaughan 
1999).  Therefore, in this protocol, BSA will be derived from actual body weight 
for all patients, including those who are greater than 20% above their ideal body 
weight.  This is a shift in dosing strategy from our previous standard, in which we 
used ideal body weight to derive BSA to determine dosage.
Rationale for Melphalan Dose and Schedule
The melphalan total dose of 140 mg/M2 has been well-studied in a variety of  
combination regimens both at MD Anderson and elsewhere and is tolerable.  In 
subsequent studies, we propose to test the addition of a third agent, e.g a 
nucleoside analogue, to busulfan plus melphalan to effect controlled inhibition of 
DNA repair which is produced by busulfan/melphalan, and thus wish to allow a 
safety margin for any additional organ toxicity which might result. We have 
provided for a 24 hr "rest day" between busulfan and melphalan for two 
purposes: 1) to allow repletion of hepatic glutathione stores which will be 
depleted by busulfan (Meister 1988) and which can exascerbate melphalan 
toxicity (Awasthi 1996, Troyano 2001) and 2)  to allow for pilot dose melphalan 
administration to consenting patients.  Ultimately, we propose to  deliver both 
busulfan and melphalan in pharmacokinetically(PK)-directed doses to minimize 
interpatient variability in toxic and therapeutic effects.  To this end, we have 
shown that when melphalan is administered as a fractionated dose over 2-3 
days, the PK of the first day's dose predicts well for the PK of the subsequent 
doses (Jones, unpublished data).  Administering melphalan over two days not 
only coincides with a pattern established here in multiple other studies, but would 
allow an alternate method of PK-directed dosing if the pilot studies do not prove 
useful.
Rationale for the Combination of Busulfan and Melphalan for Myeloma
At least two randomized trials have shown that compared to conventional agents, 
high dose chemotherapy followed by autologous bone marrow transplantation 
results in significantly prolonged survival inpatients with newly diagnosed multiple 
myeloma (MM).  However, relapse remains the most important cause of 
treatment failure in these patients.  Based on the results of randomized phase III 
trials, high-dose melphalan at 200 mg/m2 is considered the standard preparative 
regimen for MM. The median duration of remission after this regimen is only 
about 24 months, which warrants exploration of more effective  regimens. 
Earlier attempts at improving results with more intensive regimens have not 
resulted in improved outcomes. Based on at least two recent single arm 
clinical trials, a combination of busulfan and melphalan was found to be safe 
and effective in patients with myeloma. in the first trial, conditioning with oral 
busulfan 12 mg/kg plus melphalan 140 mg/m(2) was associated with longer 
progression-free survival but equivalent survival to that achieved with 
melphalan 200 mg/m(2).  There was a higher frequency of veno-occlusive 


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disease-related deaths in the busulfan arm. This latter fact together with the 
limited access to novel salvage therapies in patients conditioned with oral 
busulfan 12 mg/kg plus melphalan 140 mg/m(2) may explain the absence of a 
survival difference. Oral busulfan was used in that study; and the authors 
concluded that the use of intravenous busulfan may reduce toxicity and result 
in greater efficacy, and warrants further investigation in myeloma patients. 
In the second trial from our institution, intravenous (i.v.) busulfan (Bu) was 
combined with melphalan (Mel) in patients with advanced lymphoid 
malignancies undergoing autologous stem cell transplantation. Bu 130 mg/m
2 
was infused daily for 4 days, either as a fixed dose per BSA, or to target an 
average daily area under the curve of 5000 μmol-min, determined by a test 
dose of i.v. Bu at 32 mg/m
2 given 48 hours prior to the high-dose regimen, 
followed by a rest day, followed by 2 daily doses of Mel at 70 mg/m
2.  Eighty 
patients had i.v. Bu delivered per test dose guidance. The median daily 
systemic Bu exposure was 4867 μmol-min. One hundred two patients 
(Hodgkin lymphoma n = 49, non-Hodgkin lymphoma n = 12, multiple 
myeloma = 41) with a median age of 44 years (range: 19-65 years) were 
treated. The 2-year overall survival and progression-free survival rates were 
82% and 42%, respectively, for patients with multiple myeloma. The regimen 
was very well tolerated with treatment-related mortality at 100 days, 1 year, 
and 2 years of 1%, 3%, and 3%, respectively. Intravenous Bu-Mel was well 
tolerated. Disease control was encouraging, and should be explored in larger 
phase II studies.
We compared the CR rates and PFS in patients who received an 
auto-hematopoetic stem cell transplantation (HCT) after Bu-Mel with several 
novel preparative regimens that were used at our institution. We restricted our 
analyses to patients undergoing auto-HCT for consolidation of first remission. 
The results are summarized in the Table below.
CR (%)
Median PFS (months)
Bu-Mel
9/32 (28)
33 
TMC 
5/37 (13)
20.6
MAC
6/28 (21)
26.8
MAC-V
8/41(19)
28.8
TMC= topotecan, melphalan, cyclophosphamide (Kazmi et al. 2010)
MAC = melphalan, arsenic trioxide, Vitamin C (Qazilbash et al.  2008)
MAC-V = melphalan, arsenic trioxide, Vitamin C, bortezomib (Sharma et al. 
2009)
Based on these encouraging preliminary results, we would like to propose this 


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phase III trial to compare the safety and efficacy of a combination of a 
combination of IV busulfan and  melphalan 140 mg/m2 with melphalan 200 
mg/m2 in an autologous SCT setting. 
At least two randomized trials have shown that high dose chemotherapy 
followed by autologous bone marrow transplantation results in significantly 
prolonged survival of patients with newly diagnosed MM, when compared to 
conventional agents (Attal et al. 1996, Child et al. 2003) However, relapse 
remains the most important cause of treatment failure in these patients.  
Based on the results of randomized phase III trials, high-dose melphalan at 
200 mg/m2 is considered the standard-of-care preparative regimen for MM. 
The median duration of remission after this regimen is only about 24 months. 
(Attal et al. 1996, Child et al. 2003)That warrants exploration of more effective 
preparative regimens for MM. Earlier attempts at improving results with more 
intensive regimens have not resulted in improved outcomes. Based on at 
least two recent single arm clinical trials, a combination of busulfan and 
melphalan was found to be safe and effective in patients with myeloma. There 
is a suggestion from these trials that this combination may result in a superior 
outcome. (Lahuerta et al. 2010, Kebriei et al)
In this phase III trial we propose to compare the safety and efficacy of a 
combination of single daily dose IV busulfan and melphalan 140 mg/m2 with 
melphalan 200 mg/m2 in an autologous stem cell transplant setting. 
This was a randomized clinical trial of IV Busulfan + Melphalan (B+M) versus 
Melphalan (M) as preparative regimens for autologous hematopoietic stem 
cell transplantation (auto-HCT) for multiple myeloma.  Following the 
prescribed rule in the trial design, this trial was stopped early due to an 
imbalance in the empirical rates of complete remission at day 90 (CR90) in 
the two arms.  The empirical rates were 35% in the M arm versus 16% in the 
B+M arm.  This result was the opposite of what was anticipated when 
planning the trial, which was motivated by the hypothesis that adding IV 
Busulfan to Melphalan would improve patient outcome.
On closer inspection of the data, a very surprising result was seen in terms of 
progression free survival (PFS) time.  For PFS time, the opposite effect of that for 
CR90 was seen.  Specifically, the B+M arm has better PFS than the M arm, as 
shown in Figure 1, which  records PFS time from day 90 when CR90 is evaluated. A 
similar difference is seen for PFS time recorded from date of transplant. This 
statistical result may be considered perplexing because, within each treatment arm, 
for patients for whom CR90 was evaluated, on average the occurrence of CR90 
increased the time to failure (progression or death). That is, CR90 improved PFS in 
both arms.  
So the question has arisen of how it can be the case that 


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1)
CR90 is higher in the M arm compared to the B+M arm, 
2)
CR90 improves PFS in both arms, yet 
3)
PFS is superior in the B+M arm compared to the M arm.
A computation explaining this somewhat counterintuitive result is given in the 
Appendix.  Essentially, for each treatment arm, the time to failure probability 
distribution is a mixture (average) of the time to failure probability distributions for the 
two subgroups of patients for whom (i) treatment achieves CR90 and (ii) treatment 
does not achieve CR90.  
At this point, the trial has been stopped because the rule based on CR90 worked 
correctly, showing that the M arm is superior the B+M arm in terms of CR90, but the 
data also show that the B+M arm is superior to the M arm in terms of PFS.  
However, the current data are not sufficiently strong, in terms of sample size and 
magnitude of the difference in PFS, to provide confirmatory evidence that B+M is 
superior to M for these patients. 
Consequently, we feel strongly that this trial should be re-opened, but using a design 
based on PFS time as the primary endpoint, with CR90 as a secondary endpoint. 
3.0 Background Drug Information
Busulfan:
Therapeutic Classification: Antineoplastic Alkylating agent. 
Pharmaceutical data: Busulfan injection is a sterile, pyrogen-free solution provided in 
a mixture of dimethylacetamide (DMA) and polyethyleneglycol 400 (PEG400).  It is 
supplied in 10 ml single use ampoules at a concentration of six (6) mg busulfan per 
ml.  Each ampoule contains 60 mg of busulfan in 3.3 ml of DMA and 6.7 ml of 
PEG400.  When diluted in normal saline or D5W to a concentration of 0.5 mg/ml, the 
resulting solution must be administered within eight (8) hours of preparation 
including the three (3) hour infusion of the drug. 
Stability and storage: Ampoules should be stored refrigerated at 2-8°C (35-46°F).  
Stable at 4°C for at least twelve (12) months.  Additional stability studies are in 
progress.  DO NOT use beyond the expiration date.  DO NOT use if the solution is 
cloudy or if particulates are present. 
Solution Preparation: Prepare the busulfan solution as follows (The patient is to 
receive a dose of 130 mg/m
2 of busulfan): mix into normal saline to a final 
concentration of 0.5 mg/mL. 
In each bag 6.0 mg busulfan (1.0 ml at 6 mg/ml and 11 ml saline) should be added 
to compensate for drug lost in the tubing with each infusion (approximately 12 ml at 
0.5 mg/ml is lost in the tubing when using the controlled rate infusion pump). 


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Route of Administration: It is to be noted, that a sufficient amount of diluted busulfan 
should be added to compensate for the amount needed to prime the IV tubing; when 
hanging the infusate, the tubing should be primed with the busulfan solution and 
connected as close to the patient as possible, i.e. by a 3-way connector at the level 
of the central venous catheter.  After completed infusion, the tubing with remaining 
busulfan (approximately 12 mL) should be disconnected and discarded.  All busulfan 
infusions should be performed by programmable pump. 
The high-dose busulfan will be given by slow intravenous infusion over three (3) 
hours into a central venous catheter. 
CAUTION: DO NOT ADMINISTER AS AN INTRAVENOUS PUSH OR BOLUS. 
An infusion pump will be used with the busulfan solutions as prepared above.  A new 
infusion set must be used for administration of each dose.  Prior to and following 
each infusion, flush the catheter line with normal saline or (approximately 5 ml).  
Start the three-hour infusion at the calculated flow rate.  DO NOT infuse 
concomitantly with another intravenous solution of unknown compatibility. 
If a delay in administration occurs after the infusion solution is prepared, the properly 
identified container should be kept at room temperature (20-25°C), but 
administration must be completed within eight (8) hours of preparation including the 
three (3) hour drug infusion. 
Adverse Events: Dose limiting toxicity is expected to be hematological when used 
without stem cell support. Other toxicities seen frequently following high-dose 
busulfan in preparative regimens for bone marrow transplantation include: VOD, 
nausea, vomiting, pulmonary fibrosis, seizures, rash, and an Addison’s-like 
syndrome.   
Mechanism of action: Interferes with DNA replication and transcription of RNA 
through DNA alkylation, and ultimately results in the disruption of nucleic acid 
function. 
Animal Tumor Data: Busulfan has been shown to be active against a variety of 
animal neoplasm in vivo, including mouse sarcoma 180 and Ehrlich’s mouse ascites 
tumor. 
Human Pharmacology: Limited pharmacology data are available for the parenteral 
formulation to be used in this study and is detailed in the evaluation of IV Bu in a 
Phase II Trial using IV Bu at 0.8 mg/kg BW given over 2 hr every 6 hr for a total of 
16 doses (Andersson et al, 2002) and when administered once daily for 4 days at a 
dose of 130 mg/m2 in combination with Flu (Madden et al, AHS 2003, de Lima et al, 
BLOOD 2004).  The pharmacokinetic data suggests that the plasma decay of the 
formulation fits an open one-compartment model with linear pharmacokinetics in the 
dose range of 12 mg-130 mg/m2.  Based on studies of oral Bu, the drug is reported 


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to be extensively metabolized; twelve (12) metabolites have been isolated, but most 
have not been identified.  The drug is slowly excreted in the urine, chiefly as 
methanesulfonic acid.  Ten to fifty percent (10-50%) of a dose is excreted as 
metabolites within twenty-four (24) hours (Nadkarni 1959). 
Melphalan
Therapeutic Classification: Melphalan is an alkylating agent of the 
bischloroethylamine type.  As a result, its cytotoxicity appears to be related to the 
extent of its interstrand cross-linking with DNA, probably by binding at the N
7 position 
of guanine.  Like other bifunctional alkylating agents, it is active against both resting 
and rapidly dividing tumor cells.
FORMULATION:  Melphalan for injection is supplied as a sterile, nonpyrogenic, 
freeze-dried powder.  Each single-use vial contains melphalan hydrochloride 
equivalent to 50 mg melphalan and 20 mg povidone.
PREPARATION:  Melphalan for injection must be reconstituted by rapidly injecting 
10 mL of the supplied diluent directly into the vial of lyophilized powder using a 
sterile needle and syringe.  This provides a 5 mg/mL solution of melphalan.  
Immediately dilute the dose to be administered in 0.9% Sodium Chloride Injection, 
USP, to a concentration of 1.5 mg/mL.  Administer the diluted product over a 
minimum of 15 minutes.  Complete the administration within 60 minutes of 
reconstitution.
STORAGE AND STABILITY:  Melphalan for injection vials should be stored at 
controlled room temperature 15
o to 30
o C (59
o to 86
o F) and protected from light.  The 
time between reconstitution/dilution and administration of melphalan should be kept 
to a minimum because reconstituted and diluted solutions of melphalan are 
unstable.  Over as short a time as 30 minutes, a citrate derivative of melphalan has 
been detected in reconstituted material from the reaction of melphalan with the 
diluent.  Upon further dilution with saline, nearly 1% label strength of melphalan 
hydrolizes every 10 minutes.  A precipitate forms if the reconstituted solution is 
stored at 5
o C.  Do not refrigerate the reconstituted product. 
ADVERSE EVENTS: The following information on adverse reactions is based on 
data from both oral and IV administration of melphalan as a single agent, using 
several different dose schedules for treatment of a wide variety of malignancies.  
Please refer to the Adverse Reactions and Warnings sections of the product 
package insert.
Hematologic:  The most common side effect is bone marrow suppression.  White 
blood cell count and platelet count nadirs usually occur 2 to 3 weeks after treatment, 
with recovery in 4 to 5 weeks after treatment.  Irreversible bone marrow failure has 
been reported.
Gastrointestinal:  Gastrointestinal disturbances such as nausea and vomiting, 


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diarrhea, and oral ulceration occur infrequently.  Hepatic toxicity, including 
veno-occlusive disease, has been reported.Hypersensitivity:  Acute hypersensitivity 
reactions including anaphylaxis were reported in 2.4% of 425 patients receiving 
melphalan for myeloma.  These reactions were characterized by urticaria, pruritus, 
edema, and in some patients, tachycardia, hypotension and bronchospasm.  These 
patients appeared to respond to antihistamine and corticosteroid therapy. If a 
hypersensitivity reaction occurs, IV or oral melphalan should not be readministered 
since hypersensitivity reactions have also been reported with oral melphalan.
Carcinogenesis:  Secondary malignancies, including acute nonlymphocytic 
leukemia, myeloproliferative syndrome, and carcinoma, have been reported in 
patients with cancer treated with alkylating agents (including melphalan).
Other:  Other reported adverse reactions include skin hypersensitivity, skin 
ulceration at injection site, skin necrosis rarely requiring skin grafting, vasculitis, 
alopecia, hemolytic anemia, pulmonary fibrosis and interstitial pneumonitis. 
4.0 Patient Eligibility
Inclusion Criteria:
1.  Patients with multiple myeloma in complete remission (CR), partial remission (PR), 
or very good partial remission (VGPR), or symptomatic stable disease (no evidence 
of progression) including patients with light chain MM detected in the serum by free 
light chain assay.  
2.   Patients with non-secretory multiple myeloma [absence of a monoclonal protein (M 
protein) in serum as measured by electrophoresis (SPEP) and immunofixation 
(SIFE) and the absence of Bence Jones protein in the urine (UPEP) defined by use 
of conventional electrophoresis and immunofixation (UIFE) techniques] but with 
measurable disease on imaging studies like MRI, CT scan or PET scan.
3.   Who have received at least two cycles of initial systemic therapy and are within 2 to 
12 months of the first dose. Mobilization therapy is not considered initial therapy.  
4.   70 years of age or younger.   
5.   Karnofsky performance score 70% or higher. 
6.   Cardiac function: left ventricular ejection fraction at rest > 40% within 3 months of 
registration.
7.   Hepatic function: bilirubin < 2x the upper limit of normal and ALT and AST < 2.5x the 
upper limit of normal. 
8.   Renal function: creatinine clearance of >/= 40 mL/min, estimated or calculated. 
9.   Pulmonary function: DLCO, FEV1, FVC >/= 50% of predicted value (corrected for 
hemoglobin) within 3 months of registration.
10.  Signed informed consent form.
Exclusion Criteria:
1.   Patients with uncontrolled bacterial, viral or fungal infections (currently taking 
medication and progression of clinical symptoms). 
2.   Patients seropositive for the human immunodeficiency virus (HIV). 
3.   Patients with history of myocardial infarction within 6 months prior to enrollment or 


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has New York Heart Association (NYHA) Class III or IV heart failure, uncontrolled 
angina, severe uncontrolled ventricular arrhythmias, or electrocardiographic 
evidence of acute ischemia or active conduction system abnormalities.
4.   Patients participating in an investigational new drug protocol within 14 days before 
enrollment. 
5.   Female patients who are pregnant (positive b-HCG) or breastfeeding. 
6.   Prior stem cell transplantation allogeneic or autologous.  
7.   Prior organ transplant requiring immunosuppressive therapy. 
5.0 Treatment Plan
Mobilization and Collection of Peripheral Blood Progenitor Cells (PBPCs).
The mobilization and collection of the PBPCs is a standard procedure for which patients 
sign a separate informed consent. This procedure does not constitute part of the 
proposed research therefore can occur prior or after protocol registration. 
After registration patients will be selected to receive one of the two preparative 
regimens. The randomization will be 1:1, using a computer to assign each patient to 
either arm 1 (Busulfan-Melphalan) or 2 (Melphalan alone). 
Chemotherapy agents doses and administration.
Chemotherapy agents used in the proposed treatment plans will be dosed and 
administered as outlined below.   
When possible, Busulfan pharmacokinetics will be performed. In the event that dose 
adjustment is not possible Busulfan will be dosed at 130 mg/m
2 starting on day minus 7 
to be administrated over 3 hours. The test dose administration time is 45 minutes.  
Pharmacokinetic-guided (PK-guided) treatment arm: The Busulfan “testdose” of 32 
mg/m
2 will be based on actual body weight, no arbitrary dose adjustment(s) are allowed 
for this busulfan dose on this protocol.
The busulfan dose in the “fixed-dose” treatment arm will be calculated as follows: For 
patients whose actual body weight is < 20% above ideal body weight, the actual body 
weight isused to calculate the body surface area (BSA). For patients whose actual body 
weight is >20% above ideal body weight, an “adjusted body weight” is used to calculate 
the BSA. 
Melphalan will be dosed as follows: for patients whose actual body weight is < 20% 
above ideal body weight, the actual body weight is used to calculate the body surface 
area (BSA). For patients whose actual body weight is >20% above ideal body weight, 
an “adjusted body weight” is used to calculate the BSA. 
Formula to calculate adjusted body weight:  Adjusted BW (Kg) = IBW + 0.5 (Actual body 
weight - IBW).
ARM 1. Busulfan-Melphalan


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Busulfan "testdose" of 32 mg/m
2 can be given IV as out-patient days in advance of 
starting treatment.
Patients who receive the test dose as an outpatient  will be admitted on day -8 to start 
hydration followed by Busulfan 130 mg/m
2 or adjusted dose IV on days -7, -6, -5 and -4. 
Patients who receive the test dose as in-patient will be admitted on day -10 to start 
hydration, followed by busulfan test dose (32 mg/m
2) on day -9 then busulfan 130 
mg/m2 or adjusted dose on days -7, -6, -5, and -4. After a day of rest Melphalan 70 
mg/m
2  IV over 30 minutes minutes will be administrated on days -2 and -1 followed by 
the PBPCs infusion on D0.  Busulfan target daily area under the curve (AUC) is 5000 
mol-minute.
            
ARM 2. Melphalan alone. 
This preparative regimen can be administrated as in-patient or out-patient. If in-patient, 
patient will be admitted on day -3 to start hydration.  On day -2 the patients will receive 
high-dose melphalan at 200 mg/m
2/day IV over 30 minutes. There will be a rest day on 
day -1 followed by the PBPC infusion on D0.  
Supportive treatment
All patients will receive supportive care as clinical indicated following standard practice. 
This includes G-CSF at a dose of 5 mcg/kg/day (round up to the nearest vial) 
subcutaneously beginning on day +5, and continuing until evidence of an absolute 
neutrophil count (ANC) of 0.5 x 10
9/L.
6.0 Study Evaluations
Disease assessment prior to start treatment (baseline).
Studies listed below will be done prior to start treatment only if these were not done 
before study entry either as part of diagnostic or routine pre-transplant workup.
            1. Bone marrow aspirate and biopsies with cytogenetics.
            2. Bone survey with long bones within 6 months of registration.
            3. SPEP and serum IFE, 
            4. UPEP and urine IFE, 
            5. Serum free light chain assay, immunoglobulins IgG, IgA, IgM
            6. Beta 2 microglobulin
Disease assessment after treatment (during the study)
            Around 3 months post transplant.
            1. Bone marrow aspirate and biopsy for morphology with cytogenetics only if 
cytogenetic abnormalities were diagnosed at baseline.  
            Every three months during the first year post transplant
            1. SPEP and serum IFE only if SPEP is negative. 
            2. UPEP and urine IFE only if UPEP is negative.                 
            3. Serum free light chain assay, immunoglobulins IgG, IgA, IgM.  B-type 
naturietic peptide (BNP) only if the patient has incidental amyloidosis.


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Around one year post transplant
1. Bone survey with long bones only if abnormal at baseline.
Quality of Life Assessment (MDASI)
Participants will complete the M. D. Anderson Symptom Inventory (MDASI - MM) at 
baseline before the start of preparative regimen, and then once weekly for the first 2 
weeks and at week 4 (+/- 14 days) after stem cell infusion pending participants' 
availability.
7.0 Adverse Events Assessment and Reporting
Adverse Event Assessment and Reporting:
Severity of adverse events (AE) will be assessed according to the Common 
Terminology Criteria v3.0 (CTCAE).
Most common expected AE related to the use of high dose chemotherapy 
followed by autologous stem cell infusion are: 
 
A.  
Related to myelosuppression: thrombocytopenia, bleeding, platelets and 
RBCs transfusions.
B.
Fever: Non Neutropenic or Neutropenic without infection
C.
Infections in the presence or absence of neutropenia
D. 
Readmissions (lasting <10 days)
E. 
Cytopenias post transplant including secondary graft failure 
F.
Low blood pressure due to dehydration requiring fluid replacement 
G.
Fluid overload leading to cardiac dysfunction
H.
GI related: nausea, vomiting, diarrhea, mucositis
I.
Organ dysfunction: cardiac, pulmonary, hepatic, CNS and/ or renal 
J. 
Fatigue
K.
Neurologic: seizures, neuropathies
L.
Stem Cell Transplant Syndromes: Cytokine Storm, TTP, hemorrhagic 
cystitis, interstitial pneumonitis (including pulmonary hemorrhage).  
Adverse Events Considered Serious:
A. 
Graft failure/ rejection
B. 
Prolonged hospitalization due to infections and/or organ failure requiring 
extensive supportive care (i.e. dialysis, mechanical ventilation)
C.
Readmissions from any cause resulting in a prolonged hospitalization (>10 
days).
D.
Any expected or unexpected event resulting in an irreversible condition 
and/ or leading to death.
For the purpose of this study, abnormal laboratory findings considered 
associated to the original disease as well as isolated changes in laboratory 
parameters such as electrolyte magnesium and metabolic imbalances, uric acid 
changes, elevations of GPT, GOT, LDH and alkaline phosphatase would not be 


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considered adverse events and would not be collected in the database.  
Data Collection During Active Treatment
The last day of active treatment is the day of the PBPCs infusion. The end of 
active treatment period is 30 days from the PBPCs infusion. During the active 
treatment period collection of adverse events will reflect the onset and resolution 
date and maximum grade. Intermittent events should be labeled as such and 
followed until resolution. If a patient is taken off study while an event still ongoing, 
this will be followed until resolution unless another therapy is initiated.  
Pre-existing medical conditions will be recorded only if an exacerbation occurs 
during the active treatment period. Events not considered adverse events will not 
be collected. Co-morbid events will not be scored separately. 
AE and Protocol Deviations Reporting Requirements
Adverse events will be reported accordingly to MDACC (HSRM chapter 15.001)  
and SCT&CT Department (HSRM chapter 15.053) policy and procedures.
This study will be conducted in compliance however in the event of any protocol 
deviations or vilolations these will be reported accordingly to MDACC (HSRM 
chapter 25).
8.0 Criteria for Response
International Myeloma Working Group uniform response criteria.
All response categories require two consecutive assessments made at any time. 
All response categories require no known evidence of progressive or new bone 
lesions. 
Stringent complete response (sCR) (all of the following):
1. CR as defined.
2. Normal free light chain ratio 
3. Absence of clonal cells in bone marrow by inmmunohistochemistry or 
immunofluorescence (defined by absence of abnormal ê/ë ratio of >4:1 or <1:2)
Complete response (CR) (all of the following):
1. Negative immunofixation in serum and urine. 
2.  5% plasma cells in the bone marrow. 
3. Disappearance of any soft tissue plasmacytomas.
Note: While healing of preexisting bone lesions is not required, no new lytic lesions 
should appear. Further compression fracture of previously known spine lesion will 
not be considered as progressive disease.
Very good partial response (VGPR) (one of the following):
1. Serum and urine M protein detectable by immunofixation but not by 
electrophoresis.
2. 90% or greater reduction in serum M protein plus urine M protein level <100 mg 


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per 4h.
Partial response (PR) (all of the following):
1. Reduction by > 50% in serum monoclonal protein.
2. Reduction of urinary monoclonal protein to < 200 mg/24h or >90%.
Stable disease:
1. Not meeting criteria for CR, VGPR, PR or PD. 
Progressive disease (PD) (any one or more of the following):
1. Increase of >= 25% from baseline in:
Serum M protein (absolute increase must be >= 0.5 g/dL).
Urine M component (absolute increase must be >= 200 mg/24h).Only in patients 
without measurable serum and urine M protein levels.
Difference between involved and uninvolved FLC levels (absolute increase must 
be > 10 mg/dL).
Bone marrow plasma percentage (absolute % must be >=10%).
2. Definite development of new bone lesions or soft tissue plasmacytomas or definite 
increase in the size of existing bone lesions or soft tissue plasmacytomas.
3. Development of hypercalcemia (corrected serum calcium >11.5 mg/dL or 2.65 
mol/L) that can be solely attributed to the myeloma.
Relapse from CR (any one or more of the following): 
1. Reappearance of serum or urine M protein by immunofixation or electrophoresis. 
2. Development >=5% plasma cells in the bone marrow.
3. Appearance of any other sign of progression (i.e., new plasmacytoma, lytic bone 
lesion or hypercalcemia).
9.0 Criteria for Removal from the Study
1. Patient withdraw of the informed consent.
2. Patient's inability or unwillingness to have follow-up visits and/or laboratory tests 
required by this protocol.
3. An unexpected toxicity that is deemed unacceptable by the study chairman.
4. Disease progression.
5. After one year of treatment completion.
If a patient withdraws from the study, or is unable or unwilling to complete follow-up 
visits and/or laboratory tests required by this protocol, then (s)he will be replaced 
and will not be counted in regard to complete response and transplant-related 
mortality assessments. However, patients who experience an unexpected toxicity 
that is deemed unacceptable by the study chairman will not be replaced and will be 
counted as non-responders in regard to complete response.


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10.0 Statistical Considerations
This is a randomized group sequential design to compare B+M to M based on PFS 
time, assuming a null median PFS time of 20 months with  M, with two-sided tests 
having nominal overall type I error .029 and power .80 to detect a median PFS of 34 
months, which is a 70% increase with B+M, with up to three tests using O’Brien-Fleming 
decision boundaries. The tests will be conducted when there are a total of 45, 90, and 
135 failure events in the two arms, with respective standardized log rank test Z-score 
test cut-offs  +/-  4.0757, 2.7768, and 2.2077. Assuming an accrual rate of 5 patients 
per month, this design has an expected accrual of 205 patients total, for 205 - 92 = 113 
additional patients. 
Figure 1. Kaplan-Meier estimates of PFS starting from Day 90 post transplant
In the original design of this randomized trial, an early stopping rule based 90-day 
complete remission (CR90) was used.  Following this rule, the trial was stopped early 
due to an imbalance in the empirical rates of CR90 in the two arms.  The empirical rates 
were 35% in the M arm versus 16% in the B+M arm, which was the opposite of what 
was anticipated when planning the trial, motivated by the hypothesis that adding IV 
Busulfan to Melphalan would improve patient outcome. On closer inspection of the data, 
a very surprising result was seen in terms of progression free survival (PFS) time.  For 
PFS time, the opposite effect of that for CR90 was seen.  Specifically, the B+M arm has 
better PFS than the M arm, starting from day 90 when CR90 was evaluated. A similar 
difference was seen for PFS time recorded from date of transplant. This statistical result 
may be considered perplexing because, within each treatment arm, for patients for 
whom CR90 was evaluated on average the occurrence of CR90 increased the time to 
failure (progression or death). That is, CR90 improved PFS in both arms.  So the 
question now arises of how it can be the case that 
1)
CR90 is higher in the M arm compared to the B+M arm, 


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2)
CR90 improves PFS in both arms, yet 
3)
PFS is superior in the B+M arm compared to the M arm.
A computation explaining this somewhat counterintuitive result is given in the Appendix.  
APPENDIX
This appendix provides a detailed explanation of the counterintuitive results of this 
randomized clinical trial of IV Busulfan + Melphalanj (B+M) versus Melphalan (M) as 
preparative regimens  for autologous hematopoietic stem cell transplantation 
(auto-HCT) for multiple myeloma.
For simplicity, the following are landmark analyses starting at day 90 post SCT. They 
exclude the small number of patients who had disease progression or death prior to day 
90, hence did not have CR90 evaluated.  The same conclusions for PFS are obtained, 
however, if time is started at the time of transplant, i.e. if all patients are included. 
Notation
CR90 = the event that the patient had a CR when evaluated at day 90
T = Progression free survival (PFS) time = time to progression or death, starting at day 
90.
P(T > 12 | M, CR90) = the probability that a patient on the Melphalan arm who achieved 
CR90 had  PFS time of at least 12 months
P(T > 12 | M, NCR90) = the probability that a patient on the Melphalan arm who did 
NOT achieve CR90 had  PFS time of at least 12 months
P(T > 12 | M+B, CR90) = the probability that a patient on the Melphalan + Busulfan arm 
who achieved CR90 had  PFS time of at least 12 months
P(T > 12 | M+B, NCR90) = the probability that a patient on the Melphalan+ Busulfan 
arm who did NOT achieve CR90 had  PFS time of at least 12 months
P(T > 12 | M ) = the probability that a patient on the Melphalan arm had  PFS time of at 
least 12 months
P(T > 12 | M+B ) = the probability that a patient on the Melphalan+ Busulfan arm  had  
PFS time of at least 12 months
Pr(CR90 | M) = the probability that a patient on the Melphalan arm achieved a CR90
Pr(CR90 | M+B) = the probability that a patient on the Melphalan + Busulfan arm 


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achieved a CR90
Probability Mixture Computations
For the M arm,
P(T > 12 | M ) = P(T > 12 | M, CR90) x Pr(CR90 | M)  + P(T > 12 | M, NCR90) x {1 - 
Pr(CR90 | M)}
For the B+M arm,
P(T > 12 | M+B ) = P(T > 12 | M+B, CR90) x Pr(CR90 | M+B)  
+ P(T > 12 | M+B, NCR90) x {1 - Pr(CR90 | M+B)}
In words, these equations say that, in each treatment arm, the overall probability of 
12-month PFS (starting at day 90) is the average of two 12-month PFS probabilities: 
one for the patients who achieved a CR at day 90, and the other for the patients who do 
not achieve a CR at day 90.
Statistical Estimates from the Trial Data
Using a * to denote a statistical estimate
Pr(CR90 | M)* = .35
Pr(CR90 | M+B)* = .16
P(T > 12 | M, CR90)* = .91
P(T > 12 | M, NCR90)* = .68
P(T > 12 | M+B, CR90)* = 1.00
P(T > 12 | M+B, NCR90)* = .89
Note that the M arm has a much higher CR90 probability, .35, compared to .16 for  the 
B+M arm. This is why the trial was stopped early.  Substituting these estimates into the 
mixture model equations gives 
P(T > 12 | M )* =   .91 x .35 + .68 x (1 - .35) = .76        ( 95% ci .65 - .89 )
P(T > 12 | M +B)* = 1.00 x .16 + .89 x (1 - .16) = .91       ( 95% ci .83 - .99 )
The logrank test to compare PFS has p-value  = .047, so the M+B arm had significantly 


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higher PFS
Conclusions:  
1. The M arm had a much higher CR90 rate, more than double that of the M+B arm.
2. In each arm, CR90 increased the probability of 12-month PFS.
3. M+B had higher PFS than M among patients who achieved CR90.
4. M+B had higher PFS than M among patients who did not achieve CR90.
5.  M+B had higher overall PFS probability than the M arm
This is because the 12-month PFS probability was very high for both the CR90 and 
NCR90 groups  in the M+B arm, 1.00 and .89, respectively.  But the M arm patients who 
did not achieve CR90 had the much lower 12-month PFS probability .68.
Trial Conduct.  The randomization will use the Pocock-Simon method [Pocock 1975] 
will used to balance  dynamically on age, dichotomizing this as [age < 65 ] and [66 < 
age < 70] be carried out using the Department of Biostatistics Clinical Trials Conduct 
Website. The interim and final decision rules will be applied using a specialized 
computer program written by John Venier in the Biostatistics Department, and will be 
based on the interim and final CR data provided by the trial’s Principal Investigator.
Secondary Endpoints.  Overall survival (OS) time, transplant related mortality, NIH 
toxicities, quality of life, and 90-day complete response (CR) will be evaluated as 
secondary endpoints. CR is defined as (i) negative immofixation of the MM protein in 
urine and serum, (ii) disappearance of any soft tissue plasmacytomas, and (iii) less than 
5% plasma MM cells in the bone marrow.
Trial Conduct.  The randomization will use the Pocock-Simon method [Pocock 1975] 
will used to balance  dynamically on age, dichotomizing this as [age < 65 ] and [66 < 
age < 70] be carried out using the Department of Biostatistics Clinical Trials Conduct 
Website. 
Data Analyses.  Logistic regression models will be fit to assess the joint effects of 
treatment arm and patient covariates on the probability of CR [Venables 2002]. 
Kaplan-Meier plots [Kaplan 1958] will be used to estimate the unadjusted OS and PFS 
time distributions in the two arms. Time-to-event regression analysis will be used to 
evaluate the ability of treatment arm and patient covariates to predict OS and PFS, with 
the model underlying model chosen based on preliminary goodness-of-fit analyses of 
the data. Additionally, landmark analyses of PFS and OS will be conducted starting at 
day 90, when CR is evaluated.


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