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Maillard M, Nishii R, Yang W, Hoshitsuki K, Chepyala D, Lee SHR, Nguyen JQ, Relling MV, Crews KR, Leggas M, Singh M, Suang JLY, Yeoh AEJ, Jeha S, Inaba H, Pui CH, Karol SE, Trehan A, Bhatia P, Antillon Klussmann FG, Bhojwani D, Haidar CE, Yang JJ. Additive effects of TPMT and NUDT15 on thiopurine toxicity in children with acute lymphoblastic leukemia across multiethnic populations. J Natl Cancer Inst 2024; 116:702-710. [PMID: 38230823 PMCID: PMC11077315 DOI: 10.1093/jnci/djae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/22/2023] [Accepted: 01/04/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Thiopurines such as mercaptopurine (MP) are widely used to treat acute lymphoblastic leukemia (ALL). Thiopurine-S-methyltransferase (TPMT) and Nudix hydrolase 15 (NUDT15) inactivate thiopurines, and no-function variants are associated with drug-induced myelosuppression. Dose adjustment of MP is strongly recommended in patients with intermediate or complete loss of activity of TPMT and NUDT15. However, the extent of dosage reduction recommended for patients with intermediate activity in both enzymes is currently not clear. METHODS MP dosages during maintenance were collected from 1768 patients with ALL in Singapore, Guatemala, India, and North America. Patients were genotyped for TPMT and NUDT15, and actionable variants defined by the Clinical Pharmacogenetics Implementation Consortium were used to classify patients as TPMT and NUDT15 normal metabolizers (TPMT/NUDT15 NM), TPMT or NUDT15 intermediate metabolizers (TPMT IM or NUDT15 IM), or TPMT and NUDT15 compound intermediate metabolizers (TPMT/NUDT15 IM/IM). In parallel, we evaluated MP toxicity, metabolism, and dose adjustment using a Tpmt/Nudt15 combined heterozygous mouse model (Tpmt+/-/Nudt15+/-). RESULTS Twenty-two patients (1.2%) were TPMT/NUDT15 IM/IM in the cohort, with the majority self-reported as Hispanics (68.2%, 15/22). TPMT/NUDT15 IM/IM patients tolerated a median daily MP dose of 25.7 mg/m2 (interquartile range = 19.0-31.1 mg/m2), significantly lower than TPMT IM and NUDT15 IM dosage (P < .001). Similarly, Tpmt+/-/Nudt15+/- mice displayed excessive hematopoietic toxicity and accumulated more metabolite (DNA-TG) than wild-type or single heterozygous mice, which was effectively mitigated by a genotype-guided dose titration of MP. CONCLUSION We recommend more substantial dose reductions to individualize MP therapy and mitigate toxicity in TPMT/NUDT15 IM/IM patients.
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Affiliation(s)
- Maud Maillard
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Rina Nishii
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Wenjian Yang
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Keito Hoshitsuki
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Divyabharathi Chepyala
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Shawn H R Lee
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
- Khoo Teck Puat-National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jenny Q Nguyen
- Personalized Care Program, Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | - Mary V Relling
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Kristine R Crews
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Mark Leggas
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Meenu Singh
- Haematology-Oncology Unit, Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Joshua L Y Suang
- Khoo Teck Puat-National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Allen E J Yeoh
- Khoo Teck Puat-National University Children’s Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sima Jeha
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Hiroto Inaba
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Seth E Karol
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Amita Trehan
- Haematology-Oncology Unit, Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prateek Bhatia
- Haematology-Oncology Unit, Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Deepa Bhojwani
- Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Cyrine E Haidar
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
| | - Jun J Yang
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN, USA
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McGrady ME, Ketterl TG, Webster RT, Schwartz LE, Brock MY, Szulczewski L, Burke M, Hommel KA, Pai ALH, Mara CA, Steele AC, Regan GG, Norris RE. Feasibility pilot trial of a tailored medication adherence-promotion intervention for adolescents and young adults with cancer: Study design and protocol. Contemp Clin Trials 2024; 139:107483. [PMID: 38431133 PMCID: PMC10960689 DOI: 10.1016/j.cct.2024.107483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/13/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Medication non-adherence is common among adolescents and young adults (AYAs) with cancer and associated with poor health outcomes. AYAs with cancer endorse multiple barriers to adherence that differ across individuals, suggesting that tailoring intervention content to an AYA's specific barriers may have the potential to improve adherence. The purpose of this manuscript is to report on ORBIT-guided Phase I design efforts to create the first tailored adherence-promotion intervention for AYAs with cancer and the study protocol for the ongoing Phase II pilot feasibility trial. METHODS Phase I design included qualitative interviews (n = 15 AYAs) to understand patient preferences for adherence-promotion care, development and refinement of a best-worst scaling exercise barriers tool (n = 5 AYAs), and development of intervention modules and a tailoring algorithm. In the ongoing Phase II pilot feasibility trial, AYAs (ages 15-24 years) with cancer currently taking oral chemotherapy or prophylactic medication will be recruited from three children's hospitals. Feasibility, acceptability, and usability will be assessed and these outcomes along with data on medication adherence will be used to inform the next phases of intervention development and testing. CONCLUSIONS If promising, this program of research ultimately has the potential to equip clinicians with additional strategies for supporting adherence among AYAs with cancer. NCT05706610.
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Affiliation(s)
- Meghan E McGrady
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Tyler G Ketterl
- Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Rachel Tillery Webster
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA; Comprehensive Cancer Center, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Laura E Schwartz
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Margaret Y Brock
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Lauren Szulczewski
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Kevin A Hommel
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ahna L H Pai
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Constance A Mara
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Amii C Steele
- Division of Pediatric Psychology and Neuropsychology, Levine Children's Hospital at Atrium Health, Charlotte, NC, USA
| | - Gillian G Regan
- Division of Pediatric Psychology and Neuropsychology, Levine Children's Hospital at Atrium Health, Charlotte, NC, USA
| | - Robin E Norris
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Du S, Huang X, He X, Mao M, Chen M, Zhang R, Shao H, Lv Z, Liu X, Chuan J. Association of NUDT15 gene polymorphism with adverse reaction, treatment efficacy, and dose of 6-mercaptopurine in patients with acute lymphoblastic leukemia: a systematic review and meta-analysis. Haematologica 2024; 109:1053-1068. [PMID: 37794799 PMCID: PMC10985454 DOI: 10.3324/haematol.2023.282761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 10/26/2023] [Indexed: 10/06/2023] Open
Abstract
6-mercaptopurine (6-MP) serves as the backbone in the maintenance regimens of acute lymphoblastic leukemia (ALL). We aimed to evaluate the influence of NUDT15 gene polymorphism on the risk of myelosupression, hepatotoxicity and interruption of 6-MP, as well as treatment efficacy and dose of 6-MP in ALL patients. A total of 24 studies with 3,374 patients were included in this meta-analysis. We found 9-fold higher risk of 6-MP induced leukopenia (odds ratio [OR] =9.00, 95% confidence interval [CI]: 3.73-21.74) and 2.5-fold higher risk of 6-MP-induced neutropenia (OR=2.52, 95% CI: 1.72-3.69) for NUDT15 c.415C>T variant carriers in the dominant model. Moreover, we found that the dose intensity of 6-MP in ALL patients with one NUDT15 c.415C>T variant alleles (CT) was 19% less than that in wild-type patients (CC) (mean differences: 19.43%, 95% CI: -25.36 to -13.51). The tolerable dose intensity of 6-MP in NUDT15 c.415C>T homozygote variant (TT) and heterozygote variant (CT) carriers was 49% and 15% less than that in wild-type patients, respectively. The NUDT15 c.415C>T variant group (CT+TT) had seven times (OR=6.98, 95% CI: 2.83-17.22) higher risk of developing 6-MP intolerance than the CC group. However, NUDT15 c.415C>T polymorphism did not appear significantly associated with hepatotoxicity, treatment interruption or relapse incidence. We concluded that NUDT15 c.415C>T was a good predictor for 6-MP-induced myelosuppression in ALL patients. The dose intensity of 6-MP in ALL patients with NUDT15 c.415C>T variants was significantly lower than that in wild-type patients. This research provided a basis for further investigation into relations between NUDT15 gene and adverse reaction, treatment efficacy and dose intensity of 6-MP.
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Affiliation(s)
- Shan Du
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Xuefei Huang
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Xia He
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Mian Mao
- Department of Pharmacy, Sichuan Cancer Hospital, Chengdu
| | - Min Chen
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Rong Zhang
- Department of Pediatrics, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu
| | - Huikai Shao
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Ziyan Lv
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu
| | - Xinxia Liu
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu.
| | - Junlan Chuan
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu.
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Dong N, Ma HX, Liu XQ, Li D, Liu LH, Shi Q, Ju XL. Histidine re-sensitizes pediatric acute lymphoblastic leukemia to 6-mercaptopurine through tetrahydrofolate consumption and SIRT5-mediated desuccinylation. Cell Death Dis 2024; 15:216. [PMID: 38485947 PMCID: PMC10940622 DOI: 10.1038/s41419-024-06599-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/18/2024]
Abstract
Despite progressive improvements in the survival rate of pediatric B-cell lineage acute lymphoblastic leukemia (B-ALL), chemoresistance-induced disease progression and recurrence still occur with poor prognosis, thus highlighting the urgent need to eradicate drug resistance in B-ALL. The 6-mercaptopurine (6-MP) is the backbone of ALL combination chemotherapy, and resistance to it is crucially related to relapse. The present study couples chemoresistance in pediatric B-ALL with histidine metabolism deficiency. Evidence was provided that histidine supplementation significantly shifts the 6-MP dose-response in 6-MP-resistant B-ALL. It is revealed that increased tetrahydrofolate consumption via histidine catabolism partially explains the re-sensitization ability of histidine. More importantly, this work provides fresh insights into that desuccinylation mediated by SIRT5 is an indispensable and synergistic requirement for histidine combination therapy against 6-MP resistance, which is undisclosed previously and demonstrates a rational strategy to ameliorate chemoresistance and protect pediatric patients with B-ALL from disease progression or relapse.
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Affiliation(s)
- Na Dong
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, 250012, Shandong Province, China
| | - Hui-Xian Ma
- Cryomedicine Laboratory, Qilu Hospital of Shandong University, Jinan, 250012, Shandong Province, China
| | - Xue-Qin Liu
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, 250012, Shandong Province, China
| | - Dong Li
- Cryomedicine Laboratory, Qilu Hospital of Shandong University, Jinan, 250012, Shandong Province, China
| | - Ling-Hong Liu
- Cryomedicine Laboratory, Qilu Hospital of Shandong University, Jinan, 250012, Shandong Province, China
| | - Qing Shi
- Cryomedicine Laboratory, Qilu Hospital of Shandong University, Jinan, 250012, Shandong Province, China
| | - Xiu-Li Ju
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, 250012, Shandong Province, China.
- Cryomedicine Laboratory, Qilu Hospital of Shandong University, Jinan, 250012, Shandong Province, China.
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Arun B, Joshi M, Kakkar AK, Madki S, Ivaturi V, Chinnaswamy G, Banavali S, Gota V. Bioequivalence study followed by model-informed dose optimization of a powder for oral suspension of 6-mercaptopurine. Pediatr Blood Cancer 2024; 71:e30813. [PMID: 38110844 DOI: 10.1002/pbc.30813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/15/2023] [Accepted: 11/23/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND 6-Mercaptopurine (6MP) is the mainstay chemotherapy for acute lymphoblastic leukemia (ALL) and is conventionally available as 50 mg tablets. A new 6MP powder for oral suspension (PFOS 10 mg/mL) was developed recently by IDRS Labs, India, intended for pediatric use. A comparative pharmacokinetics of PFOS with T. mercaptopurine was conducted to determine the dose equivalence. METHODS An open-label, randomized, two-treatment, two-period, two-sequence, single oral dose, crossover, bioequivalence study was conducted on 51 healthy adult subjects. Post hoc, a population pharmacokinetic (PopPK) model was developed using the healthy volunteer data to perform simulations with various PFOS doses and select a bioequivalent dose. Further, to confirm the safety of PFOS in pediatrics, a simulation of 6MP and 6-thioguanine exposures was performed by incorporating the formulation-specific parameters derived from the healthy volunteer study into the PopPK model in childhood ALL available in literature. RESULTS The 6MP PFOS had 47% higher oral bioavailability compared to the reference product. Simulations using a two-compartmental PopPK model with dissolution and transit compartments showed that 40 mg of PFOS was found to be equivalent to 50 mg tablets. The simulated 6-thioguanine nucleotide concentrations in children using the dose adjusted for PFOS were between 114 and 703.6 pmol/8 × 108 RBC, which was within the range reported in pediatric ALL studies. CONCLUSION 6MP PFOS 10 mg/mL should be administered at a 20% lower dose than the tablet to achieve comparable exposure. 6MP PFOS addresses an unmet medical need for a liquid formulation of 6MP in the Indian subcontinent.
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Affiliation(s)
- Bhavatharini Arun
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
| | | | | | | | | | - Girish Chinnaswamy
- Department of Paediatric Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushakthinagar, Mumbai, Maharashtra, India
| | - Shripad Banavali
- Department of Paediatric Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushakthinagar, Mumbai, Maharashtra, India
| | - Vikram Gota
- Department of Clinical Pharmacology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, Maharashtra, India
- Homi Bhabha National Institute, Anushakthinagar, Mumbai, Maharashtra, India
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Hashmi SK, Bodea J, Patni T, Angel S, Bhakta NH, Jeha S, Karol SE, Ribeiro RC, Rubnitz JE, Wolf J, Li Y, Pui CH, Hijano DR, Inaba H. COVID-19 in Pediatric Patients With Acute Lymphoblastic Leukemia or Lymphoma. JAMA Netw Open 2024; 7:e2355727. [PMID: 38363571 PMCID: PMC10873761 DOI: 10.1001/jamanetworkopen.2023.55727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/18/2023] [Indexed: 02/17/2024] Open
Abstract
Importance COVID-19 in pediatric patients with acute lymphoblastic leukemia or lymphoma (ALL/LLy) has not been described in detail and may affect chemotherapy administration and long-term outcomes. Objective To describe the clinical presentation of COVID-19 and chemotherapy modifications in pediatric patients with ALL/LLy. Design, Setting, and Participants This is a retrospective case series of patients at St Jude Children's Research Hospital and its affiliate sites with newly diagnosed ALL/LLy who were treated on the Total XVII protocol (NCT03117751) between March 30, 2020, and June 20, 2022. Participants included patients aged 1 to 18 years who were receiving protocol chemotherapy. Acute symptoms and chemotherapy modifications were evaluated for 60 days after the COVID-19 diagnosis, and viral clearance, adverse events, and second SARS-CoV-2 infections were followed up during the 27-month study period. Exposures SARS-CoV-2; all patients were screened at least weekly and at symptom onset and/or after known exposure to SARS-CoV-2. Main Outcomes and Measures Description of the spectrum of COVID-19 illness and chemotherapy modifications. Results Of 308 pediatric patients, 110 (36%) developed COVID-19 at a median age of 8.2 (IQR, 5.3-14.5) years. Sixty-eight patients (62%) were male. Most patients were in the continuation/maintenance phase of chemotherapy (101 [92%]). Severe disease was rare (7 [6%]) but was associated with older age, higher white blood cell counts at ALL/LLy diagnosis, lower absolute lymphocyte counts at COVID-19 diagnosis, abnormal chest imaging findings, and SARS-CoV-2 reinfection. Rare but serious thrombotic events included pulmonary embolism and cerebral venous sinus thrombosis (n = 1 for each). No multisystem inflammatory syndrome in children or death was seen. SARS-CoV-2 reinfection occurred in 11 patients (10%) and was associated with older age and with receiving standard or high-risk vs low-risk ALL/LLy therapy. Chemotherapy interruptions occurred in 96 patients (87%) and were longer for patients with severe disease, SARS-CoV-2 reinfection, and/or a COVID-19 diagnosis during the pre-Omicron variant period vs the post-Omicron period (after December 27, 2021). Conclusions and Relevance In this case series of COVID-19 in pediatric patients with ALL/LLy, severe COVID-19 was rare, but chemotherapy administration was affected in most patients. Long-term studies are needed to establish the outcomes of COVID-19 in this population.
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Affiliation(s)
- Saman K. Hashmi
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Jessica Bodea
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Tushar Patni
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Savannah Angel
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Nickhill H. Bhakta
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Sima Jeha
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Seth E. Karol
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Raul C. Ribeiro
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Jeffrey E. Rubnitz
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Joshua Wolf
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Yimei Li
- Department of Biostatistics, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Ching-Hon Pui
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
- Department of Global Pediatric Medicine, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Diego R. Hijano
- Department of Infectious Diseases, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Hiroto Inaba
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
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Armenian SH, Hudson MM, Lindenfeld L, Chen S, Chow EJ, Colan S, Collier W, Su X, Marcus E, Echevarria M, Iukuridze A, Robison LL, Wong FL, Chen MH, Bhatia S. Effect of carvedilol versus placebo on cardiac function in anthracycline-exposed survivors of childhood cancer (PREVENT-HF): a randomised, controlled, phase 2b trial. Lancet Oncol 2024; 25:235-245. [PMID: 38215764 PMCID: PMC10872217 DOI: 10.1016/s1470-2045(23)00637-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Carvedilol improves cardiac function in patients with heart failure but remains untested as cardioprotective therapy in long-term childhood cancer survivors (ie, those who have completed treatment for childhood cancer and are in remission) at risk for heart failure due to high-dose anthracycline exposure. We aimed to evaluate the activity and safety of low-dose carvedilol for heart failure risk reduction in childhood cancer survivors at highest risk for heart failure. METHODS PREVENT-HF was a randomised, double-blind, phase 2b trial done at 30 hospitals in the USA and Canada. Patients were eligible if they had any cancer diagnosis that resulted in at least 250 mg/m2 cumulative exposure to anthracycline by age 21 years; completed their cancer treatment at least 2 years previously; an ejection fraction of at least 50% or fractional shortening of at least 25%, or both; and bodyweight of at least 40 kg. Patients were randomly assigned (1:1) with automated computer-generated permuted block randomisation (block size of 4), stratified by age at diagnosis, time since diagnosis, and history of chest-directed radiotherapy, to carvedilol (up-titrated from 3·125 g per day to 12·5 mg per day) or placebo orally for 2 years. Participants, staff, and investigators were masked to study group allocation. The primary endpoint was to establish the effect of carvedilol on standardised left ventricular wall thickness-dimension ratio Z score (LVWT/Dz). Treatment effects were analysed with a linear mixed-effects model for normally distributed data with a linear time effect and testing the significance of treatment*time interaction in the modified intention-to-treat (mITT) cohort (ie, all randomly assigned participants who had a baseline and at least one subsequent echocardiogram measurement). Safety was assessed in the ITT population (ie, all randomly assigned participants). This trial was registered with ClinicalTrials.gov, NCT027175073, and enrolment and follow-up are complete. FINDINGS Between July 3, 2012, and June 22, 2020, 196 participants were enrolled, of whom 182 (93%) were eligible and randomly assigned to either carvedilol (n=89) or placebo (n=93; ITT population). Median age was 24·7 years (IQR 19·6-36·6), 91 (50%) participants were female, 91 (50%) were male, and 119 (65%) were non-Hispanic White. As of data cutoff (June 10, 2022), median follow-up was 725 days (IQR 378-730). 151 (n=75 in the carvedilol group and n=76 in the placebo group) of 182 participants were included in the mITT population, among whom LVWT/Dz was similar between the two groups (-0·14 [95% CI -0·43 to 0·16] in the carvedilol group vs -0·45 [-0·77 to -0·13] in the placebo group; difference 0·31 [95% CI -0·10 to 0·73]; p=0·14). Two (2%) of 89 patients in the carvedilol group two adverse events of grade 2 or higher (n=1 shortness of breath and n=1 arthralgia) and none in the placebo group. There were no adverse events of grade 3 or higher and no deaths. INTERPRETATION Low-dose carvedilol appears to be safe in long-term childhood cancer survivors at risk for heart failure, but did not result in significant improvement of LVWT/Dz compared with placebo. These results do not support the use of carvedilol for secondary heart failure prevention in anthracycline-exposed childhood cancer survivors. FUNDING National Cancer Institute, Leukemia & Lymphoma Society, St Baldrick's Foundation, Altschul Foundation, Rally Foundation, American Lebanese Syrian Associated Charities.
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Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, CA, USA; Department of Pediatrics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA.
| | - Melissa M Hudson
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA; Department Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Lanie Lindenfeld
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, CA, USA; Department of Pediatrics, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Sitong Chen
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Steven Colan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Willem Collier
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Xiaohong Su
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Edward Marcus
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Meagan Echevarria
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Aleksi Iukuridze
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Leslie L Robison
- Department Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - F Lennie Wong
- Department of Population Sciences, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Ming Hui Chen
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA; Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
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8
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O'Shea M, Kuhn A, Creo AL, Kohorst M, Ferdjallah A. Profound Hypoglycemia and High Anion Gap Metabolic Acidosis in a Pediatric Leukemic Patient Receiving 6-Mercaptopurine. CHILDREN (BASEL, SWITZERLAND) 2024; 11:160. [PMID: 38397272 PMCID: PMC10886981 DOI: 10.3390/children11020160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/10/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024]
Abstract
A 13-year-old male undergoing maintenance chemotherapy with methotrexate and 6-mercaptopurine (6MP), for very high-risk B-cell acute lymphoblastic leukemia (ALL), presented with vomiting due to severe hypoglycemia with metabolic acidosis. While his laboratory values were concerning for a critically ill child, the patient was relatively well appearing. Hypoglycemia is a rare but serious side effect of 6MP with an unexpectedly variable presentation; therefore, a high index of suspicion is needed for its prompt detection and treatment. This patient also had severe metabolic acidosis, likely secondary to hypoglycemia, creating a serious clinical picture despite a well-appearing child. This example of incongruity between laboratory tests and clinical appearance adds nuance to the existing literature. Moreover, although 6MP-associated hypoglycemia is rare, it may be more prevalent than the literature suggests, as symptoms of hypoglycemia-nausea, vomiting, and somnolence-mirror common chemotherapy side effects. 6MP-induced hypoglycemia can be ameliorated with the addition of allopurinol to shunt metabolism in favor of the production of therapeutic metabolites over hepatotoxic metabolites. Additionally, a morning administration of 6MP and frequent snacks may also help to prevent hypoglycemia. Overall, this case adds to the literature of unusual reactions to 6MP including hypoglycemia in an older child without traditional risk factors.
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Affiliation(s)
- Molly O'Shea
- Mayo Clinic Alix School of Medicine, Rochester, MN 55905, USA
| | - Alexis Kuhn
- Pediatric Hematology and Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Ana L Creo
- Pediatric Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
| | - Mira Kohorst
- Pediatric Hematology and Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Asmaa Ferdjallah
- Pediatric Hematology and Oncology, Mayo Clinic, Rochester, MN 55905, USA
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9
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Krishnan S, Mahadevan A, Mungle T, Gogoi MP, Saha V. Maintenance Treatment in Acute Lymphoblastic Leukemia: A Clinical Primer. Indian J Pediatr 2024; 91:47-58. [PMID: 37493925 DOI: 10.1007/s12098-023-04687-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/15/2023] [Indexed: 07/27/2023]
Abstract
Cure rates in pediatric acute lymphoblastic leukemia (ALL) currently approach 90% in the developed world. Treatment involves 6-8 mo of intensive multi-drug chemotherapy followed by 24 mo of maintenance treatment (ALL-MT). The cornerstone of ALL-MT is the daily administration of oral 6-mercaptopurine (6MP), a purine analogue. 6MP is combined with weekly oral methotrexate (MTX), an antifolate drug, to augment therapeutic activity. Some protocols include additional chemotherapy drugs (such as vincristine and corticosteroids) during MT. The objective of ALL-MT is to ensure uninterrupted treatment at the highest tolerated doses of 6MP and MTX. This requires periodic adjustments of 6MP and MTX doses throughout treatment. Tolerance is determined through regular clinical assessments and careful monitoring of blood counts. Tolerated drug doses vary widely among patients, influenced by genetic and non-genetic factors, and require individualized dosing. Suboptimal treatment intensity in ALL-MT is associated with inferior outcomes and results from failure to treat at highest tolerated drug doses and/or interruptions in treatment due to non-adherence or toxicity. Management of MT thus requires close supervision to ensure treatment adherence, periodic drug dose modifications, and treatment to tolerance, while minimizing treatment interruptions due to toxicity. The review highlights these challenges and discusses approaches and strategies for the management of MT, focusing on the Indian context.
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Affiliation(s)
- Shekhar Krishnan
- Clinical Research Unit, Tata Translational Cancer Research Centre, Tata Medical Center, 14 Major Arterial Road (East-West), Newtown, Rajarhat, Kolkata, West Bengal, 700160, India.
- Department of Pediatric Hematology and Oncology, Tata Medical Center, Kolkata, India.
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK.
| | - Ananya Mahadevan
- Clinical Research Unit, Tata Translational Cancer Research Centre, Tata Medical Center, 14 Major Arterial Road (East-West), Newtown, Rajarhat, Kolkata, West Bengal, 700160, India
| | - Tushar Mungle
- Clinical Research Unit, Tata Translational Cancer Research Centre, Tata Medical Center, 14 Major Arterial Road (East-West), Newtown, Rajarhat, Kolkata, West Bengal, 700160, India
| | - Manash Pratim Gogoi
- Clinical Research Unit, Tata Translational Cancer Research Centre, Tata Medical Center, 14 Major Arterial Road (East-West), Newtown, Rajarhat, Kolkata, West Bengal, 700160, India
| | - Vaskar Saha
- Clinical Research Unit, Tata Translational Cancer Research Centre, Tata Medical Center, 14 Major Arterial Road (East-West), Newtown, Rajarhat, Kolkata, West Bengal, 700160, India
- Department of Pediatric Hematology and Oncology, Tata Medical Center, Kolkata, India
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
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10
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Betts AC, Murphy CC, Shay LA, Balasubramanian BA, Markham C, Roth ME, Allicock M. Polypharmacy and medication fill nonadherence in a population-based sample of adolescent and young adult cancer survivors, 2008-2017. J Cancer Surviv 2023; 17:1688-1697. [PMID: 36346577 PMCID: PMC10164839 DOI: 10.1007/s11764-022-01274-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/11/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE We examined the association between polypharmacy-an established risk factor for nonadherence in the elderly-and medication fill nonadherence in a large national sample of adolescent and young adult cancer survivors (AYAs) in the USA. METHODS We pooled data (2008-2017) from the Medical Expenditure Panel Survey. We defined polypharmacy as ≥ 3 unique medications prescribed, based on self-report and pharmacy data, and medication fill nonadherence as self-reported delay or inability to obtain a necessary medication. We estimated prevalence of medication fill nonadherence among AYAs (age 18-39 years with a cancer history). We used logistic regression to estimate the association between (1) polypharmacy and medication fill nonadherence in AYAs, and (2) total number of medications prescribed and medication fill nonadherence, controlling for sex, number of chronic conditions, disability, and survey year. RESULTS AYAs (n = 598) were predominantly female (76.2%), age 30-39 years (64.9%), and non-Hispanic White (72.1%). Nearly half were poor (19.0%) or near-poor/low income (21.6%). One in ten AYAs reported medication fill nonadherence (9.75%). Of these, more than 70% cited cost-related barriers as the reason. AYAs with polypharmacy had 2.49 times higher odds of medication fill nonadherence (95%CI 1.11-5.59), compared to those without polypharmacy. Odds of medication fill nonadherence increased by 16% with each additional medication prescribed (AOR 1.16, 95% CI 1.07-1.25). CONCLUSIONS Polypharmacy may be an important risk factor for medication fill nonadherence in AYAs in the USA. IMPLICATIONS FOR CANCER SURVIVORS Improving AYAs' medication adherence requires eliminating cost-related barriers, particularly for those with polypharmacy.
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Affiliation(s)
- Andrea C Betts
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA.
| | - Caitlin C Murphy
- Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health, Houston, TX, USA
- Center for Health Promotion and Prevention Research, UTHealth School of Public Health, Houston, TX, USA
| | - L Aubree Shay
- Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health, San Antonio, TX, USA
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Dallas, TX, USA
- Center for Health Promotion and Prevention Research, UTHealth School of Public Health, Dallas, TX, USA
| | - Christine Markham
- Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health, Houston, TX, USA
- Center for Health Promotion and Prevention Research, UTHealth School of Public Health, Houston, TX, USA
| | - Michael E Roth
- Division of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marlyn Allicock
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Dallas, TX, USA
- Center for Health Promotion and Prevention Research, UTHealth School of Public Health, Dallas, TX, USA
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11
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Franca R, Stocco G, Kiren V, Tessitore A, Fagioli F, Quarello P, Bertorello N, Rizzari C, Colombini A, Bettini LR, Locatelli F, Vinti L, Girardi K, Silvestri D, Valsecchi MG, Decorti G, Rabusin M. Impact of Mercaptopurine Metabolites on Disease Outcome in the AIEOP-BFM ALL 2009 Protocol for Acute Lymphoblastic Leukemia. Clin Pharmacol Ther 2023; 114:1082-1092. [PMID: 37550838 DOI: 10.1002/cpt.3022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 08/01/2023] [Indexed: 08/09/2023]
Abstract
In the maintenance phase of Associazione Italiana di Ematologia e Oncologia Pediatrica (AIEOP)- Berlin-Frankfurt-Muenster (BFM) acute lymphoblastic leukemia (ALL) 2009 protocol, mercaptopurine (MP) is given at the planned dose of 50 mg/m2 /day; however, dose adjustments are routinely performed to target patients' white blood cells to the optimal range of 2,000-3,000 cells/μL. Pediatric patients with ALL (n = 290, age: median (1st-3rd quartile): 4.8 (3.0-8.1) years; boys: 56.9%) were enrolled mainly in 4 medium-large Italian pediatric hospitals; 14.1% of patients relapsed after a median (1st-3rd quartile) follow-up time of 4.43 (3.82-5.46) years from maintenance beginning. MP metabolites (thionucleotide (TGN) and methyl-derivatives (MMPN)) were measured in the erythrocytes of 387 blood samples of 200 patients by high performance liquid chromatography with ultraviolet detection. Single-nucleotide polymorphisms (SNPs; (rs1800462, rs1800460, and rs1142345 in TPMT gene, rs116855232 in NUDT15, rs1127354, rs7270101, rs6051702 in ITPA, and rs2413739 in PACSIN2) were characterized by Taqman SNP genotyping assays. Cox proportional hazard models did not show an impact of TGN levels and variability on relapse. In contrast, after multivariate analysis, relapse hazard ratio (HR) increased in children with ALL of the intermediate risk arm compared with those in standard risk arm (3.44, 95% confidence interval (CI), 1.31-9.05, P = 0.012), and in carriers of the PACSIN2 rs2413739 T allele compared with those with the CC genotype (heterozygotes CT: HR, 2.32, 95% CI, 0.90-5.97, P = 0.081; and homozygous TT: HR, 4.14, 95% CI, 1.54-11.11, P = 0.005). Future studies are needed to confirm the lack of impact of TGN levels and variability on relapse in the AIEOP-BFM ALL trials, and to clarify the mechanism of PACSIN2 rs2413739 on outcome.
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Affiliation(s)
- Raffaella Franca
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Gabriele Stocco
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Valentina Kiren
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Antimo Tessitore
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Franca Fagioli
- Paediatric Onco-Haematology Department, Regina Margherita Children's Hospital, Turin, Italy
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Paola Quarello
- Paediatric Onco-Haematology Department, Regina Margherita Children's Hospital, Turin, Italy
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Nicoletta Bertorello
- Paediatric Onco-Haematology Department, Regina Margherita Children's Hospital, Turin, Italy
| | - Carmelo Rizzari
- University of Milano-Bicocca, Milan, Italy
- Pediatric Hematology Oncology Unit, MBBM Foundation, ASST Monza, Monza, Italy
| | - Antonella Colombini
- Pediatric Hematology Oncology Unit, MBBM Foundation, ASST Monza, Monza, Italy
| | - Laura Rachele Bettini
- University of Milano-Bicocca, Milan, Italy
- Pediatric Hematology Oncology Unit, MBBM Foundation, ASST Monza, Monza, Italy
| | - Franco Locatelli
- Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambin Gesù, Rome, Italy
| | - Luciana Vinti
- Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambin Gesù, Rome, Italy
| | - Katia Girardi
- Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambin Gesù, Rome, Italy
| | - Daniela Silvestri
- Pediatric Hematology Oncology Unit, MBBM Foundation, ASST Monza, Monza, Italy
| | - Maria Grazia Valsecchi
- Bicocca Centre of Bioinformatics, Biostatistics and Bioimaging, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giuliana Decorti
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Marco Rabusin
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
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12
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Wadhwa A, Chen Y, Hageman L, Hoppmann A, Angiolillo A, Dickens DS, Neglia JP, Ravindranath Y, Ritchey AK, Termuhlen A, Wong FL, Landier W, Bhatia S. Poverty and relapse risk in children with acute lymphoblastic leukemia: a Children's Oncology Group study AALL03N1 report. Blood 2023; 142:221-229. [PMID: 37070673 PMCID: PMC10375268 DOI: 10.1182/blood.2023019631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/16/2023] [Accepted: 03/16/2023] [Indexed: 04/19/2023] Open
Abstract
The association between individual-level poverty and relapse in children receiving maintenance treatment for acute lymphoblastic leukemia (ALL) remains unclear. In a secondary analysis of COG-AALL03N1, we used data from US Census Bureau to categorize patients living below year-specific federal poverty thresholds, calculated using self-reported annual household income and size of household. Participants with federal poverty thresholds above 120% of their yearly household income were categorized as living in extreme poverty. Hazard of relapse was estimated using multivariable proportional subdistributional hazards regression for patients living in extreme poverty while receiving ALL maintenance therapy after adjusting for relevant predictors. Among 592 patients in this analysis, 12.3% of the patients were living in extreme poverty. After a median follow-up of 7.9 years, the cumulative incidence of relapse at 3 years from study enrollment among those living in extreme poverty was significantly higher (14.3%) than those not living in extreme poverty (7.6%). Multivariable analysis demonstrated that children living in extreme poverty had a 1.95-fold greater hazard of relapse than those not living in extreme poverty; this association was mitigated after the inclusion of race/ethnicity in the model, likely because of collinearity between race/ethnicity and poverty. A greater proportion of children living in extreme poverty were nonadherent to mercaptopurine (57.1% vs 40.9%); however, poor adherence did not completely explain the association between poverty and relapse risk. Future studies need to understand the mechanisms underlying the association between extreme poverty and relapse risk. This trial was registered at www.clinicaltrials.gov as #NCT00268528.
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Affiliation(s)
- Aman Wadhwa
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Division of Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Yanjun Chen
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Lindsey Hageman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Anna Hoppmann
- Division of Pediatric Hematology/Oncology, University of South Carolina School of Medicine, Columbia, SC
| | | | - David S. Dickens
- Division of Pediatric Hematology/Oncology, University of Iowa, Iowa City, IA
| | - Joseph P. Neglia
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | | | - A. Kim Ritchey
- Division of Hematology/Oncology, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amanda Termuhlen
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - F. Lennie Wong
- Department of Population Sciences, City of Hope, Duarte, CA
| | - Wendy Landier
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Division of Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Division of Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
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13
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Helmig SE, Hoffman JM. Building new standards to prevent harm from medication errors in children with cancer. Cancer 2023; 129:989-991. [PMID: 36704992 DOI: 10.1002/cncr.34650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Children with cancer receive many medications outside the hospital administered by their caregivers. The study by Walsh et al. shows the number and types of medication errors in these patients. The study includes data from three different centers. Importantly, the study shows the types of errors that cause harm. The authors describe how the harmful errors can be prevented. We suggest ways these results can be used to identify which patients and families will benefit from additional attention. Providing more help at clinic and in the home may help prevent harmful medication errors in children with cancer.
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Affiliation(s)
- Sara E Helmig
- Solid Tumor Division, Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - James M Hoffman
- Office of Quality and Patient Safety and Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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14
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McGrady ME, Ketterl TG, Norris RE, Perentesis JP, Pettee D, Mara CA, Breen G, Pai ALH. Barriers to medication adherence among adolescents and young adults with cancer. Pediatr Blood Cancer 2023; 70:e30186. [PMID: 36602026 DOI: 10.1002/pbc.30186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/12/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Adherence promotion is a critical component of adolescent and young adult (AYA) cancer care, but predictors of nonadherence that could be targeted in intervention efforts remain largely unknown. The purpose of this multi-site longitudinal observational study was to examine the relationship between barriers and medication adherence among AYAs with cancer. PROCEDURE Sixty-five AYAs (ages 15-24 years; mean age = 18.97 years, SD = 2.51; Mmean time since diagnosis = 1.42 years, SD = 1.95) with newly diagnosed or relapsed cancer completed self-report measures of barriers and adherence at quarterly study visits and used an electronic adherence monitoring device for 12 months. Longitudinal mixed effects models were used to examine our primary hypothesis that greater barriers are related to lower adherence over time. Descriptive statistics were used to explore our secondary aim of describing the frequency and patterns of barriers endorsed by AYAs with cancer. RESULTS After controlling for covariates (time, medication type, race, ethnicity, diagnosis, time since diagnosis), a greater number of barriers was associated with lower electronically monitored (β = -5.99, p = .005) and self-reported (β = -1.92, p < .001) adherence. The specific barriers endorsed by AYAs differed across participants, and the majority of AYAs endorsed an entirely different pattern of barriers than any other AYA in the study. CONCLUSION Barriers are associated with nonadherence and may be a promising target for intervention. Individual variability across barriers, however, suggests that tailoring may be necessary, and a promising next step is to explore personalized approaches to adherence promotion.
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Affiliation(s)
- Meghan E McGrady
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Tyler G Ketterl
- Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robin E Norris
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - John P Perentesis
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Daniel Pettee
- Division of Pediatric Hematology Oncology, Akron Children's Hospital, Akron, Ohio, USA
- Department of Pediatrics, Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Constance A Mara
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Gabriella Breen
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ahna L H Pai
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Patient and Family Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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15
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Elitzur S, Vora A, Burkhardt B, Inaba H, Attarbaschi A, Baruchel A, Escherich G, Gibson B, Liu HC, Loh M, Moorman AV, Möricke A, Pieters R, Uyttebroeck A, Baird S, Bartram J, Barzilai-Birenboim S, Batra S, Ben-Harosh M, Bertrand Y, Buitenkamp T, Caldwell K, Drut R, Geerlinks AV, Gilad G, Grainger J, Haouy S, Heaney N, Huang M, Ingham D, Krenova Z, Kuhlen M, Lehrnbecher T, Manabe A, Niggli F, Paris C, Revel-Vilk S, Rohrlich P, Sinno MG, Szczepanski T, Tamesberger M, Warrier R, Wolfl M, Nirel R, Izraeli S, Borkhardt A, Schmiegelow K. EBV-driven lymphoid neoplasms associated with pediatric ALL maintenance therapy. Blood 2023; 141:743-755. [PMID: 36332176 DOI: 10.1182/blood.2022016975] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/19/2022] [Accepted: 10/08/2022] [Indexed: 11/06/2022] Open
Abstract
The development of a second malignancy after the diagnosis of childhood acute lymphoblastic leukemia (ALL) is a rare event. Certain second malignancies have been linked with specific elements of leukemia therapy, yet the etiology of most second neoplasms remains obscure and their optimal management strategies are unclear. This is a first comprehensive report of non-Hodgkin lymphomas (NHLs) following pediatric ALL therapy, excluding stem-cell transplantation. We analyzed data of patients who developed NHL following ALL diagnosis and were enrolled in 12 collaborative pediatric ALL trials between 1980-2018. Eighty-five patients developed NHL, with mature B-cell lymphoproliferations as the dominant subtype (56 of 85 cases). Forty-six of these 56 cases (82%) occurred during or within 6 months of maintenance therapy. The majority exhibited histopathological characteristics associated with immunodeficiency (65%), predominantly evidence of Epstein-Barr virus-driven lymphoproliferation. We investigated 66 cases of post-ALL immunodeficiency-associated lymphoid neoplasms, 52 from our study and 14 additional cases from a literature search. With a median follow-up of 4.9 years, the 5-year overall survival for the 66 patients with immunodeficiency-associated lymphoid neoplasms was 67.4% (95% confidence interval [CI], 56-81). Five-year cumulative risks of lymphoid neoplasm- and leukemia-related mortality were 20% (95% CI, 10.2-30) and 12.4% (95% CI, 2.7-22), respectively. Concurrent hemophagocytic lymphohistiocytosis was associated with increased mortality (hazard ratio, 7.32; 95% CI, 1.62-32.98; P = .01). A large proportion of post-ALL lymphoid neoplasms are associated with an immunodeficient state, likely precipitated by ALL maintenance therapy. Awareness of this underrecognized entity and pertinent diagnostic tests are crucial for early diagnosis and optimal therapy.
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Affiliation(s)
- Sarah Elitzur
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ajay Vora
- Department of Paediatric Haematology, Great Ormond Street Hospital, London, United Kingdom
| | - Birgit Burkhardt
- Pediatric Hematology and Oncology, University Hospital Münster, Münster, Germany
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Andre Baruchel
- Department of Pediatric Hematology, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Gabriele Escherich
- Department of Pediatric Hematology and Oncoogy, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Brenda Gibson
- Department of Paediatric Haematology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Hsi-Che Liu
- Division of Pediatric Hematology/Oncology, Mackay Children's Hospital and Mackay Medical College, Taipei, Taiwan
| | - Mignon Loh
- Division of Pediatric Hematology, Oncology, Bone Marrow Transplant and Cellular Therapy, Seattle Children's Hospital and the Ben Towne Center for Childhood Cancer Research, University of Washington, Seattle, WA
| | - Anthony V Moorman
- Leukaemia Research Cytogenetics Group, Wolfson Childhood Cancer Centre, Clinical and Translational Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anja Möricke
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Anne Uyttebroeck
- Department of Paediatric Haematology and Oncology, University Hospital Leuven, Leuven, Leuven, Belgium
| | - Susan Baird
- Department of Haematology, Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - Jack Bartram
- Department of Paediatric Haematology, Great Ormond Street Hospital, London, United Kingdom
| | - Shlomit Barzilai-Birenboim
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Sandeep Batra
- Pediatric Hematology/Oncology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Miriam Ben-Harosh
- Department of Pediatric Hemato-Oncology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yves Bertrand
- Institut d'Hematologie et d'Oncologie Pediatrique, Hospices Civils de Lyon, Lyon, France
| | - Trudy Buitenkamp
- Amsterdam Academic Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Kenneth Caldwell
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Ricardo Drut
- Department of Pathology, School of Medicine, La Plata National University, La Plata, Argentina
| | | | - Gil Gilad
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - John Grainger
- Faculty of Medical & Human Sciences, University of Manchester and Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Stephanie Haouy
- Department of Pediatric Oncology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Nicholas Heaney
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Mary Huang
- Department of Pediatric Hematology Oncology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA
| | - Danielle Ingham
- Paediatric Oncology, Leeds Children's Hospital, Leeds, United Kingdom
| | - Zdenka Krenova
- Department of Pediatric Oncology and Department of Pediatrics, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michaela Kuhlen
- Pediatrics and Adolescent Medicine, University of Augsburg, Augsburg, Germany
| | - Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Atsushi Manabe
- Department of Pediatrics, Hokkaido University, Graduate School of Medicine, Sapporo, Japan
| | - Felix Niggli
- Department of Pediatric Oncology, University Children's Hospital, Zurich, Switzerland
| | - Claudia Paris
- Department of Pediatric Oncology and Hematology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Shoshana Revel-Vilk
- Shaare Zedek Medical Centre and The Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | - Mohamad G Sinno
- Phoenix Children's Hospital, Center for Cancer and Blood Disorders, Phoenix, AZ
| | - Tomasz Szczepanski
- Department of Pediatric Hematology and Oncology, Zabrze and Medical University of Silesia, Katowice, Poland
| | - Melanie Tamesberger
- Department of Pediatrics and Adolescent Medicine, Kepler University Clinic, Linz, Austria
| | | | - Matthias Wolfl
- Pediatric Oncology, Hematology and Stem Cell Transplantation Program, University Children's Hospital Würzburg, Würzburg, Germany
| | - Ronit Nirel
- Department of Statistics and Data Science, Hebrew University, Jerusalem, Israel
| | - Shai Izraeli
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Arndt Borkhardt
- Department of Paediatric Oncology, Haematology and Clinical Immunology, Medical Faculty, Heinrich-Heine University, Duesseldorf, Germany
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, The University Hospital, Rigshospitalet, and Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
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16
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Zeng XL, Heneghan MB, Badawy SM. Adherence to Oral Chemotherapy in Acute Lymphoblastic Leukemia during Maintenance Therapy in Children, Adolescents, and Young Adults: A Systematic Review. Curr Oncol 2023; 30:720-748. [PMID: 36661705 PMCID: PMC9858168 DOI: 10.3390/curroncol30010056] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/26/2022] [Accepted: 12/31/2022] [Indexed: 01/08/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common malignancy in children and young adults. Treatment is long and involves 2-3 years of a prolonged maintenance phase composed of oral chemotherapies. Adherence to these medications is critical to achieving good outcomes. However, adherence is difficult to determine, as there is currently no consensus on measures of adherence or criteria to determine nonadherence. Furthermore, there have been few studies in pediatric B-ALL describing factors associated with nonadherence. Thus, we performed a systematic review of literature on oral chemotherapy adherence during maintenance therapy in ALL following PRISMA guidelines. Published studies demonstrated various objective and subjective methods of assessing adherence without generalizable definitions of nonadherence. However, the results of these studies suggested that nonadherence to oral maintenance chemotherapy was associated with increased risk of relapse. Future studies of B-ALL therapy should utilize a uniform assessment of adherence and definitions of nonadherence to better determine the impact of nonadherence on B-ALL outcomes and identify predictors of nonadherence that could yield targets for adherence improving interventions.
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Affiliation(s)
- Xiaopei L. Zeng
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA
| | - Mallorie B. Heneghan
- Division of Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, University of Utah, Salt Lake City, UT 84132, USA
| | - Sherif M. Badawy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA
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17
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Wadhwa A, Chen Y, Hageman L, Hoppmann AL, Angiolillo A, Dickens DS, Lew G, Neglia JP, Ravindranath Y, Ritchey AK, Termuhlen A, Wong FL, Landier W, Bhatia S. Body mass index during maintenance therapy and relapse risk in children with acute lymphoblastic leukemia: A Children's Oncology Group report. Cancer 2023; 129:151-160. [PMID: 36369905 PMCID: PMC10173700 DOI: 10.1002/cncr.34529] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/28/2022] [Accepted: 08/01/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Obesity at diagnosis of childhood acute lymphoblastic leukemia (ALL) is associated with greater risk of relapse; whether this association extends to obesity during maintenance is unstudied. METHODS This study used data from AALL03N1 to calculate median body mass index (BMI) for 676 children over 6 consecutive months during maintenance therapy; BMI percentile (BMI%ile) were operationalized as normal/underweight (<85%ile), overweight/obese (85%-98%ile), and extreme obesity (≥99%ile). Hazard of relapse was estimated using multivariable proportional subdistributional hazards regression after adjusting for all relevant demographic and clinical predictors. RESULTS Median age at study enrollment was 6 years and median length of follow-up was 7.9 years. Overall, 43.3% of the cohort was underweight/normal weight, 44.8% was overweight/obese, and 11.8% had extreme obesity. Cumulative incidence of relapse at 4 years from study enrollment was higher among those with extreme obesity (13.6% ± 4.5%) compared to those with underweight/normal weight (9.0% ± 2.1%). Multivariable analysis revealed that children with extreme obesity had a 2.4-fold (95% confidence interval [CI], 1.1-5.0; p = .01) greater hazard of relapse compared to those who were underweight/normal weight. Overweight/obese patients were at comparable risk to those who were underweight/normal weight (hazard ratio, 0.8; 95% CI, 0.4-1.6). Erythrocyte thioguanine nucleotide (TGN) levels were significantly lower among children with extreme obesity compared to those with underweight/normal weight (141.6 vs. 168.8 pmol/8 × 108 erythrocytes; p = .0002), however, the difference in TGN levels did not explain the greater hazard of relapse among those with extreme obesity. CONCLUSIONS Extreme obesity during maintenance therapy is associated with greater hazard of relapse in children with ALL. Underlying mechanisms of this association needs further investigation. LAY SUMMARY Findings from this study demonstrate that extreme obesity during maintenance therapy is associated with a greater hazard of relapse among children with acute lymphoblastic leukemia. We show that children with obesity have lower levels of erythrocyte thioguanine nucleotides even after adjusting for adherence to oral chemotherapy. However, these lower levels do not explain the greater hazard of relapse, paving the way for future studies to explore this association.
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Affiliation(s)
- Aman Wadhwa
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Yanjun Chen
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lindsey Hageman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anna L. Hoppmann
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anne Angiolillo
- Division of Pediatric Hematology/Oncology, Children’s National Medical Center, Washington, District of Columbia, USA
| | - David S. Dickens
- Division of Pediatric Hematology/Oncology, University of Iowa, Iowa City, Iowa, USA
| | - Glen Lew
- Division of Pediatric Hematology/Oncology, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Joseph P. Neglia
- Division of Pediatric Hematology/Oncology, University of Minnesota Masonic Children’s Hospital, Minnesota, Minnesota, USA
| | | | - A. Kim Ritchey
- Division of Hematology/Oncology, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amanda Termuhlen
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - F. Lennie Wong
- Department of Population Sciences, City of Hope, Duarte, California, USA
| | - Wendy Landier
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Division of Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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18
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Patel PA, DeGroote NP, Jackson K, Cash T, Castellino SM, Jaggi P, Esbenshade AJ, Miller TP. Infectious events in pediatric patients with acute lymphoblastic leukemia/lymphoma undergoing evaluation for fever without severe neutropenia. Cancer 2022; 128:4129-4138. [PMID: 36238979 PMCID: PMC10311637 DOI: 10.1002/cncr.34476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 07/12/2022] [Accepted: 07/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Infections cause significant treatment-related morbidity during pediatric acute lymphoblastic leukemia/lymphoma (ALL/LLy) therapy. Fevers during periods without severe neutropenia are common, but etiologies are not well-described. This study sought to describe the bloodstream infection (BSI) and non-BSI risk in children undergoing therapy for ALL/LLy. METHODS Demographic and clinical data were abstracted for febrile episodes without severe neutropenia at two children's hospitals. Treatment courses were stratified by intensity. Multivariate logistic regression evaluated characteristics associated with infection. RESULTS There were 1591 febrile episodes experienced by 524 patients. Of these, 536 (34%) episodes had ≥1 infection; BSI occurred in 30 (1.9%) episodes. No BSIs occurred in episodes with a recent procedural sedation or cytarabine exposure. Presence of hypotension, chills/rigors, higher temperature, and infant phenotype were independently associated with BSI (p < .05). Of the 572 non-BSIs, the most common was upper respiratory infection (URI) (n = 381, 67%). Compared to episodes without infection, URI symptoms, higher temperature, absolute neutrophil count 500-999/μl, and evaluation during a low-intensity treatment course were more likely to be associated with a non-BSI (p < .05) and inpatient status was less likely to be associated with a non-BSI (p < .05). CONCLUSIONS The BSI rate in pediatric patients with ALL/LLy and fever without severe neutropenia is low, but one-third of the time, patients have a non-BSI. Future research should test if the need for empiric antibiotics can be tailored based on the associations identified in this study.
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Affiliation(s)
- Pratik A. Patel
- Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
- Division of Pediatric Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Nicholas P. DeGroote
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kasey Jackson
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Thomas Cash
- Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Sharon M. Castellino
- Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Preeti Jaggi
- Division of Pediatric Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Adam J. Esbenshade
- Division of Pediatric Hematology-Oncology, Monroe Carell Jr Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Tamara P. Miller
- Division of Pediatric Hematology/Oncology, Emory University, Atlanta, Georgia, USA
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
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19
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Saultier P, Simonin M, Beaumais TAD, Rialland F, Alby-Laurent F, Lubnau M, Desplantes C, Jacqz-Aigrain E, Rohrlich P, Reguerre Y, Rabian F, Sirvent N, Plat GW, Petit A. [Practical management during maintenance therapy of pediatric acute lymphoblastic leukemia: Recommendations of the French Society for Childhood and Adolescent Cancer and Leukemia (SFCE)]. Bull Cancer 2022; 109:1132-1143. [PMID: 35863954 DOI: 10.1016/j.bulcan.2022.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/17/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022]
Abstract
Maintenance therapy is the last phase of treatment for acute lymphoblastic leukemia in children and adolescents. Although maintenance therapy is associated with toxicities and specific management issues, it is an essential phase of treatment that reduces the risk of relapse. The objective of this work is to propose a guide for the initiation, administration, and monitoring of maintenance therapy, and for the management of food, schooling, leisure, community life, risk of infection and links with family medicine.
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Affiliation(s)
- Paul Saultier
- Hôpital de la Timone Enfants, APHM, service d'hématologie, immunologie et oncologie pédiatrique, Marseille, France.
| | - Mathieu Simonin
- AP-HP, hôpital Armand-Trousseau, Sorbonne université, service d'hématologie et oncologie pédiatrique, Paris, France
| | | | - Fanny Rialland
- CHU de Nantes, service d'onco-hématologie pédiatrique, Nantes, France
| | - Fanny Alby-Laurent
- AP-HP, hôpital Armand-Trousseau, Sorbonne université, service d'hématologie et oncologie pédiatrique, Paris, France
| | - Marion Lubnau
- CHU de Nancy, service d'onco-hématologie pédiatrique, Nancy, France
| | | | - Evelyne Jacqz-Aigrain
- AP-HP, hôpital Saint-Louis, département de pharmacologie et pharmacogénétique, Paris, France
| | - Pierre Rohrlich
- CHU de Nice, service d'hématologie pédiatrique, Nice, France
| | - Yves Reguerre
- CHU de la Réunion, service d'hémato-oncologie pédiatrique, Réunion, France
| | - Florence Rabian
- AP-HP, hôpital Saint-Louis, service d'hématologie adolescents et jeunes adultes, Paris, France
| | - Nicolas Sirvent
- CHU de Montpellier, service d'hématologie et oncologie pédiatrique, Montpellier, France
| | - Geneviève Willson Plat
- CHU de Toulouse, service d'hématologie oncologie et immunologie pédiatrique, Toulouse, France
| | - Arnaud Petit
- AP-HP, hôpital Armand-Trousseau, Sorbonne université, service d'hématologie et oncologie pédiatrique, Paris, France
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20
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Guo HL, Zhao YT, Wang WJ, Dong N, Hu YH, Zhang YY, Chen F, Zhou L, Li T. Optimizing thiopurine therapy in children with acute lymphoblastic leukemia: A promising “MINT” sequencing strategy and therapeutic “DNA-TG” monitoring. Front Pharmacol 2022; 13:941182. [PMID: 36238550 PMCID: PMC9552076 DOI: 10.3389/fphar.2022.941182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
Thiopurines, including thioguanine (TG), 6-mercaptopurine (6-MP), and azathioprine (AZA), are extensively used in clinical practice in children with acute lymphoblastic leukemia (ALL) and inflammatory bowel diseases. However, the common adverse effects caused by myelosuppression and hepatotoxicity limit their application. Metabolizing enzymes such as thiopurine S-methyltransferase (TPMT), nudix hydrolase 15 (NUDT15), inosine triphosphate pyrophosphohydrolase (ITPA), and drug transporters like multidrug resistance-associated protein 4 (MRP4) have been reported to mediate the metabolism and transportation of thiopurine drugs. Hence, the single nucleotide polymorphisms (SNPs) in those genes could theoretically affect the pharmacokinetics and pharmacological effects of these drugs, and might also become one of the determinants of clinical efficacy and adverse effects. Moreover, long-term clinical practices have confirmed that thiopurine-related adverse reactions are associated with the systemic concentrations of their active metabolites. In this review, we mainly summarized the pharmacogenetic studies of thiopurine drugs. We also evaluated the therapeutic drug monitoring (TDM) research studies and focused on those active metabolites, hoping to continuously improve monitoring strategies for thiopurine therapy to maximize therapeutic efficacy and minimize the adverse effects or toxicity. We proposed that tailoring thiopurine dosing based on MRP4, ITPA, NUDT15, and TMPT genotypes, defined as “MINT” panel sequencing strategy, might contribute toward improving the efficacy and safety of thiopurines. Moreover, the DNA-incorporated thioguanine nucleotide (DNA-TG) metabolite level was more suitable for red cell 6-thioguanine nucleotide (6-TGNs) monitoring, which can better predict the efficacy and safety of thiopurines. Integrating the panel “MINT” sequencing strategy with therapeutic “DNA-TG” monitoring would offer a new insight into the precision thiopurine therapy for pediatric acute lymphoblastic leukemia patients.
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Affiliation(s)
- Hong-Li Guo
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Yue-Tao Zhao
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Visiting Graduate Student from School of Basic Medicine and Clinical Pharmacy, Pharmaceutical University, Nanjing, China
| | - Wei-Jun Wang
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Visiting Graduate Student from School of Basic Medicine and Clinical Pharmacy, Pharmaceutical University, Nanjing, China
| | - Na Dong
- Institute of Pharmaceutical Science, China Pharmaceutical University, Nanjing, China
- School of Institute of Pharmaceutical Science, Pharmaceutical University, Nanjing, China
| | - Ya-Hui Hu
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Yuan-Yuan Zhang
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Chen
- Pharmaceutical Sciences Research Center, Department of Pharmacy, Children’s Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Feng Chen, ; Li Zhou, ; Tao Li,
| | - Li Zhou
- Hematology and Oncology Department, Children’s Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Feng Chen, ; Li Zhou, ; Tao Li,
| | - Tao Li
- Department of Solid Oncology, Children’s Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Feng Chen, ; Li Zhou, ; Tao Li,
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21
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Pyke-Grimm KA, Franck LS, Halpern-Felsher B, Goldsby RE, Rehm RS. Day-to-Day Decision Making by Adolescents and Young Adults with Cancer. JOURNAL OF PEDIATRIC HEMATOLOGY/ONCOLOGY NURSING 2022; 39:290-303. [PMID: 35538622 PMCID: PMC9807778 DOI: 10.1177/27527530211068718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: Adolescents and young adults (AYAs) with cancer must negotiate the transition between childhood and adulthood while dealing with a life-threatening illness. AYA involvement in decision making varies depending on the type of decision and when decisions occur during treatment, and evidence suggests that AYAs want to be involved in decision making. Objective: To explore involvement of AYAs with cancer in day-to-day decisions affected by their cancer and treatment. Methods: This qualitative study used interpretive focused ethnography within the sociologic tradition, informed by symbolic interactionism. Semi-structured interviews and informal participant observation took place at two quaternary pediatric oncology programs. Results: Thirty-one interviews were conducted with 16 AYAs ages 15 to 20 years. Major day to day decision-making categories identified included: (1) mental mindset, (2) self-care practices, (3) self-advocacy, and (4) negotiating relationships. Participants described how they came to grips with their illness early on and decided to fight their cancer. They described decisions they made to protect their health, how they advocated for themselves and decisions they made about relationships with family and friends. Conclusions: Through day-to-day decisions, participants managed the impact of cancer and its treatment on their daily lives. Research should focus on developing and implementing interventions to empower AYAs to participate in day-to-day decisions that will affect how they manage their cancer, its treatment and ultimately their outcomes. Implications for Practice: Healthcare providers can facilitate AYA's participation in day-to-day decision making through encouraging autonomy and self-efficacy by providing support and through effective communication.
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Affiliation(s)
- Kimberly A. Pyke-Grimm
- Stanford Children's Health, Department of Nursing Research and
Evidence-Based Practice, Palo Alto, CA, USA,Division of Hematology/Oncology, Department of Pediatrics, Stanford
University School of Medicine,Department of Family Health Care Nursing, San Francisco School of
Nursing, University of California, San Francisco, CA, USA,Kimberly A. Pyke-Grimm, PhD, RN, CNS,
CPHON, Department of Nursing Research and Evidence-Based Practice, Stanford
Children's Health, 750 Welch Road, Palo Alto, CA 94304, USA.
| | - Linda S. Franck
- Department of Family Health Care Nursing, San Francisco School of
Nursing, University of California, San Francisco, CA, USA
| | - Bonnie Halpern-Felsher
- Department of Pediatrics, Division of Adolescent Medicine, Stanford University, School of Medicine, Stanford, CA, USA
| | | | - Roberta S. Rehm
- Department of Family Health Care Nursing, San Francisco School of
Nursing, University of California, San Francisco, CA, USA,*Professor Emeritus
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22
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Pedersen LH, Østergaard A, Bank V, Nersting J, Tuckuviene R, Wehner PS, Albertsen BK, Degn M, Als-Nielsen BET, Larsen HB, Schmiegelow K, Dalton SO. Socioeconomic position and maintenance therapy in children with acute lymphoblastic leukemia: A national cohort study. Pediatr Blood Cancer 2022; 69:e29508. [PMID: 34931732 DOI: 10.1002/pbc.29508] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/05/2021] [Accepted: 11/17/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Socioeconomic differences in survival among children with acute lymphoblastic leukemia (ALL) have been reported in high-income countries and there is an unmet need for strategies to identify vulnerable patient subgroups. Reported differences in survival for children from families with different socioeconomic positions seem to arise when starting maintenance therapy. This could reflect reduced physician's compliance or family adherence to maintenance therapy. METHODS This nationwide cohort study with extensive monitoring of systemic methotrexate (MTX)/6-mercaptopurine (6MP) dosing and metabolite levels, retrospectively investigated 173 Danish children treated according to The Nordic Society for Pediatric Hematology and Oncology ALL2008 protocol from 2008 to 2016. RESULTS Significantly lower prescribed doses of MTX and 6MP were seen in the children in families with short parental education (short vs. medium vs. higher education: mMTX: 13.8, 16.2, and 18.6 mg/m2 /week; p < .01; m6MP: 47.4, 64.9, and 66.1 mg/m2 /day; p = .03) or parents unemployed/not in workforce (unemployed/not in workforce vs. mixed vs. at work: mMTX: 15.0, 19.9, and 17.2 mg/m2 /week; p < .01; m6MP: 54.8, 72.0, and 65.1 mg/m2 /day; p < .01). When assessing family adherence by analyzing MTX and 6MP metabolite levels, including per prescribed dose of MTX and 6MP, we found no significant differences by levels of parental education, affiliation to work market, or income (p > .05 for all comparisons). CONCLUSIONS These results indicate that inferior physician compliance to protocol recommendations on drug dosage rather than families' adherence to therapy may contribute to the association between socioeconomic position and cure rates in childhood ALL, although precise mechanisms remain to be explored.
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Affiliation(s)
- Line Hjøllund Pedersen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.,Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Anna Østergaard
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.,Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands.,Faculty of Medicine, Utrecht University, Utrecht, Netherlands
| | - Victoria Bank
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Jacob Nersting
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Ruta Tuckuviene
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.,Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Peder Skov Wehner
- Department of Pediatric Hematology and Oncology, Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Birgitte Klug Albertsen
- Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Matilda Degn
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | | | - Hanne Baekgaard Larsen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susanne Oksbjerg Dalton
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Clinical Oncology & Palliative Care, Zealand University Hospital, Naestved, Denmark
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23
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Todd KE, McGrady ME, Starbuck E, Previtera M, Luchtman-Jones L. A systematic review of adherence to anticoagulation regimens in pediatric patients. Pediatr Blood Cancer 2022; 69:e29698. [PMID: 35476901 DOI: 10.1002/pbc.29698] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 02/09/2022] [Accepted: 03/02/2022] [Indexed: 12/28/2022]
Abstract
Thromboembolic disease rates are increasing in pediatric patients. Anticoagulation is prescribed for treatment and prevention of thromboembolic disease. While nonadherence to anticoagulation regimens predicts poor health outcomes in adults, data in anticoagulated pediatric patients are limited. We systematically reviewed the rates, outcomes, and predictors of anticoagulation nonadherence in the pediatric population. Out of a total of 3581 unique articles identified for review, 17 studies met inclusion criteria. These studies primarily evaluated patients with cardiac disease treated with vitamin K antagonists. Overall nonadherence rates varied from 3% to 42%, based upon population, definition of adherence, and measurement strategy. Patient age, goal international normalized ratio (INR), and number of concurrent potentially interacting medications correlated with nonadherence. Data examining the relationship between nonadherence and health outcomes were included in only two studies. Limitations of current literature, as well as critical knowledge gaps that require future study, are discussed.
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Affiliation(s)
- Kevin E Todd
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Meghan E McGrady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Patient Family and Wellness Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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24
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Maintenance therapy for acute lymphoblastic leukemia: basic science and clinical translations. Leukemia 2022; 36:1749-1758. [PMID: 35654820 PMCID: PMC9252897 DOI: 10.1038/s41375-022-01591-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 01/21/2023]
Abstract
Maintenance therapy (MT) with oral methotrexate (MTX) and 6-mercaptopurine (6-MP) is essential for the cure of acute lymphoblastic leukemia (ALL). MTX and 6-MP interfere with nucleotide synthesis and salvage pathways. The primary cytotoxic mechanism involves the incorporation of thioguanine nucleotides (TGNs) into DNA (as DNA-TG), which may be enhanced by the inhibition of de novo purine synthesis by other MTX/6-MP metabolites. Co-medication during MT is common. Although Pneumocystis jirovecii prophylaxis appears safe, the benefit of glucocorticosteroid/vincristine pulses in improving survival and of allopurinol to moderate 6-MP pharmacokinetics remains uncertain. Numerous genetic polymorphisms influence the pharmacology, efficacy, and toxicity (mainly myelosuppression and hepatotoxicity) of MTX and thiopurines. Thiopurine S-methyltransferase (encoded by TPMT) decreases TGNs but increases methylated 6-MP metabolites (MeMPs); similarly, nudix hydrolase 15 (encoded by NUDT15) also decreases TGNs available for DNA incorporation. Loss-of-function variants in both genes are currently used to guide MT, but do not fully explain the inter-patient variability in thiopurine toxicity. Because of the large inter-individual variations in MTX/6-MP bioavailability and metabolism, dose adjustments are traditionally guided by the degree of myelosuppression, but this does not accurately reflect treatment intensity. DNA-TG is a common downstream metabolite of MTX/6-MP combination chemotherapy, and a higher level of DNA-TG has been associated with a lower relapse hazard, leading to the development of the Thiopurine Enhanced ALL Maintenance (TEAM) strategy-the addition of low-dose (2.5-12.5 mg/m2/day) 6-thioguanine to the 6-MP/MTX backbone-that is currently being tested in a randomized ALLTogether1 trial (EudraCT: 2018-001795-38). Mutations in the thiopurine and MTX metabolism pathways, and in the mismatch repair genes have been identified in early ALL relapses, providing valuable insights to assist the development of strategies to detect imminent relapse, to facilitate relapse salvage therapy, and even to bring about changes in frontline ALL therapy to mitigate this relapse risk.
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25
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van der Linde M, van Leeuwen N, Eijkenaar F, Rijneveld AW, Pieters R, Karim-Kos HE. Effect of Treatment in a Specialized Pediatric Hemato-Oncology Setting on 5-Year Survival in Acute Lymphoblastic Leukemia: A Quasi-Experimental Study. Cancers (Basel) 2022; 14:cancers14102451. [PMID: 35626054 PMCID: PMC9139555 DOI: 10.3390/cancers14102451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 01/27/2023] Open
Abstract
Simple Summary Adolescents and young adults (AYAs) with acute lymphoblastic leukemia (ALL) have a worse prognosis than children. In addition to differences in biology—such as higher incidence of unfavorable genetic alterations in the AYA population—this might be related to the fact that ALL patients under a certain age (often 18 years) are generally treated in special pediatric hemato-oncology settings, which is associated with improved survival, while patients above that age are treated in adult hemato-oncology care settings. Based on previous research, adult treatment settings have increasingly adopted pediatric-inspired protocols, which appear to have led to increased survival of adolescent ALL patients. This study aims to assess whether there remains an effect of treatment of ALL patients in a specialized pediatric hemato-oncology setting on 5-year survival. This study provides insight into the effects of such treatment for ALL patients, and may stimulate further research into causal relationships in other oncological conditions. Abstract Survival rates of adolescents and young adults (AYAs) with acute lymphoblastic leukemia (ALL) are inferior to those of pediatric ALL patients. In part, this may be caused by differences in treatment setting. Generally, children are treated in specialized pediatric hemato-oncology settings, whereas AYAs are treated in adult hemato-oncology settings. Since 2005, adult treatment protocols have included pediatric-inspired chemotherapy, which has been the standard of care for AYAs from 2008 onwards. This study aims to assess whether, despite protocols in both settings having become more similar, there remains an effect of treatment in specialized pediatric hemato-oncology settings on 5-year survival for ALL patients in the Netherlands. We used nationwide registry data (2004–2013) on 472 ALL patients aged between 10 and 30 years old. A fuzzy regression discontinuity design was applied to estimate the treatment effect using two-stage least squares regression with the treatment threshold at 17 years and 7 months of age, adjusting for sex, age at diagnosis, and immunophenotype. We found a risk difference of 0.419 (p = 0.092; 95% CI = −0.0686; 0.907), meaning a 41.9 percentage point greater probability of surviving five years after diagnosis for ALL patients treated in specialized pediatric hemato-oncology settings. Our results suggest that ALL patients around the threshold could benefit from increased collaboration between pediatric and adult hemato-oncology in terms of survival.
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Affiliation(s)
- Margrietha van der Linde
- Department of Public Health, Center for Medical Decision Making, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
- Correspondence:
| | - Nikki van Leeuwen
- Department of Public Health, Center for Medical Decision Making, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Frank Eijkenaar
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands;
| | - Anita W. Rijneveld
- Department of Hematology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (R.P.); (H.E.K.-K.)
- University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Henrike E. Karim-Kos
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (R.P.); (H.E.K.-K.)
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), 3511 DT Utrecht, The Netherlands
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26
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Toksvang LN, Als-Nielsen B, Bacon C, Bertasiute R, Duarte X, Escherich G, Helgadottir EA, Johannsdottir IR, Jónsson ÓG, Kozlowski P, Langenskjöld C, Lepik K, Niinimäki R, Overgaard UM, Punab M, Räty R, Segers H, van der Sluis I, Smith OP, Strullu M, Vaitkevičienė G, Wik HS, Heyman M, Schmiegelow K. Thiopurine Enhanced ALL Maintenance (TEAM): study protocol for a randomized study to evaluate the improvement in disease-free survival by adding very low dose 6-thioguanine to 6-mercaptopurine/methotrexate-based maintenance therapy in pediatric and adult patients (0-45 years) with newly diagnosed B-cell precursor or T-cell acute lymphoblastic leukemia treated according to the intermediate risk-high group of the ALLTogether1 protocol. BMC Cancer 2022; 22:483. [PMID: 35501736 PMCID: PMC9063225 DOI: 10.1186/s12885-022-09522-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/10/2022] [Indexed: 12/05/2022] Open
Abstract
Background A critical challenge in current acute lymphoblastic leukemia (ALL) therapy is treatment intensification in order to reduce the relapse rate in the subset of patients at the highest risk of relapse. The year-long maintenance phase is essential in relapse prevention. The Thiopurine Enhanced ALL Maintenance (TEAM) trial investigates a novel strategy for ALL maintenance. Methods TEAM is a randomized phase 3 sub-protocol to the ALLTogether1 trial, which includes patients 0–45 years of age with newly diagnosed B-cell precursor or T-cell ALL, and stratified to the intermediate risk-high (IR-high) group, in 13 European countries. In the TEAM trial, the traditional methotrexate (MTX)/6-mercaptopurine (6MP) maintenance backbone (control arm) is supplemented with low dose (2.5–12.5 mg/m2/day) oral 6-thioguanine (6TG) (experimental arm), while the starting dose of 6MP is reduced from 75 to 50 mg/m2/day. A total of 778 patients will be included in TEAM during ~ 5 years. The study will close when the last included patient has been followed for 5 years from the end of induction therapy. The primary objective of the study is to significantly improve the disease-free survival (DFS) of IR-high ALL patients by adding 6TG to 6MP/MTX-based maintenance therapy. TEAM has 80% power to detect a 7% increase in 5-year DFS through a 50% reduction in relapse rate. DFS will be evaluated by intention-to-treat analysis. In addition to reducing relapse, TEAM may also reduce hepatotoxicity and hypoglycemia caused by high levels of methylated 6MP metabolites. Methotrexate/6MP metabolites will be monitored and low levels will be reported back to clinicians to identify potentially non-adherent patients. Discussion TEAM provides a novel strategy for maintenance therapy in ALL with the potential of improving DFS through reducing relapse rate. Potential risk factors that have been considered include hepatic sinusoidal obstruction syndrome/nodular regenerative hyperplasia, second cancer, infection, and osteonecrosis. Metabolite monitoring can potentially increase treatment adherence in both treatment arms. Trial registration EudraCT, 2018–001795-38. Registered 2020-05-15, Clinicaltrials.gov, NCT04307576. Registered 2020-03-13, https://clinicaltrials.gov/ct2/show/NCT04307576 Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09522-3.
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Affiliation(s)
- Linea Natalie Toksvang
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Bodil Als-Nielsen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | | | - Ruta Bertasiute
- Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Ximo Duarte
- Instituto Português de Oncologia Lisboa Francisco Gentil Departamento de Pediatria, Lisbon, Portugal
| | | | | | | | | | | | | | | | - Riitta Niinimäki
- Oulu University Hospital and PEDEGRO Research Unit, University of Oulu, Oulu, Finland
| | | | - Mari Punab
- Tartu University Hospital, Tartu, Estonia
| | - Riikka Räty
- Helsinki University Central Hospital, Helsinki, Finland
| | - Heidi Segers
- Leuvens Kanker Instituut (LKI), KU Leuven - UZ Leuven, Leuven, Belgium
| | | | | | - Marion Strullu
- Université de Paris, hôpital universitaire Robert-Debré (APHP), Paris, France
| | - Goda Vaitkevičienė
- Center for Pediatric Oncology and Hematology, Vilnius University, Vilnius, Lithuania
| | | | - Mats Heyman
- Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,University of Copenhagen, Copenhagen, Denmark
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27
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Utilization of Thiopurine Metabolites and Allopurinol in Pediatric Acute Lymphoblastic Leukemia: Consideration for an Algorithmic Approach. J Pediatr Hematol Oncol 2022; 44:e521-e525. [PMID: 34486570 DOI: 10.1097/mph.0000000000002313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Abstract
Persistently elevated absolute neutrophil counts during maintenance for acute lymphoblastic leukemia is a risk factor for relapse and may be related to wild-type thiopurine methyltransferase activity and overly efficient shunting of 6-mercaptopurine to hepatotoxic metabolites (6-methylmercaptopurine nucleotides), leading to low 6-thioguanine nucleotides. 6-mercaptopurine is also metabolized by xanthine oxidase, and therefore allopurinol, an inhibitor of xanthine oxidase, allows for increased 6-thioguanine nucleotides and decreased 6-methylmercaptopurine nucleotide. Here, we report our experience with allopurinol for persistently elevated absolute neutrophil count or hepatotoxicity and suggest an algorithmic approach for checking thiopurine metabolites and initiating allopurinol in acute lymphoblastic leukemia maintenance.
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28
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Tang N, Kovacevic A, Zupanec S, Sivananthan A, Patel R, Patel P, Vennettilli A, Paw Cho Sing E, Alexander S, Sung L, Dupuis LL. Perceptions of parents of pediatric patients with acute lymphoblastic leukemia on oral chemotherapy administration: A qualitative analysis. Pediatr Blood Cancer 2022; 69:e29329. [PMID: 34492743 DOI: 10.1002/pbc.29329] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/22/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To describe the experiences and perspectives of parents of pediatric patients with acute lymphoblastic leukemia (ALL) regarding oral chemotherapy administration during maintenance therapy. METHODS English-speaking parents of patients 4 to <18 years who were receiving ALL maintenance oral chemotherapy were eligible to participate in this mixed methods study. Using semi-structured interviews, we asked participants how difficult they found oral chemotherapy administration. We also probed regarding barriers and facilitators of oral chemotherapy administration and strategies used to overcome challenges. Lastly, we asked participants for their advice to future parents giving oral chemotherapy to their children. RESULTS Twenty-three participants were interviewed. One-fifth of participants stated that oral chemotherapy administration at home was hard or very hard. Common factors influencing oral chemotherapy administration were product-related (e.g., formulation) and treatment-related adverse effects (e.g., nausea), lifestyle adjustment (e.g., fitting in with family schedule), and attitudes (e.g., onus of medication administration). Strategies to address oral chemotherapy administration included several administration techniques, scheduling of medication administration, and normalization of medication taking. CONCLUSIONS Oral chemotherapy administration during ALL maintenance therapy was hard for some parents. Identification of these parents and discussion of strategies to facilitate adherence to oral chemotherapy regimens may optimize patient outcomes.
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Affiliation(s)
- Natalie Tang
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Anja Kovacevic
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sue Zupanec
- Department of Nursing, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Araby Sivananthan
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rikesh Patel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Priya Patel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ashlee Vennettilli
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Edric Paw Cho Sing
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sarah Alexander
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lillian Sung
- Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - L Lee Dupuis
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada.,Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
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29
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Khaeso K, Komvilaisak P, Chainansamit SO, Nakkam N, Suwannaying K, Kuwatjanakul P, Hikino K, Dornsena A, Kanjanawart S, Laoaroon N, Vannaprasaht S, Taketani T, Tassaneeyakul W. NUDT15 is a key genetic factor for prediction of hematotoxicity in pediatric patients who received a standard low dosage regimen of 6-mercaptopurine. Drug Metab Pharmacokinet 2021; 43:100436. [PMID: 35016134 DOI: 10.1016/j.dmpk.2021.100436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/21/2021] [Accepted: 11/25/2021] [Indexed: 12/25/2022]
Abstract
6-Mercaptopurine (6-MP) is commonly used for treatment of acute lymphoblastic leukemia (ALL). The incidence of hematotoxicity caused by this drug is quite high in Asians even using a standard low dosage regimen. The present study was aimed to elucidate the impact of thiopurine S-methyltransferase (TPMT), a nucleoside diphosphate-linked moiety X-type motif 15 (NUDT15), inosine triphosphatase (ITPA) and ATP Binding Cassette Subfamily C Member 4 (ABCC4) polymorphisms on hematotoxicity in pediatric patients who received a standard low starting dose of 6-MP. One hundred and sixty-nine pediatric patients were enrolled and their genotypes were determined. Patients who carried NUDT15∗3 and NUDT15∗2 genotypes were at a 10-15 fold higher risk of severe neutropenia than those of the wild-type during the early months of the maintenance phase. Risk of neutropenia was not significantly increased in patients with other NUDT15 variants as well as in patients with TPMT, ITPA or ABCC4 variants. These results suggest that NUDT15 polymorphisms particularly, NUDT15∗3 and NUDT15∗2, play major roles in 6-MP-induced severe hematotoxicity even when using a standard low dosage of 6-MP and genotyping of these variants is necessary in order to obtain precise tolerance doses and avoid severe hematotoxicity in pediatric patients.
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Affiliation(s)
- Kanyarat Khaeso
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Thailand
| | | | | | - Nontaya Nakkam
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Thailand
| | - Kunanya Suwannaying
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Thailand
| | | | - Keiko Hikino
- Laboratory for Pharmacogenomics, RIKEN Center for Integrative Medical Sciences, Yokohama City, Kanagawa, Japan
| | - Areerat Dornsena
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Thailand
| | - Sirimas Kanjanawart
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Thailand
| | - Napat Laoaroon
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Thailand
| | - Suda Vannaprasaht
- Department of Pharmacology, Faculty of Medicine, Khon Kaen University, Thailand
| | - Takeshi Taketani
- Department of Pediatrics, Faculty of Medicine, Shimane University, Izumo, Japan
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30
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Lasala R, Santoleri F. Association between adherence to oral therapies in cancer patients and clinical outcome: A systematic review of the literature. Br J Clin Pharmacol 2021; 88:1999-2018. [PMID: 34784654 DOI: 10.1111/bcp.15147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 01/23/2023] Open
Abstract
AIMS Adherence to therapy is a key factor in successful treatment. The aim of this systematic review is to assess the extent to which patients with better adherence to oral therapy have better clinical outcomes among cancer patients. METHODS All studies published in PubMed up to 20 October 2020, which considered the use of oral anticancer drugs for cancer patients and which correlated treatment adherence with a clinical outcome, were considered. RESULTS From the 42 studies considered in the systematic review, 14 were for oncological indications and 28 for haematological indications. There was considerable variance in calculation methods, outcomes considered, and in the definitions of adherence. However, it emerged that most studies reported a significant correlation between adherence to therapy and clinical outcome. CONCLUSION As adherence to therapy is a key factor in achieving a better clinical outcome, future studies with large samples, robust endpoints and the use of at least two methods of assessing adherence would be desirable in order to produce more robust evidence.
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31
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Parents' Experiences with Home-Based Oral Chemotherapy Prescribed to a Child Diagnosed with Acute Lymphoblastic Leukemia: A Qualitative Study. Curr Oncol 2021; 28:4377-4391. [PMID: 34898538 PMCID: PMC8628767 DOI: 10.3390/curroncol28060372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common type of cancer in children. Treatment includes home-based oral chemotherapies (OCs) (e.g., 6-mercaptopurine and dexamethasone) taken for 2 to 3 years. The management of OC can be challenging for children and their parents. However, the multifaceted experience of families with children taking OC for ALL is largely undescribed. We report the experience with these OCs from the parents’ perspective. We conducted a qualitative descriptive study. Semi-structured interviews were conducted with the parents of children with ALL aged < 15 years, followed in a specialized university-affiliated center. The interviews were fully transcribed and thematically analyzed. Thirteen of the seventeen eligible parents (76.5%) participated in the study. The parents’ motivation to follow the recommendations provided by the multidisciplinary care team regarding OC was very high. The quantity and the quality of the information received were judged adequate, and the parents reported feeling knowledgeable enough to take charge of the OC at home. Adapting to the consequences of OC on family daily life was collectively identified as the biggest challenge. This includes developing and maintaining a strict daily routine, adapting to the child’s neurobehavioral changes during dexamethasone days and adapting family social life. Our findings have several implications for enhancing the support offered to families with home-based OC for ALL. Supportive interventions should consider the family as a whole and their needs should be regularly monitored. Specific attention should be paid to the development and maintenance of a routine, to the parental burden, and to the emotional impact, especially regarding dexamethasone.
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32
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Cros-Perrial E, Saulnier S, Raza MZ, Charmelot R, Egron D, Dumontet C, Chaloin L, Peyrottes S, Jordheim LP. Cytotoxic and antitumoral activity of N-(9H-purin-6-yl) benzamide derivatives and related water-soluble prodrugs. Curr Mol Pharmacol 2021; 15:883-894. [PMID: 34649495 DOI: 10.2174/1874467214666211014164406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/23/2021] [Accepted: 09/07/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The development of small molecules as cancer treatments is still of both interest and importance. OBJECTIVE Having synthesized and identified the initial cytotoxic activity of a series of chemically related N-(9H-purin-6-yl) benzamide derivatives, we continued their evaluation on cancer cell models. We also synthesized water-soluble prodrugs of the main compound and performed in vivo experiments. METHOD We used organic chemistry to obtain compounds of interest and prodrugs. The biological evaluation included MTT assays, synergy experiments, proliferation assays by CFSE, cell cycle distribution and in vivo antitumoral activity. RESULTS Our results show activities on cancer cell lines ranging from 3-39 µM for the best compounds, with both induction of apoptosis and decrease in cell proliferation. Two compounds evaluated in vivo showed weak antitumoral activity. In addition, the lead compound and its prodrug had a synergistic activity with the nucleoside analogue fludarabine in vitro and in vivo. CONCLUSION Our work allowed us to gain better knowledge on the activity of N-(9H-purin-6-yl) benzamide derivatives and showed new examples of water-soluble prodrugs. More research is warranted to decipher the molecular mechanisms of the molecules.
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Affiliation(s)
- Emeline Cros-Perrial
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS 5286, Centre Léon Bérard, Centre de Recherche en Cancérologie de Lyon, Lyon, 69008. France
| | - Steve Saulnier
- Institut des Biomolécules Max Mousseron (IBMM), UMR 5247 CNRS, Université de Montpellier, ENSCM, Campus Triolet, cc1705, Place Eugène Bataillon, 34095 Montpellier. France
| | - Muhammad Zawwad Raza
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS 5286, Centre Léon Bérard, Centre de Recherche en Cancérologie de Lyon, Lyon, 69008. France
| | - Rémi Charmelot
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS 5286, Centre Léon Bérard, Centre de Recherche en Cancérologie de Lyon, Lyon, 69008. France
| | - David Egron
- Institut des Biomolécules Max Mousseron (IBMM), UMR 5247 CNRS, Université de Montpellier, ENSCM, Campus Triolet, cc1705, Place Eugène Bataillon, 34095 Montpellier. France
| | - Charles Dumontet
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS 5286, Centre Léon Bérard, Centre de Recherche en Cancérologie de Lyon, Lyon, 69008. France
| | - Laurent Chaloin
- Institut de Recherche en Infectiologie de Montpellier (IRIM), Université Montpellier, CNRS, 34293 Montpellier. France
| | - Suzanne Peyrottes
- Institut des Biomolécules Max Mousseron (IBMM), UMR 5247 CNRS, Université de Montpellier, ENSCM, Campus Triolet, cc1705, Place Eugène Bataillon, 34095 Montpellier. France
| | - Lars Petter Jordheim
- Univ Lyon, Université Claude Bernard Lyon 1, INSERM 1052, CNRS 5286, Centre Léon Bérard, Centre de Recherche en Cancérologie de Lyon, Lyon, 69008. France
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Pai AA, Mohan A, Benjamin ESB, Illangeswaran RSS, Xavier Raj I, Janet NB, Arunachalam AK, Kavitha ML, Kulkarni U, Devasia AJ, Fouzia NA, Abraham A, Srivastava A, George B, Mathews V, Korula A, Balasubramanian P. NUDT15 c.415C>T Polymorphism Predicts 6-MP Induced Early Myelotoxicity in Patients with Acute Lymphoblastic Leukemia Undergoing Maintenance Therapy. Pharmgenomics Pers Med 2021; 14:1303-1313. [PMID: 34629890 PMCID: PMC8495143 DOI: 10.2147/pgpm.s325813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/02/2021] [Indexed: 11/25/2022] Open
Abstract
Purpose Severe myelosuppression in patients with acute lymphoblastic leukemia (ALL) undergoing 6-MP-based maintenance therapy is attributed to TPMT gene polymorphisms, which is rare in Asian populations. This study aims to evaluate the role of selected polymorphisms in NUDT15, ITPA, and MRP4 genes in addition to TPMT in predicting 6-MP intolerance during ALL maintenance therapy. Patients and Methods We screened for the presence of NUDT15*3 (c.415 C>T, rs116855232); MRP4 c.2269 C>T (rs3765534), ITPA c.94 C>A (rs1127354) polymorphisms in addition to TPMT *2 (rs1800462), *3A (*3B and *3C; rs1800460 and rs1142345) in ALL patients with documented severe neutropenia (cohort-1; n=42). These polymorphisms were then screened in a prospective cohort of ALL patients (cohort-2; n=133) and compared with 6-MP dose reduction, early/late myelotoxicity. Results Nineteen (45%) patients in cohort-1 and 18 (14%) in cohort-2 had NUDT15 c.415 C>T variant while 4 (3%) patients in cohort-2 had TPMT*3C variant. Five (12%) in cohort-1 and 30 (24%) in cohort-2 had ITPA c.94 C>A variant while 9 (22%) and 15 (12%) had MRP4 c.2269 C>T variant in cohorts-1 and 2, respectively. All in cohort-1 and 36 (27%) in cohort-2 had severe myelotoxicity. Twenty-eight patients (66.6%) in cohort-1 and 40 (30%) patients in cohort-2 had significant 6-MP dose reduction. NUDT15 c.415 C>T variant explained severe myelotoxicity in 63% and 33% in cohort 1 and 2. TPMT*3C and ITPA c.94 C>A variants also explained myelotoxicity in cohort-2 (Median ANC: 376 vs 1014 mm3; p=0.04 and 776 vs 1023 mm3; p=0.04 respectively). NUDT15 c.415 C>T polymorphism explained significant myelotoxicity (507 vs 1298 mm3; p<0.0001) in the multivariate analysis as well (β=−0.314, p<0.0001). Conclusion NUDT15 c.415 C>T (15*3), TPMT*3C, as well as ITPA c.94 C>A and MRP4 c.2269 C>T polymorphisms explain hematotoxicities. Preemptive genotype-based (NUDT15*3, TPMT, ITPA c.94 C>A) 6-MP dosing could improve the outcome after maintenance therapy.
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Affiliation(s)
- Aswin Anand Pai
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | - Ajith Mohan
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | | | | | - Infencia Xavier Raj
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | - Nancy Beryl Janet
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | | | - M L Kavitha
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | - Uday Kulkarni
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | - Anup J Devasia
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | - N A Fouzia
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | - Aby Abraham
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | - Biju George
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | - Vikram Mathews
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
| | - Anu Korula
- Department of Haematology, Christian Medical College, Vellore, Tamilnadu, India
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Kristjánsdóttir ER, Toksvang LN, Schmiegelow K, Rank CU. Prevalence of non-adherence and non-compliance during maintenance therapy in adults with acute lymphoblastic leukemia and their associations with survival. Eur J Haematol 2021; 108:109-117. [PMID: 34562333 DOI: 10.1111/ejh.13711] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Explore patient adherence and physician compliance to protocol guidelines during maintenance therapy, including the association with survival in adults with acute lymphoblastic leukemia (ALL). METHODS Blood counts, aminotransferase levels and prescribed 6-mercaptopurine (6MP)/methotrexate (MTX) doses were compared with the protocol guidelines to assess compliance. Non-adherence to the prescribed medication was confirmed in patients with unmeasurable 6MP metabolite levels and suspected in patients with low 6MP metabolites concurrent with aminotransferase and white blood cell count within normal ranges, while potential intermittent non-adherence was defined by >1.9 fold fluctuating 6MP metabolites. RESULTS Physicians' non-compliance with insufficient dose increments of 6MP/MTX despite white blood cell counts above the target level comprised a median of 20.1% (interquartile range 9.7-39.3%) of the observed time in maintenance therapy, yet no association to relapse was found (P = .17). Non-adherence to 6MP was confirmed in 9.8% (5 of 51 patients), suspected in an additional 9.8% (5 of 51 patients), and intermittent non-adherence was suspected in 52.6% (20 of 38 patients). CONCLUSION Although no association between non-compliance and leukemic relapse was found, likely due to lack of power, increased attention to this phase of ALL therapy is indicated.
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Affiliation(s)
- Elsa Rán Kristjánsdóttir
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Linea Natalie Toksvang
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Institute of Clinical Medicine, The Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Cecilie Utke Rank
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Franca R, Braidotti S, Stocco G, Decorti G. Understanding thiopurine methyltransferase polymorphisms for the targeted treatment of hematologic malignancies. Expert Opin Drug Metab Toxicol 2021; 17:1187-1198. [PMID: 34452592 DOI: 10.1080/17425255.2021.1974398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Thiopurine methyltransferase (TPMT) catalyzes the S-methylation of thiopurines (mercaptopurine (MP) and tioguanine (TG)), chemotherapeutic agents used in the treatment of acute lymphoblastic leukemia (ALL). Polymorphisms in TPMT gene encode diminished activity enzyme, enhancing accumulation of active metabolites, and partially explaining the inter-individual differences in patients' clinical response. AREAS COVERED This review gives an overview on TPMT gene and function, and discusses the pharmacogenomic implications of TPMT variants in the prevention of severe thiopurine-induced hematological toxicities and the less known implication on TG-induced sinusoidal obstruction syndrome. Additional genetic and non-genetic factors impairing TPMT activity are considered. Literature search was done in PubMed for English articles published since1990, and on PharmGKB. EXPERT OPINION To titrate thiopurines safely and effectively, achieve the right degree of lymphotoxic effect and avoid excessive myelosuppression, the optimal management will combine a preemptive TPMT genotyping to establish a safe initial dose with a close phenotypic monitoring of TPMT activity and/or of active metabolites during long-term treatment. Compared to current ALL protocols, replacement of TG by MP during reinduction phase in TPMT heterozygotes and novel individualized TG regimens in maintenance for TPMT wild-type subjects could be investigated to improve outcomes while avoiding risk of severe hepatotoxicity.
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Affiliation(s)
- R Franca
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - S Braidotti
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - G Stocco
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - G Decorti
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.,Institute for Maternal & Child Health (I.r.c.c.s) Burlo Garofolo, Trieste, Italy
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Karol SE, Pei D, Smith CA, Liu Y, Yang W, Kornegay NM, Panetta JC, Crews KR, Cheng C, Finch ER, Inaba H, Metzger ML, Rubnitz JE, Ribeiro RC, Gruber TA, Yang JJ, Evans WE, Jeha S, Pui CH, Relling MV. Comprehensive analysis of dose intensity of acute lymphoblastic leukemia chemotherapy. Haematologica 2021; 107:371-380. [PMID: 34196166 PMCID: PMC8804576 DOI: 10.3324/haematol.2021.278411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Indexed: 11/13/2022] Open
Abstract
Chemotherapy dosages are often compromised, but most reports lack data on dosages that are actually delivered. In two consecutive acute lymphoblastic leukemia trials that differed in their asparaginase formulation, native E. coli L-asparaginase in St. Jude Total 15 (T15, n=365) and pegaspargase in Total 16 (T16, n=524), we tallied the dose intensities for all drugs on the low-risk or standard-risk arms, analyzing 504,039 dosing records. The median dose intensity for each drug ranged from 61-100%. Dose intensities for several drugs were more than 10% higher on T15 than on T16: cyclophosphamide (P<0.0001 for the standard- risk arm), cytarabine (P<0.0001 for the standard-risk arm), and mercaptopurine (P<0.0001 for the low-risk arm and P<0.0001 for the standardrisk arm). We attributed the lower dosages on T16 to the higher asparaginase dosages on T16 than on T15 (P<0.0001 for both the low-risk and standard-risk arms), with higher dose-intensity for mercaptopurine in those with anti-asparaginase antibodies than in those without (P=5.62x10- 3 for T15 standard risk and P=1.43x10-4 for T16 standard risk). Neutrophil count did not differ between protocols for low-risk patients (P=0.18) and was actually lower for standard-risk patients on T16 than on T15 (P<0.0001) despite lower dosages of most drugs on T16. Patients with low asparaginase dose intensity had higher methotrexate dose intensity with no impact on prognosis. The only dose intensity measure predicting a higher risk of relapse on both studies was higher mercaptopurine dose intensity, but this did not reach statistical significance (P=0.03 T15; P=0.07 T16). In these intensive multiagent trials, higher dosages of asparaginase compromised the dosing of other drugs for acute lymphoblastic leukemia, particularly mercaptopurine, but lower chemotherapy dose intensity was not associated with relapse.
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Affiliation(s)
- Seth E Karol
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN; Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Deqing Pei
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Colton A Smith
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Yiwei Liu
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Wenjian Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Nancy M Kornegay
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - John C Panetta
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Kristine R Crews
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Emily R Finch
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Monika L Metzger
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Jeffrey E Rubnitz
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Raul C Ribeiro
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Tanja A Gruber
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; Stanford Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - William E Evans
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Sima Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Mary V Relling
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN.
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Hoppmann AL, Chen Y, Landier W, Hageman L, Evans WE, Wong FL, Relling MV, Bhatia S. Individual prediction of nonadherence to oral mercaptopurine in children with acute lymphoblastic leukemia: Results from COG AALL03N1. Cancer 2021; 127:3832-3839. [PMID: 34161608 DOI: 10.1002/cncr.33760] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/06/2021] [Accepted: 04/26/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Poor mercaptopurine (6MP) adherence (mean adherence rate < 90%) increases the relapse risk among children with acute lymphoblastic leukemia (ALL). 6MP adherence remains difficult to measure in real time. Easily measured patient-level factors could identify patients at risk for poor adherence. METHODS The authors measured 6MP adherence via electronic monitoring for 6 months per patient. Using data from month 3, they created a risk prediction model for 6MP nonadherence in 407 children with ALL (mean age, 7.7 ± 4.4 years); they used receiver operating characteristic analyses in the training set (n = 250) and replicated this in the test set (n = 157). RESULTS Age, race/ethnicity, 6MP dose intensity, absolute neutrophil count, 6MP ingestion patterns, and household structure were retained in the prediction model. The model yielded areas under the receiver operating characteristic curve (AUCs) of 0.79 (95% confidence interval [CI], 0.71-0.85) and 0.74 (95% CI, 0.63-0.85) in the training and test sets, respectively. The model performed better for those who were ≥12 years old (AUC, 0.79; 95% CI, 0.59-0.99) than those <12 years old (AUC, 0.70; 95% CI, 0.58-0.81). Using the predicted probability of nonadherence based on receiver operating characteristic analysis, the authors developed a binary risk classifier to classify patients with a high or low probability of nonadherence. The sensitivity and specificity of the binary risk classifier were 71% and 76%, respectively. Adjusted for clinical prognosticators, the risk of relapse was 2.2-fold higher (95% CI, 0.94-5.1; P = .07) among patients with a high probability of nonadherence in comparison with those with a low probability, as identified by the risk prediction model. CONCLUSIONS The risk prediction model identified patients with a high probability of nonadherence and could be used in real time to personalize recommendations and interventions in the clinic. LAY SUMMARY The vast majority of children with acute lymphoblastic leukemia, the most common childhood cancer, are cured. The treatment of acute lymphoblastic leukemia includes taking an oral chemotherapy medicine (mercaptopurine) for approximately 2 years. Children who miss doses of this medicine (specifically children who take the medicine less than 90% of the time that it is prescribed) are more likely to suffer leukemia relapse. The authors of this article have measured mercaptopurine adherence with electronic bottle caps to determine characteristics of patients that predict nonadherence, and they have created a prediction tool that could allow physicians to identify and intervene with patients at high risk of nonadherence.
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Affiliation(s)
- Anna L Hoppmann
- Institute for Cancer Outcomes and Survivorship, Division of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yanjun Chen
- Institute for Cancer Outcomes and Survivorship, Division of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Wendy Landier
- Institute for Cancer Outcomes and Survivorship, Division of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lindsey Hageman
- Institute for Cancer Outcomes and Survivorship, Division of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Mary V Relling
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, Division of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
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Zhou XS, Lu YY, Gao YF, Shao W, Yao J. Bone marrow inhibition induced by azathioprine in a patient without mutation in the thiopurine S-methyltransferase pathogenic site: A case report. World J Clin Cases 2021; 9:4230-4237. [PMID: 34141785 PMCID: PMC8173432 DOI: 10.12998/wjcc.v9.i17.4230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/20/2021] [Accepted: 03/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Azathioprine (AZA) and its close analog 6-mercaptopurine are thiopurines widely used in the treatment of patients with cancer, organ transplantation, and autoimmune or inflammatory diseases, including systemic lupus erythematosus. Bone marrow inhibition is a common side effect of AZA, and severe bone marrow inhibition is related to decreased thiopurine S-methyltransferase (TPMT) activity.
CASE SUMMARY We herein report a patient with proliferative lupus nephritis who was using AZA for maintenance therapy, had no common TPMT pathogenic site mutations, and exhibited severe bone marrow inhibition on the 15th day after oral administration.
CONCLUSION This report alerts physicians to the fact that even though the TPMT gene has no common pathogenic site mutation, severe myelosuppression may also occur.
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Affiliation(s)
- Xiao-Shuang Zhou
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030012, Shanxi Province, China
- Department of Nephrology, The Affiliated People's Hospital of Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Yuan-Yue Lu
- Department of Nephrology, The Affiliated People's Hospital of Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Yan-Fang Gao
- Department of Nephrology, The Affiliated People's Hospital of Shanxi Medical University, Taiyuan 030032, Shanxi Province, China
| | - Wen Shao
- Department of Gastroenterology, Shanxi Bethune Hospital, Taiyuan 030012, Shanxi Province, China
| | - Jia Yao
- Department of Gastroenterology, Shanxi Bethune Hospital, Taiyuan 030012, Shanxi Province, China
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Lee JM, Shim YJ, Kim DH, Jung N, Ha JS. The Effect of NUDT15, TPMT, APEX1, and ITPA Genetic Variations on Mercaptopurine Treatment of Pediatric Acute Lymphoblastic Leukemia. CHILDREN-BASEL 2021; 8:children8030224. [PMID: 33804051 PMCID: PMC7998516 DOI: 10.3390/children8030224] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/03/2021] [Accepted: 03/08/2021] [Indexed: 12/18/2022]
Abstract
Mercaptopurine (MP) is a commonly used maintenance regimen for childhood acute lymphoblastic leukemia (ALL). However, 6-MP has a narrow therapeutic index, which causes dose-limiting toxicities in hematopoietic tissues. Recent studies reported several candidate pharmacogenetic markers such as TPMT, NUDT15, ITPA, and APEX1, which predict the possibility of 6-MP related toxicities. The aim of this study is to evaluate the effect of major variants of these genes on 6-MP intolerances and toxicities in pediatric acute lymphoblastic leukemia (ALL) patients. A total of 83 pediatric ALL patients were included (56 males and 27 females). The NUDT15 c.415C>T (rs116855232), NUDT15 c.55_56insGAGTCG (rs746071566), ITPA c.94C>A (rs1127354), ITPA c.IVS2+21A>C (rs7270101), APEX c.190A>G (rs2307486), and TPMT variants were analyzed by sanger sequencing. Correlations between indexes of 6-MP-related toxicities or 6-MP intolerance (absolute neutrophil count [ANC] at several time point, days of ANC < 1 × 103/mm3, days of ANC < 0.5 × 103/mm3, frequency of febrile neutropenia, maximum AST and ALT, 6-MP dose and 6-MP dose intensity during maintenance therapy) and genetic variations were analyzed. The NUDT15 c.415C>T allele carrier showed significantly low 6-MP doses at the final maintenance therapy period than the wild type carrier (p = 0.007). The 6-MP dose intensities at the sixth and final maintenance period were also significantly low in NUDT15 c.415C>T carriers (p = 0.003 and 0.008, respectively). However, indexes for neutropenia, days of febrile neutropenia, maximum AST, and ALT levels were not associated with the presence of c.415C>T as well as other analyzed variants. When analyzing the effect of the coexistence of NUDT15 c.415C>T and ITPA c.94C>A, no significant differences were found between the NUDT15 c.415C>T carrier and carrier with both variations. The NUDT15 c.415C>T was the most useful marker to predict 6-MP intolerance among analyzed variants in our study population. Although we could not find association of those variants with 6-MP induced toxicities and the synergistic effects of those variants, a well-planed larger scale study would be helpful in clarifying new candidates and their clinical effects.
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Affiliation(s)
- Jae Min Lee
- Department of Pediatrics, Yeungnam University College of Medicine, Daegu 42415, Korea;
| | - Ye Jee Shim
- Department of Pediatrics, Keimyung University School of Medicine, Daegu 42601, Korea; (Y.J.S.); (N.J.)
| | - Do-Hoon Kim
- Department of Laboratory Medicine, Keimyung University School of Medicine, Daegu 42601, Korea;
| | - Nani Jung
- Department of Pediatrics, Keimyung University School of Medicine, Daegu 42601, Korea; (Y.J.S.); (N.J.)
| | - Jung-Sook Ha
- Department of Laboratory Medicine, Keimyung University School of Medicine, Daegu 42601, Korea;
- Correspondence: ; Tel.: +82-53-258-7938
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Heneghan MB, Hussain T, Barrera L, Cai SW, Haugen M, Morgan E, Rossoff J, Weinstein J, Hijiya N, Cella D, Badawy SM. Access to Technology and Preferences for an mHealth Intervention to Promote Medication Adherence in Pediatric Acute Lymphoblastic Leukemia: Approach Leveraging Behavior Change Techniques. J Med Internet Res 2021; 23:e24893. [PMID: 33599621 PMCID: PMC7932843 DOI: 10.2196/24893] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/04/2020] [Accepted: 01/07/2021] [Indexed: 12/16/2022] Open
Abstract
Background Suboptimal adherence to 6-mercaptopurine (6-MP) is prevalent in pediatric acute lymphoblastic leukemia (ALL) and associated with increased risk of relapse. Rapid uptake of personal technology makes mobile health (mHealth) an attractive platform to promote adherence. Objective Study objectives were to examine access to mobile technology and preferences for an mHealth intervention to improve medication adherence in pediatric ALL. Methods A cross-sectional survey was administered in oncology clinic to parents of children with ALL as well as adolescents and young adults (AYAs) with ALL receiving maintenance chemotherapy. Results A total of 49 parents (median age [IQR] 39 [33-42] years; female 76% [37/49]) and 15 patients (median age [IQR] 17 [16-19]; male 80% [12/15]) participated. All parents and AYAs owned electronic tablets, smartphones, or both. Parents’ most endorsed mHealth app features included a list of medications (71%, 35/49), information about 6-MP (71%, 35/49), refill reminders (71%, 35/49), and reminders to take 6-MP (71%, 35/49). AYAs' most endorsed features included refill reminders (73%, 11/15), reminders to take 6-MP (73%, 11/15), and tracking 6-MP (73%, 11/15). Conclusions Parents and AYAs reported ubiquitous access to mobile technology and strong interest in multiple adherence-specific mHealth app features. Parents and AYAs provided valuable insight into preferred features for a multifunctional behavioral intervention (mHealth app) to promote medication adherence in pediatric ALL.
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Affiliation(s)
- Mallorie B Heneghan
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Tasmeen Hussain
- Division of Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Leonardo Barrera
- Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Stephanie W Cai
- Department of Obstetrics & Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Maureen Haugen
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Elaine Morgan
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jenna Rossoff
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joanna Weinstein
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Nobuko Hijiya
- Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - David Cella
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Rosdiana DS, Setiabudy R, Andalusia R, Gatot D, Louisa M, Bardosono S, Instiaty I. TPMT Genetic Variability and Its Association with Hematotoxicity in Indonesian Children with Acute Lymphoblastic Leukemia in Maintenance Therapy. Pharmgenomics Pers Med 2021; 14:199-210. [PMID: 33568932 PMCID: PMC7868246 DOI: 10.2147/pgpm.s288988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/29/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Hematotoxicity monitoring in children with acute lymphoblastic leukemia (ALL) is critical to preventing life-threatening infections and drug discontinuation. The primary drug that causes hematotoxicity in ALL children is 6-mercaptopurine (6-MP). Genetic variability of the drug-metabolizing enzymes of 6-MP, thiopurine S-methyltransferase (TPMT), is one factor that might increase the susceptibility of children to hematotoxicity. The present study aimed to determine the variability in TPMT genotypes and phenotypes and its association with the occurrence of hematotoxicity in ALL children in maintenance therapy. PATIENTS AND METHODS A cross-sectional study was conducted at Cipto Mangunkusumo and Dharmais National Cancer Hospital, Jakarta, Indonesia, from June 2017 to October 2018. We included ALL patients, 1-18 years, who were receiving at least one month of 6-MP during maintenance therapy according to the Indonesian protocol for ALL 2013. Direct sequencing was used to determine TPMT*3A, *3B, and *3C genotypes, and LC-MS/MS analysis was performed to measure the plasma concentrations of 6-MP and its metabolites. Association analysis between the TPMT genotype and hematotoxicity was evaluated using the unpaired t-test or Mann-Whitney's test. RESULTS The prevalence of neutropenia, anemia, and thrombocytopenia in ALL children during maintenance therapy was 51.9%, 44.3%, and 6.6%, respectively. We found a low frequency of TPMT*3C, which is 0.95%. No association was found between hematotoxicity and TPMT genotypes or age, nutritional status, serum albumin levels, risk stratification, the daily dose of 6-MP, and cotrimoxazole co-administration. However, hematotoxicity was associated with 6-methylmercaptopurine (6-MeMP) plasma concentrations and the ratio 6-MeMP/6-thioguanine (6-TGN). We also found no association between TPMT genotypes and TPMT phenotypes. CONCLUSION The 6-MeMP/6-TGN ratio is associated with hematotoxicity in ALL children during maintenance therapy but is not strong enough to predict hematotoxicity.
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Affiliation(s)
- Dewi Selvina Rosdiana
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Rianto Setiabudy
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Rizka Andalusia
- Dharmais National Cancer Hospital, Jakarta, Indonesia
- Drug Registration Directorate, National Agency for Drug and Food Control, Jakarta, Indonesia
| | - Djajadiman Gatot
- Division of Hematology-Oncology, Department of Pediatrics, Faculty of Medicine, Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Melva Louisa
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Saptawati Bardosono
- Department of Nutrition, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Instiaty Instiaty
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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DNA-thioguanine nucleotide as a treatment marker in acute lymphoblastic leukemia patients with NUDT15 variant genotypes. PLoS One 2021; 16:e0245667. [PMID: 33481917 PMCID: PMC7822258 DOI: 10.1371/journal.pone.0245667] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/06/2021] [Indexed: 12/26/2022] Open
Abstract
Background Large inter-individual variations in drug metabolism pose a challenge in determining 6-mercaptopurine (6MP) doses. As the last product of 6MP metabolism, DNA-thioguanine nucleotide (DNA-TGN) could reflect the efficacy of 6MP, especially in patients harboring variants in the 6MP metabolism pathway. The aim of this study was to investigate the clinical significance of DNA-TGN monitoring in Korean pediatric acute lymphoblastic leukemia (ALL) patients, focusing on the NUDT15 genotype. Methods The subjects of this study were patients who underwent ALL treatment with 6MP. Tests for the NUDT15 and TPMT genotypes were performed, and prospective DNA-TGN and erythrocyte TGN samples were collected after two weeks or more of 6MP treatment. DNA-TGN was quantified using the liquid chromatography-tandem mass spectrometry method. Results A total of 471 DNA-TGN measurements in 71 patients were analyzed, which ranged from 1.0 to 903.1 fmol thioguanine/μg DNA. The 6MP intensity demonstrated a significant relationship with DNA-TGN concentration (P<0.001). Patients harboring NUDT15 variants were treated with a lower dose of 6MP (P<0.001); however, there was no significant difference in DNA-TGN concentration when compared to patients carrying wild-type NUDT15 (P = 0.261). These patients also presented higher variation in DNA-TGN levels (P = 0.002) and DNA-TGN/6MP intensity (P = 0.019) compared to patients carrying wild-type NUDT15. DNA-TGN concentration did not show a significant correlation with WBC count (P = 0.093). Conclusions Patients harboring NUDT15 variants demonstrated similar DNA-TGN concentrations even at low doses of 6MP and showed high variability in DNA-TGN. Particularly in patients with NUDT15 variants who need a reduced 6MP dose, DNA-TGN could be applied as a useful marker to monitor the therapeutic effect of 6MP.
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Angiolillo AL, Schore RJ, Kairalla JA, Devidas M, Rabin KR, Zweidler-McKay P, Borowitz MJ, Wood B, Carroll AJ, Heerema NA, Relling MV, Hitzler J, Lane AR, Maloney KW, Wang C, Bassal M, Carroll WL, Winick NJ, Raetz EA, Loh ML, Hunger SP. Excellent Outcomes With Reduced Frequency of Vincristine and Dexamethasone Pulses in Standard-Risk B-Lymphoblastic Leukemia: Results From Children's Oncology Group AALL0932. J Clin Oncol 2021; 39:1437-1447. [PMID: 33411585 DOI: 10.1200/jco.20.00494] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE AALL0932 evaluated two randomized maintenance interventions to optimize disease-free survival (DFS) while reducing the burden of therapy in children with newly diagnosed NCI standard-risk (SR) B-acute lymphoblastic leukemia (B-ALL). METHODS AALL0932 enrolled 9,229 patients with B-ALL; 2,364 average-risk (AR) patients were randomly assigned (2 × 2 factorial design) at the start of maintenance therapy to vincristine/dexamethasone pulses every 4 (VCR/DEX4) or every 12 (VCR/DEX12) weeks, and a starting dose of weekly oral methotrexate of 20 mg/m2 (MTX20) or 40 mg/m2 (MTX40). RESULTS Five-year event-free survival and overall survival (OS) from enrollment (with 95% CIs), for all eligible and evaluable SR B-ALL patients (n = 9,226), were 92.0% (91.1% and 92.8%) and 96.8% (96.2% and 97.3%), respectively. The 5-year DFS and OS from the start of maintenance for randomly assigned AR patients were 94.6% (93.3% and 95.9%) and 98.5% (97.7% and 99.2%), respectively. The 5-year DFS and OS for patients randomly assigned to receive VCR/DEX4 (n = 1,186) versus VCR/DEX12 (n = 1,178) were 94.1% (92.2% and 96.0%) and 98.3% (97.2% and 99.4%) v 95.1% (93.3% and 96.9%) and 98.6% (97.7% and 99.6%), respectively (P = .86 and .69). The 5-year DFS and OS for AR patients randomly assigned to receive MTX20 versus MTX40 were 95.1% (93.3% and 96.8%) and 98.8% (97.9% and 99.7%) v 94.2% (92.2% and 96.1%) and 98.1% (97.0% and 99.2%), respectively (P = .92 and .89). CONCLUSIONS The 0NCI-SR AR B-ALL who received VCR/DEX12 had outstanding outcomes despite receiving one third of the vincristine/dexamethasone pulses previously used as standard of care on Children's Oncology Group (COG) trials. The higher starting dose of MTX of 40 mg/m2/week did not improve outcomes when compared with 20 mg/m2/week. The decreased frequency of vincristine/dexamethasone pulses has been incorporated into frontline COG B-ALL trials to decrease the burden of therapy for patients and their families.
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Affiliation(s)
- Anne L Angiolillo
- Children's National Medical Center, Washington, DC.,George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Reuven J Schore
- Children's National Medical Center, Washington, DC.,George Washington University School of Medicine and Health Sciences, Washington, DC
| | - John A Kairalla
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Karen R Rabin
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX
| | | | - Michael J Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brent Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | | | - Nyla A Heerema
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | | | - Kelly W Maloney
- Children's Hospital Colorado and the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Cindy Wang
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Mylène Bassal
- Division of Pediatric Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON
| | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY
| | - Naomi J Winick
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Elizabeth A Raetz
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital, and the Helen Diller Family Comprehensive Cancer Institute, University of California, San Francisco, San Francisco, CA
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Mebrahtu G, M Moleki M, Okoth Achila O, Seyoum Y, Adnoy ET, Ovberedjo M. Antihypertensive Medication Adherence and Associated Factors: A Cross-Sectional Analysis of Patients Attending a National Referral Hospital in Asmara, Eritrea. Patient Prefer Adherence 2021; 15:2619-2632. [PMID: 34848951 PMCID: PMC8627305 DOI: 10.2147/ppa.s319987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/28/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Recent research suggests that poor adherence to antihypertensive medication (AHM) is a major problem in the management of hypertension. This study was therefore designed to evaluate the frequency of AHM and associated risk factors in patients attending a national referral hospital in Asmara, Eritrea. METHODS A total of 335 respondents (females: 222 (66.3%) participated in this cross-sectional study. Adherence to Medication was evaluated using a modified version of the Medication Adherence Report Scale (MARS). Additional data were abstracted from patients' medical records and a WHO STEPwise questionnaire. RESULTS The mean (±SD) age of the study participants was 59.65 (±12.20) years (females: 56.82 (±9.95) vs males: 57.17 (±9.60) years, p-value=0.001). Similarly, the median (IQR) for diastolic blood pressure (DBP) and systolic blood pressure (SBP) were 85.00 mmHg (IQR: 80.00-90.00 mmHg) and 145.00 mmHg (IQR: 130.00-160.00 mmHg), respectively. Overall, 246 (73.4%) and 244 (72.8%) participants had poor knowledge and poor adherence to AHM, respectively. In the multivariate analysis, factors associated with increased odds of poor adherence to AHM included sex (females: adjusted odds ratio (aOR): 4.95; 95% CI: 1.52-16.11, p value=0.008); employment status (Ref: employed/NGO) (self-employed: aOR: 1.95; 95% CI: 0.45-8.48, p-value=0.373) (housewife: aOR: 0.13; 95% CI: 0.04-0.413, p-value=0.001) (unemployed: aOR: 1.38; 95% CI:0.32-5.98; p-value=0.670); lack of attendance of health talk at the clinic (aOR: 2.33; 95% CI: 1.17-4.63; p-value=0.016); high cost of transportation (yes: aOR: 6.87; 95% CI: 3.25-14.52; p-value<0.001); knowledge (poor: aOR: 6.23; 95% CI: 2.36-18.05, p-value<0.001) and hypertension stage (Stage 3: aOR: 5.55; 95% CI, 1.44-21.37, p-value=0.013). Low level of knowledge regarding hypertension-related complications or associated risk factors was also noted. CONCLUSION The high level of poor adherence to anti-hypertension medications and low level of knowledge on hypertension should raise concern. Overall, decentralization of health care services and educational support are vital intervention pathways in this population.
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Affiliation(s)
- Goitom Mebrahtu
- Division of Clinical Services, Ministry of Health, Asmara, Eritrea
| | - Mary M Moleki
- Department of Health Studies, University of South Africa (UNISA), Pretoria, South Africa
| | - Oliver Okoth Achila
- Department of Clinical Laboratory Services, Orotta School of Medicine and Health Sciences, Asmara, Eritrea
- Correspondence: Oliver Okoth Achila Email
| | - Yemane Seyoum
- Department of Internal Medicine, Orotta School of Medicine and Health Sciences, Asmara, Eritrea
| | - Elias T Adnoy
- Public Health Unit, Orotta School of Medicine and Health Science, Asmara, Eritrea
| | - Martin Ovberedjo
- Eritrea Country Office, World Health Organisation (WHO), Asmara, Eritrea
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Plasma imatinib levels and ABCB1 polymorphism influences early molecular response and failure-free survival in newly diagnosed chronic phase CML patients. Sci Rep 2020; 10:20640. [PMID: 33244077 PMCID: PMC7691501 DOI: 10.1038/s41598-020-77140-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 11/02/2020] [Indexed: 11/09/2022] Open
Abstract
Achieving early molecular response (EMR) has been shown to be associated with better event free survival in patients with chronic phase chronic myeloid leukemia (CP-CML) on Imatinib therapy. We prospectively evaluated the factors influencing the 2-year failure free survival (FFS) and EMR to imatinib therapy in these patients including day29 plasma Imatinib levels, genetic variants and the gene expression of target genes in imatinib transport and biotransformation. Patients with low and intermediate Sokal score had better 2-year FFS compared to those with high Sokal Score (p = 0.02). Patients carrying ABCB1-C1236T variants had high day29 plasma imatinib levels (P = 0.005), increased EMR at 3 months (P = 0.044) and a better 2 year FFS (P = 0.003) when compared to those with wild type genotype. This translates to patients with lower ABCB1 mRNA expression having a significantly higher intracellular imatinib levels (P = 0.029). Higher day29 plasma imatinib levels was found to be strongly associated with patients achieving EMR at 3 months (P = 0.022), MMR at 12 months (P = 0.041) which essentially resulted in better 2-year FFS (p = 0.05). Also, patients who achieved EMR at 3 months, 6 months and MMR at 12 months had better FFS when compared to those who did not. This study suggests the incorporation of these variables in to the imatinib dosing algorithm as predictive biomarkers of response to Imatinib therapy.
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Abstract
The last decade has witnessed great advances in our understanding of the genetic and biological basis of childhood acute lymphoblastic leukemia (ALL), the development of experimental models to probe mechanisms and evaluate new therapies, and the development of more efficacious treatment stratification. Genomic analyses have revolutionized our understanding of the molecular taxonomy of ALL, and these advances have led the push to implement genome and transcriptome characterization in the clinical management of ALL to facilitate more accurate risk-stratification and, in some cases, targeted therapy. Although mutation- or pathway-directed targeted therapy (e.g., using tyrosine kinase inhibitors to treat Philadelphia chromosome [Ph]-positive and Phlike B-cell-ALL) is currently available for only a minority of children with ALL, many of the newly identified molecular alterations have led to the exploration of approaches targeting deregulated cell pathways. The efficacy of cellular or humoral immunotherapy has been demonstrated with the success of chimeric antigen receptor T-cell therapy and the bispecific engager blinatumomab in treating advanced disease. This review describes key advances in our understanding of the biology of ALL and optimal approaches to risk-stratification and therapy, and it suggests key areas for basic and clinical research.
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Affiliation(s)
- Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, TN.
| | - Charles G Mullighan
- Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, TN; Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN.
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Jiang C, Yang W, Moriyama T, Liu C, Smith C, Yang W, Qian M, Li Z, Tulstrup M, Schmiegelow K, Crews KR, Zhang H, Pui CH, Evans W, Relling M, Bhatia S, Yang JJ. Effects of NT5C2 Germline Variants on 6-Mecaptopurine Metabolism in Children With Acute Lymphoblastic Leukemia. Clin Pharmacol Ther 2020; 109:1538-1545. [PMID: 33124053 DOI: 10.1002/cpt.2095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/19/2020] [Indexed: 01/21/2023]
Abstract
6-mercaptopurine (6-MP) is widely used in the treatment of acute lymphoblastic leukemia (ALL), and its cytotoxicity is primarily mediated by thioguanine nucleotide (TGN) metabolites. A recent genomewide association study has identified germline polymorphisms (e.g., rs72846714) in the NT5C2 gene associated with 6-MP metabolism in patients with ALL. However, the full spectrum of genetic variation in NT5C2 is unclear and its impact on 6-MP drug activation has not been comprehensively examined. To this end, we performed targeted sequencing of NT5C2 in 588 children with ALL and identified 121 single nucleotide polymorphisms nominally associated with erythrocyte TGN during 6-MP treatment (P < 0.05). Of these, 61 variants were validated in a replication cohort of 372 children with ALL. After considering linkage disequilibrium and multivariate analysis, we confirmed two clusters of variants, represented by rs72846714 and rs58700372, that independently affected 6-MP metabolism. Functional studies showed that rs58700372 directly altered the activity of an intronic enhancer, with the variant allele linked to higher transcription activity and reduced 6-MP metabolism (lower TGN). By contrast, rs72846714 was not located in a regulatory element and instead its association signal was explained by linkage disequilibrium with a proximal functional variant rs12256506 that activated NT5C2 transcription in-cis. Our results indicated that NT5C2 germline variation significantly contributes to interpatient variability in thiopurine drug disposition.
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Affiliation(s)
- Chuang Jiang
- Department of Hematology & Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Wenjian Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Takaya Moriyama
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Chengcheng Liu
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Colton Smith
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Wentao Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Maoxiang Qian
- Department of Hematology and Oncology, Institute of Pediatrics, Children's Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Medical Epigenetics, International Co-laboratory of Medical Epigenetics and Metabolism, Ministry of Science and Technology, Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - Ziping Li
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Morten Tulstrup
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kristine R Crews
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Hui Zhang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - William Evans
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Mary Relling
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Karol SE, Yang JJ. Pharmacogenomics and ALL treatment: How to optimize therapy. Semin Hematol 2020; 57:130-136. [PMID: 33256902 DOI: 10.1053/j.seminhematol.2020.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 01/28/2023]
Abstract
Inherited genetic variations may alter drug sensitivity in patients with acute lymphoblastic leukemia, predisposing to adverse treatment side effects. In this review, we discuss evidence from children and young adults with acute lymphoblastic leukemia to review the available pharmacogenomic data with an emphasis on clinically actionable and emerging discoveries, for example, genetic variants in thiopurine methyltransferase and NUDT15 that alter 6-mercaptopurine dosing. We also highlight the need for ongoing pharmacogenomic research to validate the significance of recent findings. Further research in young adults, as well as with novel therapeutics, is needed to provide optimal therapy in future trials.
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Affiliation(s)
- Seth E Karol
- Departments of Oncology, St. Jude Children's Research Hospital, Memphis, TN.
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
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Valgimigli M, Garcia-Garcia HM, Vrijens B, Vranckx P, McFadden EP, Costa F, Pieper K, Vock DM, Zhang M, Van Es GA, Tricoci P, Baber U, Steg G, Montalescot G, Angiolillo DJ, Serruys PW, Farb A, Windecker S, Kastrati A, Colombo A, Feres F, Jüni P, Stone GW, Bhatt DL, Mehran R, Tijssen JGP. Standardized classification and framework for reporting, interpreting, and analysing medication non-adherence in cardiovascular clinical trials: a consensus report from the Non-adherence Academic Research Consortium (NARC). Eur Heart J 2020; 40:2070-2085. [PMID: 29992264 DOI: 10.1093/eurheartj/ehy377] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 03/20/2018] [Accepted: 07/04/2018] [Indexed: 01/02/2023] Open
Abstract
Non-adherence has been well recognized for years to be a common issue that significantly impacts clinical outcomes and health care costs. Medication adherence is remarkably low even in the controlled environment of clinical trials where it has potentially complex major implications. Collection of non-adherence data diverge markedly among cardiovascular randomized trials and, even where collected, is rarely incorporated in the statistical analysis to test the consistency of the primary endpoint(s). The imprecision introduced by the inconsistent assessment of non-adherence in clinical trials might confound the estimate of the calculated efficacy of the study drug. Hence, clinical trials may not accurately answer the scientific question posed by regulators, who seek an accurate estimate of the true efficacy and safety of treatment, or the question posed by payers, who want a reliable estimate of the effectiveness of treatment in the marketplace after approval. The Non-adherence Academic Research Consortium is a collaboration among leading academic research organizations, representatives from the U.S. Food and Drug Administration and physician-scientists from the USA and Europe. One in-person meeting was held in Madrid, Spain, culminating in a document describing consensus recommendations for reporting, collecting, and analysing adherence endpoints across clinical trials. The adoption of these recommendations will afford robustness and consistency in the comparative safety and effectiveness evaluation of investigational drugs from early development to post-marketing approval studies. These principles may be useful for regulatory assessment, as well as for monitoring local and regional outcomes to guide quality improvement initiatives.
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Affiliation(s)
- Marco Valgimigli
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Hector M Garcia-Garcia
- Interventional Cardiology Department, MedStar Washington Hospital Center, Washington, DC, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium.,Faculty of Medicine and Life Sciences Hasselt University, Hasselt, Belgium
| | | | - Francesco Costa
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland.,Department of Clinical and Experimental Medicine, Policlinic "G Martino", University of Messina, Italy
| | - Karen Pieper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - David M Vock
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Usman Baber
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gabriel Steg
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat Hospital, Paris, France
| | - Gilles Montalescot
- Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Patrick W Serruys
- International Centre for Circulatory Health, NHLI, Imperial College London, London, UK
| | - Andrew Farb
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration
| | - Stephan Windecker
- Department of Cardiology, Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Antonio Colombo
- Interventional Cardiology Department, San Raffaele Scientific Institute, Milan, Italy.,Interventional Cardiology Department, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Fausto Feres
- Division of Cardiology, Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Peter Jüni
- Institute of Primary Health Care, Toronto, Canada
| | - Gregg W Stone
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Roxana Mehran
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jan G P Tijssen
- European Cardiovascular Research Institute, Rotterdam, The Netherlands.,Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Rank CU, Schmiegelow K. Optimal approach to the treatment of young adults with acute lymphoblastic leukemia in 2020. Semin Hematol 2020; 57:102-114. [PMID: 33256899 DOI: 10.1053/j.seminhematol.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 01/19/2023]
Abstract
Akin to the introduction of tyrosine kinase inhibitors to Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL), pediatric-based asparaginase-heavy approaches have revolutionized the treatment of young adults with the Philadelphia chromosome-negative subset the past decades. Once again, we are approaching a new era. An era of precision medicine with immunotherapy and other molecularly targeted treatments that offers unique opportunities to customize treatment intensity with or without hematopoietic stem cell transplantation, reduce the burden of toxicities, and combat persistent residual disease. Recently approved agents for refractory/relapsed B-cell precursor ALL include the chimeric antigen receptor-modified T-cells, the anti-CD22 monoclonal antibody-drug conjugate, inotuzumab ozogamicin, and the bispecific anti-CD19 T-cell engager, blinatumomab. These agents are expected to move widely into the frontline setting along with the proteasome inhibitors, bortezomib and carfilzomib, as well as tyrosine kinase inhibitors for Philadelphia-like rearrangements that are especially frequent among young adults. To this add the BH3 mimetics, venetoclax and navitoclax, which are being widely explored in refractory/relapsed as well as frontline settings for B- and T-cell ALL. The promising anti-CD38 monoclonal antibody, daratumumab, is entering the scene of refractory/relapsed T-ALL, whereas the old purine analogue, nelarabine, is being evaluated in a new upfront setting. This review focuses on 2 main questions: How do we optimize frontline as well as salvage ALL treatment of young adults in the 2020s? Not least, how do we address the current burden of serious toxicities unique to young adults?
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Affiliation(s)
- Cecilie Utke Rank
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark.
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