Cyclophosphamide, Bortezomib, and Dexamethasone in Treating Patients With Newly Diagnosed Multiple Myeloma

• Proportion of confirmed responses defined as a complete response (CR), nCR, partial response (PR), or very good PR after the first 4 months of treatment [ Designated as safety issue: No ]
• Hematological response rate [ Designated as safety issue: No ]

• Progression Free Survival (PFS) [ Time Frame: up to 5 years ] [ Designated as safety issue: No ]

  PFS was defined as the time from registration to progression or death due to any cause.

  Progression was defined as any one or more of the following:

  An increase of 25% from lowest confirmed response in:

  • Serum M-component (absolute increase >= 0.5g/dl)
  • Urine M-component (absolute increase >= 200mg/24hour
  • Difference between involved and uninvolved Free Light Chain levels (absolute increase >= 10mg/dl)
  • Bone marrow plasma cell percentage (absolute increase of >=10%)
  • Definite development of new bone lesion or soft tissue plasmacytomas
• Overall Survival (OS) [ Time Frame: From date of registration until death (up to 5 years) ] [ Designated as safety issue: No ]
  OS was defined as the time from registration to death of any cause.
• Number of Participants Who Responded to Treatment (Complete Response,CR; Near Complete Response, nCR; Very Good Partial Response, VGPR; or Partial Response, PR) After 4 Cycles [ Time Frame: 4 cycles ] [ Designated as safety issue: No ]

  Response that was confirmed on 2 consecutive evaluations after 8 months of treatment.

  CR, nCR and VGPR as defined in the primary outcome.

  Partial Response(PR): >=50% reduction in serum M-component and/or

  Urine M-Component >=90% reduction or <200mg per 24hours; or >=50% decrease in difference between involved and uninvolved FLC levels.

• Duration of Response [ Time Frame: Duration of study (up to 12 cycles) ] [ Designated as safety issue: No ]
  Duration of response was calculated from the documentation (date) of first response (CR, nCR, VGPR, or PR) until the date of progression or last follow-up in the subset of patients who responded.
• Number of Participants Who Responded to Treatment (CR, nCR, VGPR or PR) After 8 Cycles [ Time Frame: After 8 cycles of treatment ] [ Designated as safety issue: No ]

  Response that was confirmed on 2 consecutive evaluations after 8 cycles of treatment.

  Criteria for CR, nCR, VGPR and PR are defined in prior outcomes.

• Number of Participants Who Responded to Treatment (CR, nCR, VGPR or PR) After 12 Cycles [ Time Frame: After 12 cycles of treatment ] [ Designated as safety issue: No ]

  Response that was confirmed on 2 consecutive evaluations after 12 cycles of treatment.

  Criteria for CR, nCR, VGPR and PR are defined in prior outcomes.

• Number of Participants With Severe Adverse Events [ Time Frame: Every cycle during treatment (up to 12 cycles) ] [ Designated as safety issue: Yes ]
  Severe adverse events were defined as grade 3 or higher, regardless of attribution to study drugs. Adverse events were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) version 3.
• Participants Who Successfully Completed Collection of Peripheral Blood Stem Cells for Transplant [ Time Frame: After 4 cycles of treatment ] [ Designated as safety issue: No ]
  Evaluation of the ability to successfully collect peripheral blood stem cells following four months (cycles) of combination therapy.

• Progression-free survival [ Designated as safety issue: No ]
• Duration of response [ Designated as safety issue: No ]
• Stem cell collection and engraftment [ Designated as safety issue: No ]
• Ability to induce complete response rate beyond 4 courses at completion of planned therapy [ Designated as safety issue: No ]

RATIONALE: Drugs used in chemotherapy such as cyclophosphamide and dexamethasone work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Bortezomib may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Giving cyclophosphamide and dexamethasone together with bortezomib may kill more cancer cells.

PURPOSE: This phase II trial is studying giving cyclophosphamide and dexamethasone together with bortezomib to see how well it works in treating patients with newly diagnosed multiple myeloma.

OBJECTIVES:

Primary

* To evaluate the response rate (complete response [CR], near CR [nCR], and very good partial response) in patients with newly diagnosed multiple myeloma treated with bortezomib in combination with cyclophosphamide and dexamethasone .

Secondary

• Determine the overall response rate (partial response, PR, or better) in these patients after 4, 8, and 12 courses of this regimen.
• Determine the duration of progression-free and overall survival of patients treated with this regimen.
• To evaluate the toxicity of this regimen in these patients.
• To evaluate the ability to successfully collect peripheral blood stem cells from these patients after 4 months of this regimen.
• To evaluate the CR or nCR rate in these patients after 8 and 12 courses of this regimen.

OUTLINE: This is a multicenter study.

Patients receive oral cyclophosphamide on days 1, 8, 15, and 22; bortezomib IV on days 1, 4, 8 , and 11 OR days 1, 8, 15 and 22; and dexamethasone on days 1-4, 9-12, and 17-20 in courses 1 and 2 and days 1, 18, 15, and 22 in all subsequent courses. Courses repeats every 28 days for up to 12 courses in the absence of disease progression or unacceptable toxicity.

• Drug: bortezomib

  First 33 patients: 1.3 mg/m^2 IV Days 1, 4, 8 & 11

  Remaining 30 patients: 1.5 mg/m^2 IV Days 1, 8, 15 & 22

• Drug: cyclophosphamide
  300mg/m^2 PO days 1, 8, 15 & 22
• Drug: dexamethasone

  First 33 patients: 40 mg PO Days 1-4, 9-12, 17-20

  Remaining 30 patients: 40 mg PO Days 1-4, 9-12, 17-20 for cycles 1-2; Days 1, 8, 15, 22 for cycle 3+2 for cycle 3 and beyond

• Reeder CB, Reece DE, Kukreti V, Chen C, Trudel S, Hentz J, Noble B, Pirooz NA, Spong JE, Piza JG, Zepeda VH, Mikhael JR, Leis JF, Bergsagel PL, Fonseca R, Stewart AK. Cyclophosphamide, bortezomib and dexamethasone induction for newly diagnosed multiple myeloma: high response rates in a phase II clinical trial. Leukemia. 2009 Jul;23(7):1337-41. Epub 2009 Feb 19.
• Reeder CB, Reece DE, Kukreti V, Chen C, Trudel S, Laumann K, Hentz J, Pirooz NA, Piza JG, Tiedemann R, Mikhael JR, Bergsagel PL, Leis JF, Fonseca R, Stewart AK. Once- versus twice-weekly bortezomib induction therapy with CyBorD in newly diagnosed multiple myeloma. Blood. 2010 Apr 22;115(16):3416-7. No abstract available.

DISEASE CHARACTERISTICS:

• Confirmed diagnosis of symptomatic multiple myeloma

  • Durie Salmon stage 2 or higher
  • Previously untreated multiple myeloma (including immunomodulatory drugs such as thalidomide) with the exception of bisphosphonates

• Evaluable or measurable disease, as defined by at least one of the following:

  • Serum monoclonal protein ≥ 1 g/dL (measurable disease)
  • Urine monoclonal protein ≥ 200 mg/24 hours by protein electrophoresis (measurable disease)
  • Serum-free light chains (FLC) ≥ 10 mg/dL, kappa or lambda, accompanied by an abnormal kappa/lambda ratio

Serum FLC's should only be used for patients without measurable serum or urine m-spike

- Monoclonal bone marrow plasmacytosis ≥ 30% (evaluable disease)

* Patients diagnosed with smoldering myeloma or monoclonal gammopathy of undetermined significance are not eligible

PATIENT CHARACTERISTICS:

Inclusion criteria:

• Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) of 0, 1, or 2

  - ECOG PS of 3 will be allowed if secondary to pain in the opinion of the Investigator

• Total bilirubin normal OR direct bilirubin ≤ 2.0 mg/dL
• Alkaline phosphatase ≤ 3 times upper limit of normal (ULN)
• AST ≤ 3 times ULN
• Creatinine ≤ 3.5 mg/dL
• Absolute neutrophil count ≥ 1,000/mm³ without transfusion or growth factor
• Platelet count ≥ 100,000/mm³ without transfusion or growth factor
• Willingness and the physical and mental capability to provide written informed consent
• Willingness to return to Mayo Clinic Arizona/Princess Margaret Hospital for follow-up
• Not pregnant or nursing
• Negative pregnancy test
• Fertile patients must use effective contraception

Exclusion criteria:

• Peripheral sensory neuropathy ≥ grade 2 as defined by National Cancer Institute (NCI) Common Terminology for Common Adverse Events (CTCAE) version 3.0
• Known hypersensitivity to compounds containing boron or mannitol
• Active uncontrolled infection

• Severe cardiac comorbidity including but not limited to:

  • New York Heart Association class III or IV heart failure
  • History of myocardial infarction within the past 6 months
  • Uncontrolled angina or electrocardiographic (ECG) evidence of acute ischemia
  • Severe uncontrolled ventricular arrhythmias or ECG evidence of active conduction system abnormalities
  • Cardiac amyloidosis with hypotension (i.e., systolic blood pressure < 100 mm Hg)
• Any serious medical condition, laboratory abnormality, or psychiatric illness that would prevent study compliance or completion of study treatment

PRIOR CONCURRENT THERAPY:

• See Disease Characteristics
• Prior high-dose corticosteroid therapy for 12 days or less is permitted for emergent complications from newly diagnosed multiple myeloma
• More than 14 days since prior investigational agents

• No concurrent steroids or any other anticancer agents or treatments

  - Patients may receive the equivalent of up to 20 mg prednisone per day for concurrent illness or adrenal replacement therapy

• Concurrent palliative radiotherapy for bony pain or fracture is allowed