Abstract: The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally.

Abstract: Introduction: Daratumumab (DARA) is approved across lines of therapy for multiple myeloma. In the primary analysis of the phase 2 GRIFFIN trial (NCT02874742) in pts with transplant-eligible NDMM (median follow-up, 13.5 mo), D-RVd improved the rate of stringent complete response (sCR) by the end of post-autologous stem cell transplant (ASCT) consolidation versus RVd (42.4% vs 32.0%; odds ratio [OR], 1.57; 95% CI, 0.87-2.82; 1-sided P=0.068) (Voorhees PM, et al. Blood. 2020). With longer follow-up (median, 27.4 mo) after 12 months of maintenance therapy, sCR rates deepened for D-RVd versus RVd (63.6% vs 47.4%, 2-sided P=0.0253), as did the rate of minimal residual disease (MRD; 10 -5) negativity (62.5% vs 27.2%, P & lt;0.0001) (Kaufman JL, et al. Blood. 2020). Here, we present an analysis among clinically relevant subgroups (age ≥65 years, International Staging System [ISS] stage III disease, and high cytogenetic risk [del17p, t(4;14), or t(14;16) abnormalities] ) after 24 months of maintenance therapy (median follow-up, 38.6 mo). Methods: Eligible pts with transplant-eligible NDMM were randomized 1:1 to D-RVd or RVd. Pts received 4 RVd or D-RVd induction cycles, high dose therapy, ASCT, 2 RVd or D-RVd consolidation cycles, and maintenance with lenalidomide (R) alone or with DARA (D-R) for 24 months. During induction and consolidation (21-day cycles), pts received R (25 mg PO on Days 1-14), bortezomib (1.3 mg/m 2 SC on Days 1, 4, 8, and 11), and dexamethasone (40 mg PO QW) ± DARA (16 mg/kg IV on Days 1, 8, and 15 of Cycles 1-4 and Day 1 of Cycles 5-6). During maintenance (Cycles 7-32; 28-day cycles), pts received R (10 mg PO on Days 1-21; if tolerated, 15 mg in Cycles 10+) ± DARA (16 mg/kg IV Q8W, or Q4W per pt decision after Amendment 2) until disease progression or up to 24 months. The primary endpoint was sCR rate by the end of post-ASCT consolidation. Responses were assessed per International Myeloma Working Group criteria by a validated computer algorithm. Additional endpoints included progression-free survival (PFS) and MRD-negativity (10 -5) rate by next-generation sequencing. Results: In total, 207 pts were randomized (D-RVd, n=104; RVd, n=103); each group had a similar number of pts with age ≥65 years (n=28; n=28), ISS stage III disease (n=14; n=14), or high cytogenetic risk (n=16; n=14). Among response-evaluable pts, the rate of sCR after 24 months of maintenance therapy was numerically higher for D-RVd versus RVd among pts ≥65 years (63.0% vs 40.7%, OR, 2.47, 95% CI, 0.83-7.39), but similar for D-RVd and RVd pts with ISS stage III disease (57.1% vs 61.5%, OR, 0.83, 95% CI, 0.18-3.88) and high cytogenetic risk (43.8% vs 38.5%, OR, 1.24, 95% CI, 0.28-5.53; Figure). MRD-negativity (10 -5) rates favored D-RVd versus RVd across all subgroups: ≥65 years (67.9% vs 17.9%), ISS stage III disease (71.4% vs 35.7%), and high cytogenetic risk (43.8% vs 28.6%; Figure). With 38.6 months median follow-up, median PFS was not reached (NR) for pts ≥65 years in either treatment group (6 pts progressed: D-RVd, n=1; RVd, n=5). Among pts with ISS stage III disease, median PFS was NR for D-RVd and 33.1 months for RVd (7 pts progressed: D-RVd, n=1; RVd, n=6). Among pts with high cytogenetic risk, median PFS was NR for D-RVd and 36.1 months for RVd (10 pts progressed: D-RVd, n=5; RVd, n=5; Figure). In pts ≥65 years, grade 3/4 treatment-emergent adverse events (TEAEs) occurred in 88.9% of D-RVd pts and 77.8% of RVd pts; the most common (≥20%) were neutropenia (37.0%; 29.6%) and lymphopenia (25.9%; 11.1%). Serious TEAEs occurred in 55.6% and 40.7% of pts, respectively. TEAEs led to study treatment discontinuation in 33.3% of D-RVd pts and 25.9% of RVd pts. One death due to a TEAE (unrelated to study treatment) occurred in a D-RVd pt ≥65 years of age. Conclusion: Subgroup analyses of pts in GRIFFIN show that the addition of DARA to RVd induction/consolidation and R maintenance, in conjunction with ASCT, may benefit clinically relevant subgroups. sCR rates were improved for D-RVd versus RVd in pts ≥65 years but not in pts with ISS stage III disease or high cytogenetic risk. Improved MRD-negativity rates were observed for D-RVd in all subgroups. Although immature and with limited pt numbers, PFS results also trended towards favoring D-RVd in these subgroups. Among pts ≥65 years, TEAEs and serious TEAEs were numerically higher for D-RVd. These results support the use of DARA in transplant-eligible NDMM pts among high-risk subgroups, although larger studies are needed. Figure 1 Figure 1. Disclosures Anderson: Celgene, BMS, Janssen, GSK, Karyopharm, Oncopeptides, Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Kaufman: Sutro, Takeda: Research Funding; Roche/Genetech, Tecnopharma: Consultancy, Honoraria; Janssen: Honoraria; Novartis: Research Funding; Heidelberg Pharma: Research Funding; Incyte, celgene: Consultancy; BMS: Consultancy, Research Funding; Amgen: Research Funding; Tecnofarma SAS, AbbVie: Honoraria; Fortis Therapeutics: Research Funding; Incyte, TG Therapeutics: Membership on an entity's Board of Directors or advisory committees; Genentech, AbbVie, Janssen: Consultancy, Research Funding. Sborov: Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline: Consultancy; SkylineDx: Consultancy; Sanofi: Consultancy. Reeves: Pharma Essentia: Consultancy, Honoraria; Takeda: Honoraria; Bristol-Myers Squibb: Speakers Bureau; Incyte Corporation: Honoraria. Rodriguez: Takeda: Consultancy, Speakers Bureau; Oncopeptides: Consultancy, Honoraria; Amgen: Consultancy, Speakers Bureau; Janssen: Consultancy, Speakers Bureau; Karyopharm: Consultancy, Speakers Bureau; BMS: Consultancy, Speakers Bureau. Chari: Genentech: Consultancy, Membership on an entity's Board of Directors or advisory committees; Shattuck Labs: Consultancy, Membership on an entity's Board of Directors or advisory committees; Takeda: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Secura Bio: Consultancy, Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline: Consultancy, Membership on an entity's Board of Directors or advisory committees; Pharmacyclics: Research Funding; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees; Seattle Genetics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Millenium/Takeda: Consultancy, Research Funding; BMS/Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Karyopharm: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen Oncology: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Antengene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Sanofi Genzyme: Consultancy, Membership on an entity's Board of Directors or advisory committees; Oncopeptides: Consultancy, Membership on an entity's Board of Directors or advisory committees. Silbermann: Sanofi Genzyme: Membership on an entity's Board of Directors or advisory committees, Research Funding; Janssen Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Costa: Karyopharm: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Amgen: Consultancy, Honoraria, Research Funding, Speakers Bureau; BMS: Consultancy, Honoraria, Research Funding; Sanofi: Consultancy, Honoraria, Speakers Bureau; Janssen: Consultancy, Honoraria, Research Funding. Shah: Janssen: Research Funding; Nektar: Research Funding; Kite: Consultancy; Karyopharm: Consultancy; Indapta Therapeutics: Consultancy; Bluebird Bio: Research Funding; BMS/Celgene: Research Funding; Amgen: Consultancy; CareDx: Consultancy; Poseida: Research Funding; Precision Biosciences: Research Funding; Oncopeptides: Consultancy; CSL Behring: Consultancy; GSK: Consultancy; Sanofi: Consultancy; Sutro Biopharma: Research Funding; Teneobio: Research Funding. Bumma: Janssen: Membership on an entity's Board of Directors or advisory committees; Amgen: Speakers Bureau; Sanofi: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Holstein: Oncopeptides: Membership on an entity's Board of Directors or advisory committees, Research Funding; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Genentech, GSK, Janssen, Secura Bio, Sorrento: Honoraria; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees. Jakubowiak: Celgene: Membership on an entity's Board of Directors or advisory committees; Gracell: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; GSK: Membership on an entity's Board of Directors or advisory committees; Sanofi: Membership on an entity's Board of Directors or advisory committees; Karyopharm: Membership on an entity's Board of Directors or advisory committees; Janssen: Membership on an entity's Board of Directors or advisory committees; BMS: Membership on an entity's Board of Directors or advisory committees. Wildes: Carevive: Consultancy; Seattle Genetics: Consultancy; Sanofi: Consultancy; Janssen: Consultancy. Orlowski: Amgen, Inc., BioTheryX, Inc., Bristol-Myers Squibb, Celgene, EcoR1 Capital LLC, Genzyme, GSK Biologicals, Janssen Biotech, Karyopharm Therapeutics, Inc., Neoleukin Corporation, Oncopeptides AB, Regeneron Pharmaceuticals, Inc., Sanofi-Aventis, and Takeda P: Consultancy, Honoraria; Asylia Therapeutics, Inc., BioTheryX, Inc., and Heidelberg Pharma, AG.: Other: Laboratory research funding; CARsgen Therapeutics, Celgene, Exelixis, Janssen Biotech, Sanofi-Aventis, Takeda Pharmaceuticals North America, Inc.: Other: Clinical research funding; Asylia Therapeutics, Inc.: Current holder of individual stocks in a privately-held company, Patents & Royalties; Amgen, Inc., BioTheryX, Inc., Bristol-Myers Squibb, Celgene, Forma Therapeutics, Genzyme, GSK Biologicals, Janssen Biotech, Juno Therapeutics, Karyopharm Therapeutics, Inc., Kite Pharma, Neoleukin Corporation, Oncopeptides AB, Regeneron Pharmaceuticals, I: Membership on an entity's Board of Directors or advisory committees. Shain: Sanofi Genzyme: Consultancy, Speakers Bureau; AbbVie: Membership on an entity's Board of Directors or advisory committees, Research Funding; Adaptive Biotechnologies Corporation: Consultancy, Speakers Bureau; Novartis Pharmaceuticals Corporation: Consultancy; GlaxoSmithLine, LLC: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; BMS: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Karyopharm Therapeutics Inc.: Honoraria, Research Funding; Amgen Inc: Consultancy, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen oncology: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Cowan: BMS: Research Funding; Secura Bio: Consultancy; GSK: Consultancy; Harpoon: Research Funding; Cellectar: Consultancy; Sanofi: Consultancy, Research Funding; AbbVie: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Nektar: Research Funding. Pei: Janssen: Current Employment, Current equity holder in publicly-traded company. Cortoos: Janssen: Current Employment, Current equity holder in publicly-traded company. Patel: Janssen: Current Employment. Bartlett: Janssen: Current Employment. Vermeulen: Janssen: Current Employment, Current equity holder in publicly-traded company. Lin: Janssen: Current Employment. Voorhees: Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Sanofi: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Karyopharm: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Oncopeptides: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Abbvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Secura Bio: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees. Richardson: AbbVie: Consultancy; Oncopeptides: Consultancy, Research Funding; Celgene/BMS: Consultancy, Research Funding; Regeneron: Consultancy; AstraZeneca: Consultancy; Secura Bio: Consultancy; Janssen: Consultancy; Protocol Intelligence: Consultancy; Karyopharm: Consultancy, Research Funding; Takeda: Consultancy, Research Funding; GlaxoSmithKline: Consultancy; Sanofi: Consultancy; Jazz Pharmaceuticals: Consultancy, Research Funding. OffLabel Disclosure: The specific regimen combination is not yet approved, but individual components are.