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Matching Resources with Stratified Recommendations for Myeloma Care

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Two recent publications highlight the need to adapt guidelines to accommodate treatment that is truly available in different countries and regions of the world. Myeloma treatment guidelines for Asia appear in The Lancet, and those for Latin America appear in the Brazilian Journal of Hematology.

In setting guidelines, one needs to consider the four As: Availability, Approval Status, Affordability and Access--to everything from routine diagnostics, standard therapies, novel agents and clinical trials. These factors influence responses to therapy, toxicities/tolerance and cost efficiency.

Rather remarkably, the outcomes in Asia and Latin America are quite good, and have survival rates comparable to those in the US and Europe, despite much later diagnosis and considerably reduced access to the newer IMiDs and proteasome inhibitors. Revlimid is still not approved in Korea and Brazil, for example, and there is extremely limited access to Pomalidomide and Carfilzomib, both approved by the FDA in the US.

At the patient level it is difficult to cope with the knowledge that better options are available elsewhere in the world. But patients should also be reassured by the fact that options widely used outside the US, such as the CyBorD regimen (Cytoxan/Velcade/DEX), are perhaps not so inferior to a more common regimen in the US such as VRD (Velcade/Revlimid/DEX). The myeloma community is forced to look more closely at the "standards of care" and, in many instances, conclude that older more widely available approaches are actually no so bad in terms of overall outcomes. Formal, randomized studies are needed to compare available regimens with novel combinations not widely available.

But clearly, the big deficiency is at the level of access to newer agents in clinical trials. This type of access can definitely extend lives. With this in mind, the International Myeloma Foundation, through the International Myeloma Working Group, is committed to accelerating and enhancing access to newer agents. We support applications for new drug approvals whenever possible and we are now starting a new Novel Agent Access Program through the Asian Myeloma Network (AMN), which will allow access to drugs such as Pomalidomide in the years prior to approval in, for example, several countries in Asia. Companion programs for education of both physicians and patients are key in an effort to achieve best outcomes.

As a baseline it is very important and helpful to have these two publications summarizing basic, limited, enhanced and maximum options that are currently available. Within this framework the stage is set to attempt to provide equitable care to myeloma patients globally.

This is a difficult task, but will certainly not be achieved without aggressively setting forth! The myeloma community is strong and can work collectively to achieve the best for patients everywhere.

This is a difficult task, but will certainly not be achieved without aggressively setting forth! The myeloma community is strong and can work collectively to achieve the best for patients everywhere.

Dr. Durie sincerely appreciates and reads all comments left here. However, he cannot answer specific medical questions and encourages readers to contact the trained IMF Hotline staff instead. Questions are answered with input from Dr. Durie and/or other scientific advisors and IMWG members as appropriate. To contact the IMF Hotline, call  800-452-CURE, toll-free in the US and Canada, or send an email to hotline@myeloma.org. Hotline hours are 9 am to 4 pm PST. Friday summer hours are 9 am to 3 pm PDT. Thank  you.


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