Teresa Meenaghan

Home administration of bortezomib: Making a difference to myeloma patients' lives

IntroductionMultiple myeloma is a clonal malignancy of plasma cells, char-acterized by anaemia, renal dysfunction, lytic bone lesions and thepresence of excess monoclonal immunoglobulin. It is the secondmost common hematological disorder (Devenney and Erickson,2004). It remains a complex disease to diagnose and treat.However, our understanding of the biology of myeloma continuesto develop, and hence a number of new potential therapies havebeen identified, with improved outcomes and survival (Kumaret al., 2008).The introduction of novel agents, such as immunomodulatorydrugsorproteasomeinhibitors,eitheraloneorincombinationwithtraditional agents for the treatment of myeloma has led to a majorimprovement in patient outcomes, including survival, in the pastdecade. Based on significant improvements in response rates andoverallsurvival in elderlypatients when combined with melphalanin elderly patients (San Miguel et al., 2008), Bortezomib, a protea-someinhibitor,isnowlicensedasfrontlinetreatmentformyeloma.Bortezomib combined with dexamethasone has also proven to bea very effective induction therapy in younger patients prior toautologous stem cell transplant (Harousseau et al., 2006) and isnow viewed by some as the new standard for initial therapy ofyounger patients. Younger patients are those less than 65 years ofage and eligible for stem cell transplant. However, they must alsohave good performance status and without other co-morbidities.Initiatives in the home administration of chemotherapy areevident internationally (e.g. Lashlee and O’Hanlon Curry, 2007).With regard to the home administration of bortezomib, a pilotfeasibilityprojectofhomeadministrationofbortezomibtopatientswith myeloma has recently been reported from BournmouthHospital in England (McCarthy et al., 2009). However, that pilotprogram only included patients with relapsed disease and patientshadtolivewithina12 mileradiusofthehospital.Inaddition,Day1and Day 4 doses were administered in the hospital, and bloodsamples were taken on each visit. Three of our patient group werenewly diagnosed, receiving initial treatment for their myeloma.Furthermore, all patients on our program received first doses ofbortezomib safely at home. In addition, bloods on our program areonly taken on Day 8; the platelet nadir is day 11 so checking on day8 detects any significant drop prior to this. Finally, our patients liveas far away as 100 miles from the hospital.Why the initiative was startedGalway University Hospital (GUH) is a regional Irish hospitalserving a local urban and widely dispersed rural population. Giventhe emerging data supporting its use in all categories of patientswith multiple myeloma, there has been a major increase in the useofbortezomibastreatmentofmultiplemyelomapatientsattendingGUH. Since bortezomib requires frequent intravenous administra-tion(usuallytwiceaweek,fortwoconsecutiveweekswitha10dayrest period) this has impacted significantly on the hospital’s hae-matology day unit facility, which has severe capacity issues. Theadministration of bortezomib only takes ten seconds. However,

Clofarabine in the treatment of poor risk acute myeloid leukaemia.

Clofarabine is a second generation nucleoside analogue. It inhibits DNA repair and activates the mitochondrial apoptotic pathway leading to cell death. In vitro clofarabine has demonstrated synergy with daunorubicin and Ara‐C and in phase II clinical trials has shown promising activity in poor risk Acute myeloid leukaemia (AML) patients. In our institution over a 24 month period 22 AML patients (11 M, 11 F) with poor risk features, deemed unsuitable for standard therapy, were treated with clofarabine, alone (eight patients) or in combination (14 patients) for up to three cycles of treatment. The median age was 67.5 years (24–76) with 16 patients > 60 years. At the time of treatment 18 patients had active AML. Four patients intolerant of standard induction received clofarabine as consolidation. The overall response rate (ORR) for the 18 patients with active AML was 61%, nine patients (50%) achieving a complete response (CR). Induction and consolidation were well tolerated with no unexpected toxicities. Predictably, all patients developed grade 4 neutropenia but the median duration was only 20 days (17–120). Induction mortality was acceptable at 17%. In conclusion, clofarabine (alone or in combination) is active in poor risk AML with an acceptable safety profile and should be considered a potential option in poor risk AML patients. Copyright

Multiple myeloma: managing a complex blood cancer

This article gives a comprehensive overview of multiple myeloma (MM), a complex blood cancer involving overproduction of plasma cells. Although MM remains incurable, patients are living longer as a result of multiple treatment options. However, MM patients are also living with a higher symptom burden. The overall aims in managing MM are therefore to control disease progression, prolong survival and improve quality of life.