Outcomes of Patients with Newly Diagnosed Myeloma Both Transplant Eligible and Ineligible in North Africa: A Usmirc- Morocco/Tunisia Collaboration

Abstract

Background: Multiple myeloma (MM) is the second most common hematological malignancy. According to 2020 global cancer statistics, the mortality rate was reported at 1.8 per 100,000, with an incidence rate of 2.3 per 100000. The global incidence of MM is on the rise due to increasing life expectancies. While there has been a substantial increase in therapeutic options for MM patients, especially in the USA, with improvement in overall survival (OS) of > 10 years, yet there is still a significant unmet need for treatment options in North Africa, primarily due to limited access to many novel therapies. Methods: A retrospective analysis of patients (pts) with MM was conducted between 2012-2024 at two centers in Tunisia and Morocco in collaboration with the U.S Myeloma Innovations Research Collaborative (USMIRC). We included consecutive pts with a confirmed diagnosis of MM and received treatment in both centers. Baseline demographic data were described, and outcomes were evaluated for two subgroups: transplant-eligible (TE) and transplant-ineligible (TI). Responses, including overall response rate (ORR) and very good partial response or better (≥VGPR), were evaluated using the International Myeloma Working Group (IMWG) criteria. Statistical analysis was done using Kaplan-Meier method for progression-free (PFS) and overall survival (OS) calculations. Results: Based on the analysis, 146 pts were included, 82 (56%) from Morocco and 64 (44%) from Tunisia. A total of 67 (46%) were female, and 38 (26%) had international staging system, stage III disease, with 11 (7.5%) displaying high-risk cytogenetics. Additionally, 84 (58%) pts were TE vs 62 (42%), with a median age at diagnosis of 56 (28-67) vs 72 (60-89) years. In the TE group, triplet therapy was commonly used in induction therapy in 82 (98%) of pts, commonly Bortezomib/Thalidomide/dexamethasone (VTD) in 59 (70%) pts while in TI 55 (89%) pts, commonly Melphalan, prednisone and thalidomide (MPT) in 34 (55%) pts. Conditioning regimen with melphalan 200 mg/m2 was received by 98% of patients in the TE cohort. The ORR in the TE was 100% with 56 pts (67%) achieving VGPR and better, while in TI, the ORR was 51% with 21 pts (34%) achieving VGPR and better. After a median follow-up of 96.4 months (95% CI, 68.4, NA), the PFS for pts TE was 46.5 months (95% CI, 32.3-61.5) and OS was 100 months (95% CI,96.4-NA), while in TI, the PFS was 16.7 months (95% CI,13.6-35.6) and OS was 45.1 months (95% CI, 96.4-NA). The Median OS for all patients (both TI and TE) was 96.4 months 95% CI:68.4- NA). The commonest cause of mortality in the whole cohort was myeloma in 34 (83%), while infection was the second commonest cause in 5 (12%) pts. Although the majority of pts in both groups received triplet therapy as induction therapy the lack of using more novel agents such as daratumumab/Isatuximab and lenalidomide was an issue due to less adequate access to these agents Conclusion: These findings showcase the inferior outcomes of myeloma patients in North Africa (Morocco/Tunisia) both TE and TI, compared to standard OS in USA. It is unfortunate that the majority of triple therapies used lack at least one novel therapy, which could have a long-term impact on overall survival. This disparity is likely due to limited access to these novel treatments in low-middle-income countries. Our aim is to explore potential health system-level solutions to address inequalities in therapies, particularly in the context of induction therapy.