1
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Zeidan AM, Ando K, Rauzy O, Turgut M, Wang MC, Cairoli R, Hou HA, Kwong YL, Arnan M, Meers S, Pullarkat V, Santini V, Malek K, Kiertsman F, Niolat J, Ramos PM, Menssen HD, Fenaux P, Miyazaki Y, Platzbecker U. Sabatolimab plus hypomethylating agents in previously untreated patients with higher-risk myelodysplastic syndromes (STIMULUS-MDS1): a randomised, double-blind, placebo-controlled, phase 2 trial. Lancet Haematol 2024; 11:e38-e50. [PMID: 38065203 DOI: 10.1016/s2352-3026(23)00333-2] [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: 08/03/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Sabatolimab is an immunotherapy targeting T-cell immunoglobulin domain and mucin domain-3 (TIM-3), an immuno-myeloid regulator expressed on immune cells and leukaemic stem cells. In this trial, we compared the efficacy and safety of sabatolimab plus hypomethylating agent with placebo plus hypomethylating agents in previously untreated patients with higher-risk myelodysplastic syndromes. METHODS STIMULUS-MDS1 was a multicentre, randomised, double-blind, placebo-controlled, phase 2 study done at 54 investigational sites in 17 countries. Adult patients (aged ≥18 years) with intermediate-risk, high-risk, and very high-risk myelodysplastic syndromes (according to Revised International Prognostic Scoring System criteria) who had not received previous treatment were included. Patients were randomly assigned (1:1) to intravenous sabatolimab (400 mg on day 8 and 22) or placebo plus a hypomethylating agent (intravenous decitabine 20 mg/m2 on day 1-5 or intravenous or subcutaneous azacitidine 75 mg/m2 on day 1-7 or day 1-5 and day 8 and 9) every 28 days until treatment discontinuation. The two primary endpoints were complete response rate and progression-free survival, assessed in the full analysis set, which included all randomly assigned patients. Complete response was analysed, as prespecified, 7 months after the last patient was randomly assigned. All other analyses presented, including progression-free survival, were done at the final data cutoff prespecified via a protocol amendment on Sept 2, 2021. Safety was assessed in in all patients who received at least one dose of study treatment. This study is registered with ClinicalTrials.gov, NCT03946670, and is ongoing. FINDINGS Between July 29, 2019, and Aug 10, 2020, 127 patients were randomly assigned to sabatolimab plus a hypomethylating agent group (sabatolimab group; n=65) or placebo plus a hypomethylating agent (placebo group; n=62). The median age of participants was 73 years (IQR 69-77), of whom 86 (68%) of 127 patients were male and 77 (61%) were White. The primary endpoints were not met. Complete response (cutoff date of March 10, 2021) was achieved in 14 (22%; 95% CI 12·3-33·5) of 65 patients in the sabatolimab group vs 11 (18%; 9·2-29·5) of 62 patients in the placebo group (p=0·77). At the cutoff date of the final analysis (March 1, 2022), median follow-up for progression-free survival was 17·8 months (IQR 16·6-19·4) in the sabatolimab group and 19·2 months (17·7-22·3) in the placebo group, and the median progression-free survival was 11·1 months (95% CI 7·6-17·6) in the sabatolimab group vs 8·5 months (6·9-11·3) in the placebo group (hazard ratio 0·75 [95% CI 0·48-1·17]; p=0·1022). The most common adverse events of any grade were neutropenia (35 [56%] of 62 patients in the sabatolimab group vs 43 [68%] of 63 patients in the placebo group), thrombocytopenia (30 [48%] vs 32 [51%]), constipation (29 [47%] vs 24 [38%]), diarrhoea (27 [44%] vs 14 [22%]), anaemia (22 [35%] vs 34 [54%]), febrile neutropenia (22 [35%] vs 15 [24%]), and leukopenia (15 [24%] vs 20 [32%]). One patient developed a serious potential treatment-related immune-mediated adverse event in the sabatolimab group. There was one treatment-related death in the sabatolimab group due to pneumonitis. INTERPRETATION The addition of sabatolimab to hypomethylating agents in this study did not result in a significant improvement in complete response rates or progression-free survival. Sabatolimab had a manageable safety in most patients with higher-risk myelodysplastic syndromes. A randomised phase 3 trial is ongoing to assess the potential benefit of sabatolimab plus azacitidine on overall survival in this setting. FUNDING Novartis Pharmaceuticals.
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Affiliation(s)
- Amer M Zeidan
- Yale Cancer Center, Yale University, New Haven, CT, USA.
| | - Kiyoshi Ando
- Tokai University School of Medicine, Isehara, Japan
| | - Odile Rauzy
- Institut Universitaire du Cancer Toulouse Oncopole, Toulouse University Hospital, Toulouse, France
| | | | - Ming-Chung Wang
- Kaohsiung-Chang Gung Memorial Hospital, Kaohsiung City, Taiwan
| | - Roberto Cairoli
- ASST Niguarda Hospital, Milan, Italy; Università degli Studi di Milano Bicocca, Milan, Italy
| | - Hsin-An Hou
- National Taiwan University Hospital, Taipei, Taiwan
| | - Yok-Lam Kwong
- University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Montserrat Arnan
- Institut Català d'Oncologia-Hospital Duran i Reynals, IDIBELL, Hospitalet Llobregat, Barcelona, Spain
| | | | | | | | | | | | | | | | | | - Pierre Fenaux
- Hôpital Saint-Louis, Université Paris Cité, Paris, France
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2
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Stahl M, DeZern AE. Is there a path forward for immunotherapy in patients with myelodysplastic syndromes? Lancet Haematol 2024; 11:e5-e7. [PMID: 38065202 DOI: 10.1016/s2352-3026(23)00343-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023]
Affiliation(s)
- Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Amy E DeZern
- Department of Oncology, Sidney Kimmel Cancer Center at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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3
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Stahl M, Bewersdorf JP, Xie Z, Porta MGD, Komrokji R, Xu ML, Abdel-Wahab O, Taylor J, Steensma DP, Starczynowski DT, Sekeres MA, Sanz G, Sallman DA, Roboz GJ, Platzbecker U, Patnaik MM, Padron E, Odenike O, Nimer SD, Nazha A, Majeti R, Loghavi S, Little RF, List AF, Kim TK, Hourigan CS, Hasserjian RP, Halene S, Griffiths EA, Gore SD, Greenberg P, Figueroa ME, Fenaux P, Efficace F, DeZern AE, Daver NG, Churpek JE, Carraway HE, Buckstein R, Brunner AM, Boultwood J, Borate U, Bejar R, Bennett JM, Wei AH, Santini V, Savona MR, Zeidan AM. Classification, risk stratification and response assessment in myelodysplastic syndromes/neoplasms (MDS): A state-of-the-art report on behalf of the International Consortium for MDS (icMDS). Blood Rev 2023; 62:101128. [PMID: 37704469 DOI: 10.1016/j.blre.2023.101128] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/31/2023] [Accepted: 08/16/2023] [Indexed: 09/15/2023]
Abstract
The guidelines for classification, prognostication, and response assessment of myelodysplastic syndromes/neoplasms (MDS) have all recently been updated. In this report on behalf of the International Consortium for MDS (icMDS) we summarize these developments. We first critically examine the updated World Health Organization (WHO) classification and the International Consensus Classification (ICC) of MDS. We then compare traditional and molecularly based risk MDS risk assessment tools. Lastly, we discuss limitations of criteria in measuring therapeutic benefit and highlight how the International Working Group (IWG) 2018 and 2023 response criteria addressed these deficiencies and are endorsed by the icMDS. We also address the importance of patient centered care by discussing the value of quality-of-life assessment. We hope that the reader of this review will have a better understanding of how to classify MDS, predict clinical outcomes and evaluate therapeutic outcomes.
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Affiliation(s)
- Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Jan Philipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhuoer Xie
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Matteo Giovanni Della Porta
- IRCCS Humanitas Clinical and Research Center & Humanitas University, Department of Biomedical Sciences, via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Rami Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Mina L Xu
- Departments of Pathology & Laboratory Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Omar Abdel-Wahab
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Justin Taylor
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Daniel T Starczynowski
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mikkael A Sekeres
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Guillermo Sanz
- Health Research Institute La Fe, Valencia, Spain; Hospital Universitario y Politécnico La Fe, Valencia, Spain; CIBERONC, IS Carlos III, Madrid, Spain
| | - David A Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Gail J Roboz
- Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA
| | | | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Olatoyosi Odenike
- Leukemia Program, University of Chicago Medicine and University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | - Stephen D Nimer
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Aziz Nazha
- Department of Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ravi Majeti
- Division of Hematology, Department of Medicine, Cancer Institute, and Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard F Little
- National Cancer Institute, Cancer Therapy Evaluation Program, Rockville, MD, USA
| | - Alan F List
- Precision BioSciences, Inc., Durham, NC, USA
| | - Tae Kon Kim
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, and Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD, 20892, USA
| | | | - Stephanie Halene
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | | | - Steven D Gore
- National Cancer Institute, Cancer Therapy Evaluation Program, Rockville, MD, USA
| | - Peter Greenberg
- Division of Hematology, Department of Medicine, Cancer Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Maria E Figueroa
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Pierre Fenaux
- Hôpital Saint Louis, Assistance Publique Hôpitaux de Paris and Paris Cité University, Paris, France
| | - Fabio Efficace
- Italian Group for Adult Hematologic Diseases (GIMEMA), Health Outcomes Research Unit, Rome, Italy
| | - Amy E DeZern
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jane E Churpek
- Department of Hematology, Oncology, and Palliative Care, Carbone Cancer Center, The University of Wisconsin-Madison, Madison, WI, USA
| | - Hetty E Carraway
- Leukemia Program, Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rena Buckstein
- Department of Medical Oncology/ Hematology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Andrew M Brunner
- Leukemia Program, Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Jacqueline Boultwood
- Blood Cancer UK Molecular Haematology Unit, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Uma Borate
- Ohio State University Comprehensive Cancer Center/ James Cancer Hospital, Ohio State University, Columbus, OH, USA
| | - Rafael Bejar
- Division of Hematology and Oncology, Moores Cancer Center, UC San Diego, La Jolla, CA, USA
| | - John M Bennett
- University of Rochester Medical Center, Department of Pathology and Laboratory Medical Center, Rochester, NY, USA
| | - Andrew H Wei
- Department of Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Walter and Eliza Hall Institute of Medical Research and University of Melbourne, Victoria, Australia
| | | | - Michael R Savona
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT, USA.
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4
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Sharplin K, Proudman W, Chhetri R, Tran ENH, Choong J, Kutyna M, Selby P, Sapio A, Friel O, Khanna S, Singhal D, Damin M, Ross D, Yeung D, Thomas D, Kok CH, Hiwase D. A Personalized Risk Model for Azacitidine Outcome in Myelodysplastic Syndrome and Other Myeloid Neoplasms Identified by Machine Learning Model Utilizing Real-World Data. Cancers (Basel) 2023; 15:4019. [PMID: 37627047 PMCID: PMC10452100 DOI: 10.3390/cancers15164019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 08/04/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023] Open
Abstract
Azacitidine is an approved therapy for higher-risk myelodysplastic syndrome (MDS). However, only 30-40% patients respond to azacitidine, and the responses may take up to six cycles to become evident. Delayed responses and the myelosuppressive effects of azacitidine make it challenging to predict which patients will benefit. This is further compounded by a lack of uniform prognostic tools to identify patients at risk of early treatment failure. Hence, we performed a retrospective analysis of 273 consecutive azacytidine-treated patients. The median overall survival was 16.25 months with only 9% alive at 5 years. By using pre-treatment variables incorporated into a random forest machine learning model, we successfully identified those patients unlikely to benefit from azacytidine upfront (7.99 vs. 22.8 months, p < 0.0001). This model also identified those who required significantly more hospitalizations and transfusion support. Notably, it accurately predicted survival outcomes, outperforming the existing prognostic scoring system. By integrating somatic mutations, we further refined the model and identified three distinct risk groups with significant differences in survival (5.6 vs. 10.5 vs. 43.5 months, p < 0.0001). These real-world findings emphasize the urgent need for personalized prediction tools tailored to hypomethylating agents, reducing unnecessary complications and resource utilization in MDS treatment.
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Affiliation(s)
- Kirsty Sharplin
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - William Proudman
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Rakchha Chhetri
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
| | - Elizabeth Ngoc Hoa Tran
- Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
| | - Jamie Choong
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Monika Kutyna
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
| | - Philip Selby
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
| | - Aidan Sapio
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Oisin Friel
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Beaumont Hospital, D09 V2N0 Dublin, Ireland
| | - Shreyas Khanna
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
| | - Deepak Singhal
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
| | - Michelle Damin
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - David Ross
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, SA 5000, Australia
- Genetic and Molecular Pathology, SA Pathology, Adelaide, SA 5000, Australia
| | - David Yeung
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, SA 5000, Australia
| | - Daniel Thomas
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, SA 5000, Australia
| | - Chung H. Kok
- Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, SA 5000, Australia
| | - Devendra Hiwase
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
- Precision Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA 5000, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA 5000, Australia
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, SA 5000, Australia
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5
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Sekeres MA, Kim N, DeZern AE, Norsworthy KJ, Garcia JS, de Claro RA, Theoret MR, Jen EY, Ehrlich LA, Zeidan AM, Komrokji RS. Considerations for Drug Development in Myelodysplastic Syndromes. Clin Cancer Res 2023; 29:2573-2579. [PMID: 36688922 PMCID: PMC10349686 DOI: 10.1158/1078-0432.ccr-22-3348] [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: 10/28/2022] [Revised: 12/07/2022] [Accepted: 01/17/2023] [Indexed: 01/24/2023]
Abstract
Myelodysplastic syndromes (MDS) have historically been challenging diseases for drug development due to their biology, preclinical modeling, and the affected patient population. In April 2022, the FDA convened a panel of regulators and academic experts in MDS to discuss approaches to improve MDS drug development. The panel reviewed challenges in MDS clinical trial design and endpoints and outlined considerations for future trial design in MDS to facilitate drug development to meaningfully meet patient needs. Challenges for defining clinical benefit in patients with MDS include cumbersome response criteria, standardized transfusion thresholds, and application and validation of patient reported outcome instruments. Clinical trials should reflect the biology of disease evolution, the advanced age of patients with MDS, and how patients are treated in real-world settings to maximize the likelihood of identifying active drugs. In patients with lower-risk disease, response criteria for anemic patients should be based on baseline transfusion dependency, improvement in symptoms, and quality of life. For higher-risk patients with MDS, trials should include guidance to prevent dose reductions or delays that could limit efficacy, specify minimal durations of treatment (in the absence of toxicity or progression), and have endpoints focused on overall survival and durable responses. MDS trials should be designed from the outset to allow the practicable application of new therapies in this high-needs population, with drugs that can be administered and tolerated in community settings, and with endpoints that meaningfully improve patients' lives over existing therapies.
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Affiliation(s)
- Mikkael A. Sekeres
- Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL
| | - Nina Kim
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Kelly J. Norsworthy
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | | | - R. Angelo de Claro
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Marc R. Theoret
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, MD
| | - Emily Y. Jen
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Lori A. Ehrlich
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, and Yale Cancer Center, Yale University, New Haven, CT
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6
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Frumm SM, Shimony S, Stone RM, DeAngelo DJ, Bewersdorf JP, Zeidan AM, Stahl M. Why do we not have more drugs approved for MDS? A critical viewpoint on novel drug development in MDS. Blood Rev 2023; 60:101056. [PMID: 36805300 DOI: 10.1016/j.blre.2023.101056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/15/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023]
Abstract
Approval of new agents to treat higher risk (HR) myelodysplastic syndrome (MDS) has stalled since the approval of DNA methyltransferase inhibitors (DNMTi). In addition, the options for patients with lower risk (LR) MDS who have high transfusion needs and do not harbor ring sideroblasts or 5q- syndrome are limited. Here, we review the current treatment landscape in MDS and identify areas of unmet need, such as treatment after failure of erythropoiesis-stimulating agents or DNMTis, TP53-mutated disease, and MDS with potentially targetable mutations. We discuss how our understanding of MDS pathogenesis can inform therapy development, including treating HR-MDS similarly to AML and pursuing therapies to address splicing factor mutations and dysregulated inflammation. We then bring a critical lens to current methodology of MDS studies and propose solutions to improve the efficiency and yield of these clinical trials, including using the most meaningful response metrics and expanding enrollment.
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Affiliation(s)
- Stacey M Frumm
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Shai Shimony
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Rabin Medical Center and Faculty of Medicine, Tel Aviv University, Israel
| | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jan Phillipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine, and Yale Cancer Center, Yale University, New Haven, CT, USA
| | - Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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7
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Stahl M, Abdel-Wahab O, Wei AH, Savona MR, Xu ML, Xie Z, Taylor J, Starczynowski D, Sanz GF, Sallman DA, Santini V, Roboz GJ, Patnaik MM, Padron E, Odenike O, Nazha A, Nimer SD, Majeti R, Little RF, Gore S, List AF, Kutchroo V, Komrokji RS, Kim TK, Kim N, Hourigan CS, Hasserjian RP, Halene S, Griffiths EA, Greenberg PL, Figueroa M, Fenaux P, Efficace F, DeZern AE, Della Porta MG, Daver NG, Churpek JE, Carraway HE, Brunner AM, Borate U, Bennett JM, Bejar R, Boultwood J, Loghavi S, Bewersdorf JP, Platzbecker U, Steensma DP, Sekeres MA, Buckstein RJ, Zeidan AM. An agenda to advance research in myelodysplastic syndromes: a TOP 10 priority list from the first international workshop in MDS. Blood Adv 2023; 7:2709-2714. [PMID: 36260702 PMCID: PMC10333740 DOI: 10.1182/bloodadvances.2022008747] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Omar Abdel-Wahab
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew H. Wei
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne and Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Michael R. Savona
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Mina L. Xu
- Departments of Pathology & Laboratory Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT
| | - Zhuoer Xie
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Justin Taylor
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Daniel Starczynowski
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Guillermo F. Sanz
- Hematology Department, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Health Research Institute La Fe, Valencia, Spain
- CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| | - David A. Sallman
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | - Gail J. Roboz
- Weill Cornell Medicine and The New York Presbyterian Hospital, New York, NY
| | - Mrinal M. Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Eric Padron
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | - Aziz Nazha
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Stephen D. Nimer
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Ravindra Majeti
- Division of Hematology, Department of Medicine, Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Richard F. Little
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Steven Gore
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | | | - Vijay Kutchroo
- Evergrande Center for Immunologic Diseases, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Rami S. Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Tae Kon Kim
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nina Kim
- National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | | | - Stephanie Halene
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT
| | | | - Peter L. Greenberg
- Division of Hematology, Department of Medicine, Cancer Institute, Stanford University School of Medicine, Stanford, CA
| | - Maria Figueroa
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | | | - Fabio Efficace
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Amy E. DeZern
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, MD
| | - Matteo G. Della Porta
- Humanitas Clinical and Research Center & Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Naval G. Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jane E. Churpek
- Department of Hematology, Oncology, and Palliative Care, Carbone Cancer Center, The University of Wisconsin-Madison, Madison, WI
| | - Hetty E. Carraway
- Leukemia Program, Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - Uma Borate
- Division of Hematology, Department of Internal Medicine, James Cancer Center, Ohio State University, Columbus, OH
| | - John M. Bennett
- Hematopathology Division, Departments of Pathology and Medicine, University of Rochester Medical Center, Rochester, NY
| | - Rafael Bejar
- Division of Hematology and Oncology, Moores Cancer Center, UC San Diego, La Jolla, CA
| | - Jacqueline Boultwood
- Blood Cancer UK Molecular Haematology Unit, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jan Philipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Uwe Platzbecker
- Department of Hematology and Cellular Therapy, Medical Clinic and Policlinic I, Leipzig University Hospital, Leipzig, Germany
| | | | - Mikkael A. Sekeres
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Rena J. Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, CT
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8
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Blum S, Tsilimidos G, Bresser H, Lübbert M. Role of Bcl-2 inhibition in myelodysplastic syndromes. Int J Cancer 2023; 152:1526-1535. [PMID: 36444492 DOI: 10.1002/ijc.34377] [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: 05/19/2022] [Revised: 10/09/2022] [Accepted: 11/02/2022] [Indexed: 11/30/2022]
Abstract
Myelodysplasic syndromes (MDS) are diseases occurring mainly in the elderly population. Although hematopoietic stem cell transplantation is the only hope for cure, a majority of the patients suffering from MDS are too old or frail for intensive treatment regimens such as intensive chemotherapy and transplantation. The gold standard for those patients is currently treatment with hypomethylating agents, although real-life data could not reproduce the overall survival rates reported for the pivotal azacitidine phase III study. MDS treatment is often inspired by treatment for acute myeloid leukemia (AML). The new gold standard for elderly and frail patients not able to undergo intensive treatment regimens in AML is the combination of hypomethylating agents with venetoclax, a BCL-2 inhibitor that also showed excellent treatment outcomes in other hematological malignancies. In this review, we explain the rationale for the use of venetoclax in hematological malignancies, study outcomes available so far and the current knowledge of its use in MDS.
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Affiliation(s)
- Sabine Blum
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Gerasimos Tsilimidos
- Service and Central Laboratory of Haematology, Department of Oncology and Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Helena Bresser
- Department of Internal Medicine I, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg Medical Center, Freiburg, Germany
| | - Michael Lübbert
- Department of Internal Medicine I, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg Medical Center, Freiburg, Germany
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9
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Zeidan AM, Giagounidis A, Sekeres MA, Xiao Z, Sanz GF, Hoef MV, Ma F, Hertle S, Santini V. STIMULUS-MDS2 design and rationale: a phase III trial with the anti-TIM-3 sabatolimab (MBG453) + azacitidine in higher risk MDS and CMML-2. Future Oncol 2023; 19:631-642. [PMID: 37083373 DOI: 10.2217/fon-2022-1237] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
Patients with higher-risk myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML) unfit for hematopoietic stem cell transplantation have poor outcomes. Novel therapies that provide durable benefit with favorable tolerability and clinically meaningful improvement in survival are needed. T-cell immunoglobulin domain and mucin domain-3 (TIM-3) is an immuno-myeloid regulator expressed on immune and leukemic stem cells in myeloid malignancies. Sabatolimab is a novel immunotherapy targeting TIM-3 with a potential dual mechanism of reactivating the immune system and directly targeting TIM-3+ leukemic blasts suppressing the growth of cancer cells. Here, we describe the aims and design of the phase III STIMULUS-MDS2 trial, which aims to demonstrate the potential for sabatolimab plus azacitidine to improve survival for patients with higher-risk MDS and CMML-2 (NCT04266301). Clinical Trial Registration: NCT04266301 (ClinicalTrials.gov).
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Affiliation(s)
- Amer M Zeidan
- Yale University & Yale Cancer Center, New Haven, CT 06510, USA
| | | | - Mikkael A Sekeres
- Division of Hematology, Sylvester Cancer Center, University of Miami, Miami, FL 33065, USA
| | - Zhijian Xiao
- Blood Diseases Hospital, Chinese Academy of Medical Sciences, Tianjin, 300020, China
| | - Guillermo F Sanz
- Hospital Universitario y Politécnico La Fe, Valencia, 46026, Spain
- Health Research Institute La Fe (IIS La Fe), Valencia, 46026, Spain
- CIBERONC, Instituto de Salud Carlos III, Madrid, 28029, Spain
| | | | - Fei Ma
- Novartis Pharmaceuticals Corporation, East Hanover, NJ 07936, USA
| | | | - Valeria Santini
- MDS Unit, Hematology, University of Florence, Florence, 50121, Italy
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10
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Abstract
Myelodysplastic syndromes (MDS) are a family of myeloid cancers with diverse genotypes and phenotypes characterized by ineffective haematopoiesis and risk of transformation to acute myeloid leukaemia (AML). Some epidemiological data indicate that MDS incidence is increasing in resource-rich regions but this is controversial. Most MDS cases are caused by randomly acquired somatic mutations. In some patients, the phenotype and/or genotype of MDS overlaps with that of bone marrow failure disorders such as aplastic anaemia, paroxysmal nocturnal haemoglobinuria (PNH) and AML. Prognostic systems, such as the revised International Prognostic Scoring System (IPSS-R), provide reasonably accurate predictions of survival at the population level. Therapeutic goals in individuals with lower-risk MDS include improving quality of life and minimizing erythrocyte and platelet transfusions. Therapeutic goals in people with higher-risk MDS include decreasing the risk of AML transformation and prolonging survival. Haematopoietic cell transplantation (HCT) can cure MDS, yet fewer than 10% of affected individuals receive this treatment. However, how, when and in which patients with HCT for MDS should be performed remains controversial, with some studies suggesting HCT is preferred in some individuals with higher-risk MDS. Advances in the understanding of MDS biology offer the prospect of new therapeutic approaches.
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11
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Mohty R, Al Hamed R, Bazarbachi A, Brissot E, Nagler A, Zeidan A, Mohty M. Treatment of myelodysplastic syndromes in the era of precision medicine and immunomodulatory drugs: a focus on higher-risk disease. J Hematol Oncol 2022; 15:124. [PMID: 36045390 PMCID: PMC9429775 DOI: 10.1186/s13045-022-01346-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 11/22/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous clonal disease of myeloid neoplasms characterized by ineffective hematopoiesis, variable degree of cytopenias, and an increased risk of progression to acute myeloid leukemia (AML). Molecular and genetic characterization of MDS has led to a better understanding of the disease pathophysiology and is leading to the development of novel therapies. Targeted and immune therapies have shown promising results in different hematologic malignancies. However, their potential use in MDS is yet to be fully defined. Here, we review the most recent advances in therapeutic approaches in MDS, focusing on higher-risk disease. Allogeneic hematopoietic cell transplantation is beyond the scope of this article.
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Affiliation(s)
- Razan Mohty
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Rama Al Hamed
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Eolia Brissot
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, and INSERM, Saint-Antoine Research Centre, 75012, Paris, France
| | - Arnon Nagler
- Hematology and Bone Marrow Transplant Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Amer Zeidan
- Division of Hematology/Oncology, Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, and INSERM, Saint-Antoine Research Centre, 75012, Paris, France.
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12
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Hu C, Wang X. Predictive and prognostic value of gene mutations in myelodysplastic syndrome treated with hypomethylating agents: a meta-analysis. Leuk Lymphoma 2022; 63:2336-2351. [PMID: 35543621 DOI: 10.1080/10428194.2022.2070913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although the effect of gene mutations on overall response rate (ORR) and overall survival (OS) in myelodysplastic syndrome (MDS) treated with hypomethylating agents (HMAs) has been explored, the effect is still controversial. We performed this meta-analysis to investigate the effect. The pooled odds ratio (OR) and 95% confidence interval (CI) for ORR and the pooled hazard ratio (HR) and 95%CI for OS were chosen to estimate the effect. The pooled OR of TET2 was 0.73 (95%CI: 0.59-0.91, p = 0.005) and the pooled OR of ASXL1 was 1.38 (95%CI: 1.12-1.71, p = 0.003). As for prognosis, the pooled HR of RUNX1 was 1.45 (95%CI: 1.15-1.85, p = 0.002). The pooled HR of TP53 was 2.30 (95%CI: 1.83-2.90, p < 0.001) and the pooled HR of U2AF1 was 1.41 (95%CI: 1.15-1.74, p = 0.001). There was no statistical difference shown in other genes. Therefore, TET2 mutation and ASXL1 wild-type were the predictor of better response to HMAs. Mutations of TP53, RUNX1, and U2AF1 were associated with poor prognosis in MDS.
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Affiliation(s)
- Chaolu Hu
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoqin Wang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
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13
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A Randomized Phase 2 Trial of Azacitidine ± Durvalumab as First-line Therapy for Higher-Risk Myelodysplastic Syndromes. Blood Adv 2021; 6:2207-2218. [PMID: 34972214 PMCID: PMC9006291 DOI: 10.1182/bloodadvances.2021005487] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/29/2021] [Indexed: 11/20/2022] Open
Abstract
This is the first reported randomized trial of immune checkpoint inhibitor therapy in HR-MDS. Azacitidine combined with the PD-L1 inhibitor durvalumab was feasible but did not improve outcomes over azacitidine alone.
Azacitidine-mediated hypomethylation promotes tumor cell immune recognition but may increase the expression of inhibitory immune checkpoint molecules. We conducted the first randomized phase 2 study of azacitidine plus the immune checkpoint inhibitor durvalumab vs azacitidine monotherapy as first-line treatment for higher-risk myelodysplastic syndromes (HR-MDS). In all, 84 patients received 75 mg/m2 subcutaneous azacitidine (days 1-7 every 4 weeks) combined with 1500 mg intravenous durvalumab on day 1 every 4 weeks (Arm A) for at least 6 cycles or 75 mg/m² subcutaneous azacitidine alone (days 1-7 every 4 weeks) for at least 6 cycles (Arm B). After a median follow-up of 15.25 months, 8 patients in Arm A and 6 in Arm B remained on treatment. Patients in Arm A received a median of 7.9 treatment cycles and those in Arm B received a median of 7.0 treatment cycles with 73.7% and 65.9%, respectively, completing ≥4 cycles. The overall response rate (primary end point) was 61.9% in Arm A (26 of 42) and 47.6% in Arm B (20 of 42; P = .18), and median overall survival was 11.6 months (95% confidence interval, 9.5 months to not evaluable) vs 16.7 months (95% confidence interval, 9.8-23.5 months; P = .74). Durvalumab-related adverse events (AEs) were reported by 71.1% of patients; azacitidine-related AEs were reported by 82% (Arm A) and 81% (Arm B). Grade 3 or 4 hematologic AEs were reported in 89.5% (Arm A) vs 68.3% (Arm B) of patients. Patients with TP53 mutations tended to have a worse response than patients without these mutations. Azacitidine increased programmed cell death ligand 1 (PD-L1 [CD274]) surface expression on bone marrow granulocytes and monocytes, but not blasts, in both arms. In summary, combining azacitidine with durvalumab in patients with HR-MDS was feasible but with more toxicities and without significant improvement in clinical outcomes over azacitidine alone. This trial was registered at www.clinicaltrials.gov as #NCT02775903.
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14
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Rozema J, van Roon EN, Kibbelaar RE, Veeger NJGM, Slim CL, de Wit H, Hoogendoorn M. Patterns of transfusion burden in an unselected population of patients with myelodysplastic syndromes: A population-based study. Transfusion 2021; 61:2877-2884. [PMID: 34480360 PMCID: PMC9293228 DOI: 10.1111/trf.16631] [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: 04/13/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 12/27/2022]
Abstract
Background Ineffective hematopoiesis in patients with myelodysplastic syndromes (MDS) often results in transfusion dependence. The burden of frequent transfusions in the real‐world MDS population is largely unknown. Study design and methods An observational, retrospective, population‐based study, using the HemoBase registry, was performed including all patients diagnosed with MDS between 2005 and 2017 in Friesland, a province in the Netherlands with approximately 650,000 inhabitants. Detailed clinical information was collected from the electronic health records. Transfusion burden was classified according to the International Working Group 2018 criteria: not transfusion dependent, low (LTB), or high transfusion burden (HTB). Univariate and multivariable regression analyses were performed. Results Of 292 patients, 136 (46.6%) had a HTB of ≥8 units/16 weeks and 17 (5.8%) had a LTB of 3–7 units/16 weeks. This was present in all types of MDS patients, but patients aged 75–84 years (odds ratio [OR] 4.02, 95% confidence interval [CI]: 1.84–8.82), high‐risk MDS patients (OR 2.88, 95% CI: 1.08–7.68) and MDS‐EB‐2 patients (OR 7.07, 95% CI: 2.17–22.90) were particularly at risk for a HTB. Discussion This study provides a reliable estimate of the transfusion burden in real‐world MDS patients, with almost half of the patients having a HTB. A HTB was observed in all MDS subtypes and both low‐ and high‐risk MDS. Therefore, we conclude that the entire MDS population might benefit from novel agents that reduce the transfusion need and that might have beneficial effects on patient outcomes and healthcare utilization outcomes.
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Affiliation(s)
- Johanne Rozema
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Eric N van Roon
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacy and Pharmacology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Robby E Kibbelaar
- Department of Pathology, Pathology Friesland, Leeuwarden, The Netherlands
| | - Nic J G M Veeger
- Science Bureau Department, Science Bureau, Medical Center Leeuwarden, Leeuwarden, The Netherlands.,Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Christiaan L Slim
- Location Medical Center Leeuwarden, Certe Medical Diagnostics & Advice, Leeuwarden, The Netherlands
| | - Harry de Wit
- Location Medical Center Leeuwarden, Certe Medical Diagnostics & Advice, Leeuwarden, The Netherlands
| | - Mels Hoogendoorn
- Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
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15
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Volpe VO, Garcia-Manero G, Komrokji RS. Myelodysplastic Syndromes: A New Decade. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:1-16. [PMID: 34544674 DOI: 10.1016/j.clml.2021.07.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
Myelodysplastic syndromes (MDS) are a group of heterogeneous clonal hematopoietic stem cell disorders. The 2020 Surveillance, Epidemiology, and End Results data demonstrates the incidence rate of MDS increases with age especially in those greater than 70 years of age. Risk stratification that impact prognosis, survival, and rate of acute myeloid leukemia (AML) transformation in MDS is largely dependent on revised International Prognostic Scoring System along with molecular genetic testing as a supplement. Low risk MDS typically have a more indolent disease course in which treatment is only initiated to ameliorate symptoms of cytopenias. In many, anemia is the most common cytopenia requiring treatment and erythroid stimulating agents, are considered first line. In contrast, high risk MDS tend to behave more aggressively for which treatment should be initiated rapidly with Hypomethylating Agents (HMA) being in the frontline. In those with high risk MDS and eligible, evaluation for allogeneic stem cell transplant should be considered as this is the only potential curative option for MDS. With the use of molecular genetic testing, a personalized approach to therapy in MDS has ensued. As the treatment landscape in MDS continues to flourish with novel targeted agents, we ambitiously seek to improve survival rates especially among the relapsed/refractory and transplant ineligible.
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Affiliation(s)
- Virginia O Volpe
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | | | - Rami S Komrokji
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL.
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16
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Nachtkamp K, Stark J, Kündgen A, Schroeder T, Strupp C, Strapatsas J, Schuler E, Kaivers J, Giagounidis A, Rautenberg C, Aul C, Runde V, Haas R, Kobbe G, Gattermann N, Germing U. Eligibility for clinical trials is unsatisfactory for patients with myelodysplastic syndromes, even at a tertiary referral center. Leuk Res 2021; 108:106611. [PMID: 33990002 DOI: 10.1016/j.leukres.2021.106611] [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: 02/28/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 12/01/2022]
Abstract
Participation in clinical trials may allow patients with MDS to gain access to therapies not otherwise available. However, access is limited by strict inclusion and exclusion criteria, reflecting academic or regulatory questions addressed by the respective studies. We performed a simulation in order to estimate the average proportion of MDS patients eligible for participation in a clinical trial. The simulation drew upon 1809 patients in the Düsseldorf MDS Registry whose clinical data allowed eligibility screening for a wide range of clinical trials. This cohort was assumed to be alive and available for study participation. The simulation also posited that all MDS trials (n = 47) conducted in our center between 1987 and 2016 were open for recruitment. In addition, study activities in the year 2016 were analyzed to determine the proportion of patients eligible for at least one of the 9 MDS trials open at that time. On average, each clinical trial was suitable for about 18 % of patients in the simulation cohort. Conversely, 34 % of the patients were eligible for at least one of the 9 clinical studies in 2016. Inclusion/exclusion criteria of studies initiated by the pharmaceutical industry excluded more than twice the fraction of patients compared with investigator initiated trials (potential inclusion of 10 % vs. 21 %, respectively). Karyotype (average exclusion rate 58 %), comorbidities (40 %), and prior therapies (55 %) were the main reasons for exclusion. We suggest that in- and exclusion criteria should be less restrictive, in order to meet the needs of the real-life population of elderly MDS patients.
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Affiliation(s)
- Kathrin Nachtkamp
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany.
| | - Josefine Stark
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Andrea Kündgen
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Thomas Schroeder
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Corinna Strupp
- Department of Oncology, Rheinland Klinikum Dormagen, Dr.-Geldmacher-Straße 20, 41540 Dormagen, Germany
| | - Judith Strapatsas
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Esther Schuler
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Jennifer Kaivers
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Aristoteles Giagounidis
- Department of Oncology and Hematology, VKKD Marienhospital Duesseldorf, Rochusstr. 2, 40479 Düsseldorf, Germany
| | - Christina Rautenberg
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Carlo Aul
- Department of Oncology and Hematology, VKKD Marienhospital Duesseldorf, Rochusstr. 2, 40479 Düsseldorf, Germany
| | - Volker Runde
- Department of Hematology and Oncology, Katholisches Karl-Leisner-Klinikum, Voßheider Str. 214, 47574 Goch, Germany
| | - Rainer Haas
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Guido Kobbe
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Norbert Gattermann
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
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Epigenetics in a Spectrum of Myeloid Diseases and Its Exploitation for Therapy. Cancers (Basel) 2021; 13:cancers13071746. [PMID: 33917538 PMCID: PMC8038780 DOI: 10.3390/cancers13071746] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The genome is stored in the limited space of the nucleus in a highly condensed form. The regulation of this packaging contributes to determining the accessibility of genes and is important for cell function. Genes affecting the genome’s packaging are frequently mutated in bone marrow cells that give rise to the different types of blood cells. Here, we first discuss the molecular functions of these genes and their role in blood generation under healthy conditions. Then, we describe how their mutations relate to a subset of diseases including blood cancers. Finally, we provide an overview of the current efforts of using and developing drugs targeting these and related genes. Abstract Mutations in genes encoding chromatin regulators are early events contributing to developing asymptomatic clonal hematopoiesis of indeterminate potential and its frequent progression to myeloid diseases with increasing severity. We focus on the subset of myeloid diseases encompassing myelodysplastic syndromes and their transformation to secondary acute myeloid leukemia. We introduce the major concepts of chromatin regulation that provide the basis of epigenetic regulation. In greater detail, we discuss those chromatin regulators that are frequently mutated in myelodysplastic syndromes. We discuss their role in the epigenetic regulation of normal hematopoiesis and the consequence of their mutation. Finally, we provide an update on the drugs interfering with chromatin regulation approved or in development for myelodysplastic syndromes and acute myeloid leukemia.
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18
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Calgarotto AK, Longhini AL, Pericole de Souza FV, Duarte ASS, Ferro KP, Santos I, Maso V, Olalla Saad ST, Torello CO. Immunomodulatory Effect of Green Tea Treatment in Combination with Low-dose Chemotherapy in Elderly Acute Myeloid Leukemia Patients with Myelodysplasia-related Changes. Integr Cancer Ther 2021; 20:15347354211002647. [PMID: 33754891 PMCID: PMC7995304 DOI: 10.1177/15347354211002647] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Green tea (GT) treatment was evaluated for its effect on the immune and antineoplastic response of elderly acute myeloid leukemia patients with myelodysplasia-related changes (AML-MRC) who are ineligible for aggressive chemotherapy and bone marrow transplants. The eligible patients enrolled in the study (n = 10) received oral doses of GT extract (1000 mg/day) alone or combined with low-dose cytarabine chemotherapy for at least 6 months and/or until progression. Bone marrow (BM) and peripheral blood (PB) were evaluated monthly. Median survival was increased as compared to the control cohort, though not statistically different. Interestingly, improvements in the immunological profile of patients were found. After 30 days, an activated and cytotoxic phenotype was detected: GT increased total and naïve/effector CD8+ T cells, perforin+/granzyme B+ natural killer cells, monocytes, and classical monocytes with increased reactive oxygen species (ROS) production. A reduction in the immunosuppressive profile was also observed: GT reduced TGF-β and IL-4 expression, and decreased regulatory T cell and CXCR4+ regulatory T cell frequencies. ROS levels and CXCR4 expression were reduced in bone marrow CD34+ cells, as well as nuclear factor erythroid 2–related factor 2 (NRF2) and hypoxia-inducible factor 1α (HIF-1α) expression in biopsies. Immune modulation induced by GT appears to occur, regardless of tumor burden, as soon as 30 days after intake and is maintained for up to 180 days, even in the presence of low-dose chemotherapy. This pilot study highlights that GT extracts are safe and could improve the immune system of elderly AML-MRC patients.
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Affiliation(s)
| | | | | | | | | | - Irene Santos
- University of Campinas, Campinas, São Paulo, Brazil
| | - Victor Maso
- University of Campinas, Campinas, São Paulo, Brazil
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19
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Hasserjian RP, Buckstein R, Patnaik MM. Navigating Myelodysplastic and Myelodysplastic/Myeloproliferative Overlap Syndromes. Am Soc Clin Oncol Educ Book 2021; 41:328-350. [PMID: 34010050 DOI: 10.1200/edbk_320113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Myelodysplastic syndromes (MDS) and MDS/myeloproliferative neoplasms (MPNs) are clonal diseases that differ in morphologic diagnostic criteria but share some common disease phenotypes that include cytopenias, propensity to acute myeloid leukemia evolution, and a substantially shortened patient survival. MDS/MPNs share many clinical and molecular features with MDS, including frequent mutations involving epigenetic modifier and/or spliceosome genes. Although the current 2016 World Health Organization classification incorporates some genetic features in its diagnostic criteria for MDS and MDS/MPNs, recent accumulation of data has underscored the importance of the mutation profiles on both disease classification and prognosis. Machine-learning algorithms have identified distinct molecular genetic signatures that help refine prognosis and notable associations of these genetic signatures with morphologic and clinical features. Combined geno-clinical models that incorporate mutation data seem to surpass the current prognostic schemes. Future MDS classification and prognostication schema will be based on the portfolio of genetic aberrations and traditional features, such as blast count and clinical factors. Arriving at these systems will require studies on large patient cohorts that incorporate advanced computational analysis. The current treatment algorithm in MDS is based on patient risk as derived from existing prognostic and disease classes. Luspatercept is newly approved for patients with MDS and ring sideroblasts who are transfusion dependent after erythropoietic-stimulating agent failure. Other agents that address red blood cell transfusion dependence in patients with lower-risk MDS and the failure of hypomethylating agents in higher-risk disease are in advanced testing. Finally, a plethora of novel targeted agents and immune checkpoint inhibitors are being evaluated in combination with a hypomethylating agent backbone to augment the depth and duration of response and, we hope, improve overall survival.
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Affiliation(s)
| | - Rena Buckstein
- Division of Hematology/Oncology, Sunnybrook Odette Cancer Center, Toronto, Ontario, Canada
| | - Mrinal M Patnaik
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, MN
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20
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Lewis R, Bewersdorf JP, Zeidan AM. Clinical Management of Anemia in Patients with Myelodysplastic Syndromes: An Update on Emerging Therapeutic Options. Cancer Manag Res 2021; 13:645-657. [PMID: 33531837 PMCID: PMC7846829 DOI: 10.2147/cmar.s240600] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/13/2021] [Indexed: 12/18/2022] Open
Abstract
For the majority of patients with lower-risk myelodysplastic syndrome (LR-MDS), one of the primary clinical goals is to alleviate the symptoms associated with the resultant cytopenias and to minimize the transfusion burden. While supportive red blood cell (RBC) transfusions and erythropoiesis-stimulating agents (ESAs) may lead to clinical improvement, frequent transfusions are often complicated by iron overload and decreased quality of life; furthermore, most patients either do not respond to ESAs or will eventually develop resistance. As such, there is a great need for further therapeutic options in the management of anemia related to MDS. Several additional therapeutics are now available in select patients with LR-MDS and symptomatic anemia including luspatercept, lenalidomide, and immunosuppressive therapy. Furthermore, several novel agents are currently in development to address this area of clinical need such as imetelstat and roxadustat. In this article, we review the currently available therapeutic options for symptomatic anemia in LR-MDS as well as review the therapeutic agents in development.
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Affiliation(s)
- Russell Lewis
- Department of Medicine, Section of Hematology, Yale University, New Haven, CT, USA
| | | | - Amer M Zeidan
- Department of Medicine, Section of Hematology, Yale University, New Haven, CT, USA
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21
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Bewersdorf JP, Zeidan AM. Randomized trials with checkpoint inhibitors in acute myeloid leukaemia and myelodysplastic syndromes: What have we learned so far and where are we heading? Best Pract Res Clin Haematol 2020; 33:101222. [PMID: 33279182 DOI: 10.1016/j.beha.2020.101222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 10/28/2020] [Indexed: 12/11/2022]
Abstract
The treatment of acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS) has seen dramatic advances with the approval of multiple novel agents in recent years. However, unlike solid malignancies, immune checkpoint inhibitors have yet to garner regulatory approval in AML and MDS with recent randomized clinical trials yielding only underwhelming results. Novel targets have been explored in early phase clinical trials with impressive results leading to ongoing subsequent controlled trials. However, major challenges in the field remain such as the validation of predictive genetic, molecular, and immunophenotypic biomarkers, optimization of clinical trial design, and the identification of novel synergistic combination therapies. Herein, we review recent clinical trial data focusing on randomized clinical trials and highlight limitations of the currently available evidence in an effort to suggest options for advancing the field.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA.
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22
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Bewersdorf JP, Zeidan AM. Good but not good enough: Clinical trial participation of patients with myelodysplastic syndromes. Cancer 2020; 126:4664-4667. [PMID: 32767670 DOI: 10.1002/cncr.33106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/23/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Jan Philipp Bewersdorf
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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23
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Brierley CK, Zabor EC, Komrokji RS, DeZern AE, Roboz GJ, Brunner AM, Stone RM, Sekeres MA, Steensma DP. Low participation rates and disparities in participation in interventional clinical trials for myelodysplastic syndromes. Cancer 2020; 126:4735-4743. [PMID: 32767690 DOI: 10.1002/cncr.33105] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND The development of novel therapies for the myelodysplastic syndromes (MDS) is hampered by inadequate trial recruitment. Factors contributing to low trial accrual are incompletely understood. METHODS This study analyzed a pooled patient database from institutions of the US MDS Clinical Research Consortium to compare the characteristics of participants in interventional trials with those of patients who did not enroll in a trial. RESULTS Data were identified for 1919 patients with MDS, and 449 of these patients (23%) participated in an interventional clinical trial. The median age of all patients was 68 years, and 64% were male. Patients who participated in trials were significantly younger than nonparticipants (P = .014), and men were more likely to participate in a trial (71% of trial participants were male, whereas 61% of nonparticipants were; P < .001). Race and ethnicity were not associated with trial enrollment. Patients in more affluent ZIP codes had a higher participation rate (P < .001). Patients with intermediate- and high-risk disease according to the revised International Prognostic Scoring System were overrepresented (P = .004), and trial participants less frequently had treatment-related disease (P < .001). In multivariable analyses, participation in a clinical trial was associated with a reduced hazard of death (P = .004). Even at large referral centers, only a minority of patients with MDS enrolled in interventional trials. CONCLUSIONS Restrictive trial eligibility criteria that exclude patients with MDS on account of age, comorbidities, or a history of another cancer are limit enrollment of MDS patients to clinical trials. Gaining insight into the barriers to trial accrual may help investigators and study sponsors to design trials that will accrue more rapidly and augment treatment options for patients with MDS.
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Affiliation(s)
| | - Emily C Zabor
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.,Leukemia Program, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rami S Komrokji
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Amy E DeZern
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Gail J Roboz
- Weill Cornell Medical College, New York, New York
| | - Andrew M Brunner
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard M Stone
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Mikkael A Sekeres
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.,Leukemia Program, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - David P Steensma
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
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24
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Affiliation(s)
- Mario Cazzola
- From Fondazione IRCCS Policlinico San Matteo and the University of Pavia, Pavia, Italy
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25
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Bewersdorf JP, Zeidan AM. Management of higher risk myelodysplastic syndromes after hypomethylating agents failure: are we about to exit the black hole? Expert Rev Hematol 2020; 13:1131-1142. [DOI: 10.1080/17474086.2020.1819233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Amer M. Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
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26
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Davidoff AJ, Hu X, Bewersdorf JP, Wang R, Podoltsev NA, Huntington SF, Gore SD, Ma X, Zeidan AM. Hypomethylating agent (HMA) therapy use and survival in older adults with Refractory Anemia with Excess Blasts (RAEB) in the United States (USA): a large propensity score-matched population-based study †. Leuk Lymphoma 2020; 61:1178-1187. [PMID: 31878809 PMCID: PMC7735409 DOI: 10.1080/10428194.2019.1703970] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/16/2019] [Accepted: 12/06/2019] [Indexed: 12/13/2022]
Abstract
Hypomethylating agents (HMA) showed overall survival (OS) benefits in patients with higher-risk myelodysplastic syndromes (HR-MDS) in clinical trials. We conducted a retrospective cohort study of Surveillance, Epidemiology, and End Results (SEER)-Medicare data of patients ≥66 years diagnosed with refractory anemia with excess blasts (RAEB), a proxy for HR-MDS, in 01/2001-04/2004 (pre-period) or 01/2006-12/2011 (post-period). Association between post-period diagnosis and OS was examined using propensity scores (PS)-matched samples. Among 1876 RAEB patients, median OS was 9 months and 30.8% received HMAs (3.6% in pre-period; 43.0% in post-period) with no association between post-period diagnosis and OS. In the top PS quartile, post-period diagnosis was associated with a 74% lower risk of death (Hazard ratio [HR] = 0.26, 95%-CI: 0.10-0.69, p = 0.007), while outcomes were worse in the lowest PS quartile (HR = 2.80, 95%-CI: 1.06-7.36, p = 0.037). HMA lead to a 3-month OS benefit for patients most likely to receive HMA but not for unselected RAEB cohort.
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Affiliation(s)
- Amy J. Davidoff
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT
| | - Xin Hu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
| | | | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT
| | - Nikolai A. Podoltsev
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT
| | - Scott F. Huntington
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT
| | - Steven D. Gore
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT
| | - Xiaomei Ma
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT
| | - Amer M. Zeidan
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT
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27
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Buckstein RJ. Integrating patient-centered factors in the risk assessment of MDS. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:373-380. [PMID: 31808887 PMCID: PMC6913474 DOI: 10.1182/hematology.2019000041] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Myelodysplastic syndromes are clonal myeloid neoplasms that primarily present in older adults. Although leukemia develops in approximately 25% to 30% of individuals, the significantly shortened survival in this population is attributed more commonly to nonleukemic causes. The current prognostic scoring systems for leukemia and overall survival based on disease characteristics are becoming increasingly sophisticated and accurate with the incorporation of molecular data. The addition of patient-related factors such as comorbidity, disability, frailty, and fatigue to these new models may improve their predictive power for overall survival, treatment toxicity, and health care costs. To improve the generalizability of clinical trial results to the real world, geriatric assessment testing should become a standard of care in MDS clinical trials.
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Affiliation(s)
- Rena J Buckstein
- Odette Cancer Center, Sunnybrook Health Sciences Center, Toronto, ON, Canada
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28
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Wang QY, Li Y, Liang ZY, Yin Y, Liu W, Wang Q, Dong YJ, Sun YH, Xu WL, Ren HY. Decitabine-Containing Conditioning Regimen for Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Intermediate- and High-Risk Myelodysplastic Syndrome/Acute Myeloid Leukemia: Potential Decrease in the Incidence of Acute Graft versus Host Disease. Cancer Manag Res 2019; 11:10195-10203. [PMID: 31824191 PMCID: PMC6900353 DOI: 10.2147/cmar.s229768] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/21/2019] [Indexed: 01/08/2023] Open
Abstract
Purpose To evaluate the role of Decitabine in the allo-HSCT conditioning regimen for intermediate- and high-risk patients with MDS or AML. Patients and methods Retrospective analysis of data pertaining to 76 intermediate- and high-risk patients with MDS or AML who underwent allo-HSCT between December 2005 and June 2018 at the Peking University First Hospital. Forty patients received Decitabine-containing conditioning regimen before transplantation, while thirty-six patients received regimen without Decitabine. Results Over a median follow-up of 40 months (range, 1 to 155), the cumulative incidence of grade II to IV acute graft versus host disease was 12.4% [95% confidence interval (CI) 4.9–30.9%] in the Decitabine group and 41.5% (95% CI 28.1–61.2%) in the non-Decitabine group (P=0.005). On multivariate analysis, Decitabine-containing conditioning regimen was found to protect against grade II to IV aGVHD (HR=0.279, 95% CI 0.102–0.765, P=0.013). Incidence of respiratory infection in the Decitabine and non-Decitabine groups was 22.5% and 52.78%, respectively (P=0.012). No significant between-group difference was observed with respect to 3-year OS, DFS, or RR (P=0.980, 0.959, and 0.573, respectively), while the median relapse time was longer in the Decitabine group [7 months (range, 2–12) versus 3 months (range, 2–4), P=0.171]. Decitabine-containing conditioning showed a tendency for lower relapse rate among higher risk patients, as assessed by IPSS R; however, the between-group difference was not statistically significant (P=0.085). Conclusion Inclusion of Decitabine in the conditioning regimen for allo-HSCT in intermediate- and high-risk patients may lower the incidence of aGVHD and respiratory infections, and contribute to longer median relapse time.
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Affiliation(s)
- Qing Ya Wang
- Department of Hematology, Peking University First Hospital, Peking University, Beijing, People's Republic of China
| | - Yuan Li
- Department of Hematology, Peking University First Hospital, Peking University, Beijing, People's Republic of China
| | - Ze Yin Liang
- Department of Hematology, Peking University First Hospital, Peking University, Beijing, People's Republic of China
| | - Yue Yin
- Department of Hematology, Peking University First Hospital, Peking University, Beijing, People's Republic of China
| | - Wei Liu
- Department of Hematology, Peking University First Hospital, Peking University, Beijing, People's Republic of China
| | - Qian Wang
- Department of Hematology, Peking University First Hospital, Peking University, Beijing, People's Republic of China
| | - Yu Jun Dong
- Department of Hematology, Peking University First Hospital, Peking University, Beijing, People's Republic of China
| | - Yu Hua Sun
- Department of Hematology, Peking University First Hospital, Peking University, Beijing, People's Republic of China
| | - Wei Lin Xu
- Department of Hematology, Peking University First Hospital, Peking University, Beijing, People's Republic of China
| | - Han Yun Ren
- Department of Hematology, Peking University First Hospital, Peking University, Beijing, People's Republic of China
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29
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Zeidan AM, Hu X, Zhu W, Stahl M, Wang R, Huntington SF, Giri S, Bewersdorf JP, Podoltsev NA, Gore SD, Ma X, Davidoff AJ. Association of provider experience and clinical outcomes in patients with myelodysplastic syndromes receiving hypomethylating agents. Leuk Lymphoma 2019; 61:397-408. [PMID: 31570040 DOI: 10.1080/10428194.2019.1663423] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Population level survival of patients with myelodysplastic syndromes (MDS) treated with hypomethylating agents (HMA) is inferior to clinical trials. Using SEER-Medicare data, we identified 2086 MDS patients diagnosed in 2004-13, aged ≥66 years at diagnosis, and receiving ≥1 HMA cycle after 2005. We used multivariate logistic regression and Cox proportional hazards models to assess the impact of provider experience on persistent HMA therapy and overall survival (OS), respectively. Median number of HMA cycles was 4 and median OS was 10 months. Thirty-two percent of patients were treated by providers with ≥1 prior HMA initiation in the last 2 years and were more likely to receive ≥4 cycles of HMA therapy (OR = 1.29, 95% CI = 1.06-1.57; p = .01). No significant association was found between MDS or HMA initiation volume and survival. In conclusion, while HMA initiation volume was associated with persistent HMA treatment, neither MDS nor HMA initiation volumes were associated with OS in older MDS patients.
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Affiliation(s)
- Amer M Zeidan
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Xin Hu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Weiwei Zhu
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Maximilian Stahl
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA.,Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, USA
| | - Scott F Huntington
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Smith Giri
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Jan Philipp Bewersdorf
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Nikolai A Podoltsev
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Steven D Gore
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA.,Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Xiaomei Ma
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA.,Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, USA
| | - Amy J Davidoff
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA.,Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT, USA
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30
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Buisman SC, de Haan G. Epigenetic Changes as a Target in Aging Haematopoietic Stem Cells and Age-Related Malignancies. Cells 2019; 8:E868. [PMID: 31405121 PMCID: PMC6721661 DOI: 10.3390/cells8080868] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 12/14/2022] Open
Abstract
Aging is associated with multiple molecular and functional changes in haematopoietic cells. Most notably, the self-renewal and differentiation potential of hematopoietic stem cells (HSCs) are compromised, resulting in myeloid skewing, reduced output of red blood cells and decreased generation of immune cells. These changes result in anaemia, increased susceptibility for infections and higher prevalence of haematopoietic malignancies. In HSCs, age-associated global epigenetic changes have been identified. These epigenetic alterations in aged HSCs can occur randomly (epigenetic drift) or are the result of somatic mutations in genes encoding for epigenetic proteins. Mutations in loci that encode epigenetic modifiers occur frequently in patients with haematological malignancies, but also in healthy elderly individuals at risk to develop these. It may be possible to pharmacologically intervene in the aberrant epigenetic program of derailed HSCs to enforce normal haematopoiesis or treat age-related haematopoietic diseases. Over the past decade our molecular understanding of epigenetic regulation has rapidly increased and drugs targeting epigenetic modifications are increasingly part of treatment protocols. The reversibility of epigenetic modifications renders these targets for novel therapeutics. In this review we provide an overview of epigenetic changes that occur in aging HSCs and age-related malignancies and discuss related epigenetic drugs.
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Affiliation(s)
- Sonja C Buisman
- European Research Institute for the Biology of Ageing, University Medical Center Groningen, University of Groningen, 9700 Groningen, The Netherlands.
| | - Gerald de Haan
- European Research Institute for the Biology of Ageing, University Medical Center Groningen, University of Groningen, 9700 Groningen, The Netherlands
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31
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Chokr N, Pine AB, Bewersdorf JP, Shallis RM, Stahl M, Zeidan AM. Getting personal with myelodysplastic syndromes: is now the right time? Expert Rev Hematol 2019; 12:215-224. [PMID: 30977414 PMCID: PMC6540985 DOI: 10.1080/17474086.2019.1592673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 03/06/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Commonly used scoring systems rely on blood counts, histological and cytological examination of bone marrow and peripheral blood as well as cytogenetic assessments to estimate prognosis of patients with myelodysplastic syndromes (MDS) and guide therapy decisions. Next-generation sequencing (NGS) has identified recurrent genetic abnormalities in up to 90% of patients with MDS and may provide important information regarding the pathogenesis of the disease, diagnostic and prognostic evaluation, and therapy selection. Areas covered: Herein, the authors review the role of NGS in diagnosis, treatment, and prognosis of MDS at various disease stages, and discuss advantages and caveats of incorporating molecular genetics in routine management of MDS. While a vast majority of patients harbor recurrent mutations implicated in MDS pathogenesis, similar mutations can be detected in otherwise healthy individuals with other hematologic malignancies. Besides establishing a diagnosis, NGS may be used to monitor minimal residual disease following treatment. Expert opinion: As more targeted therapies become available, assessment of genetic mutations will become central to individualized therapy selection and may improve diagnostic accuracy and further guide management for each patient. However, multiple challenges remain before NGS can be incorporated into routine clinical practice.
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Affiliation(s)
- Nora Chokr
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Alexander B. Pine
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Jan Philipp Bewersdorf
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Rory M. Shallis
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Maximilian Stahl
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Amer M. Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, USA
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32
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Zeidan AM, Shallis RM, Wang R, Davidoff A, Ma X. Epidemiology of myelodysplastic syndromes: Why characterizing the beast is a prerequisite to taming it. Blood Rev 2019; 34:1-15. [DOI: 10.1016/j.blre.2018.09.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 09/01/2018] [Accepted: 09/17/2018] [Indexed: 02/08/2023]
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33
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Steensma DP, Brunner AM, DeZern AE, Garcia-Manero G, Komrokji RS, Odenike OS, Roboz GJ, Savona MR, Stone RM, Sekeres MA. Low clinical trial accrual of patients with myelodysplastic syndromes: Causes and potential solutions. Cancer 2018; 124:4601-4609. [PMID: 30289970 DOI: 10.1002/cncr.31769] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/03/2018] [Accepted: 08/21/2018] [Indexed: 11/11/2022]
Abstract
Despite few effective therapies, only a small percentage of patients diagnosed with myelodysplastic syndromes (MDS) in the United States are enrolled in prospective, interventional clinical trials. MDS-specific barriers to trial accrual include a high frequency of elderly patients with comorbid conditions, atypical disease features and uncertainty regarding the diagnosis (because other nonclonal processes also can cause dysplasia and cytopenias), a history of another nonmyeloid neoplasm resulting in therapy-related MDS, rapid disease recurrence after allogeneic stem cell transplantation, and an arbitrary division between MDS and acute myeloid leukemia. In addition, barriers to accrual that are common to other oncology populations, such as difficulty traveling to clinical trial enrollment sites and narrow trial eligibility criteria, also prevent patients with MDS from enrolling in studies. Collectively these barriers must be assessed systematically, and creative solutions are needed to improve outcomes for this needy patient population.
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Affiliation(s)
- David P Steensma
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrew M Brunner
- Division of Hematology and Medical Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Amy E DeZern
- Division of Hematological Malignancies, Sidney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | | | - Rami S Komrokji
- Moffitt Cancer Center, Malignant Hematology Department, Tampa, Florida
| | - Olatoyosi S Odenike
- Division of Hematology and Medical Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Gail J Roboz
- Division of Hematology & Oncology, Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Michael R Savona
- Division of Hematology & Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee
| | - Richard M Stone
- Division of Hematological Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mikkael A Sekeres
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
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Shallis RM, Chokr N, Stahl M, Pine AB, Zeidan AM. Immunosuppressive therapy in myelodysplastic syndromes: a borrowed therapy in search of the right place. Expert Rev Hematol 2018; 11:715-726. [PMID: 30024293 DOI: 10.1080/17474086.2018.1503049] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Myelodysplastic syndromes (MDS) encompass a heterogenous collection of clonal hematopoietic stem cell disorders defined by dysregulated hematopoiesis, peripheral cytopenias, and a risk of leukemic progression. Increasing data support the role of innate and adaptive immune pathways in the pathogenesis and disease course of MDS. The role of immunosuppressive therapy has an established role in the treatment of other hematologic diseases, such as aplastic anemia whose pathogenesis is postulated to reflect that of MDS with regards to many aspects of immune activation. Areas covered: This paper discusses the current understanding of immune dysregulation as it pertains to MDS, the clinical experience with immunosuppressive therapy in the management of MDS, as well as future prospects which will likely improve therapeutic options and outcomes for patients with MDS. Expert commentary: Though limited by paucity of high quality data, immunomodulatory and immunosuppressive therapies for the treatment of MDS have shown meaningful clinical activity in selected patients. Continued clarification of the immune pathways that are dysregulated in MDS and establishing predictors for clinical benefit of immunosuppressive therapy are vital to improve the use and outcomes with these therapies.
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Affiliation(s)
- Rory M Shallis
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Nora Chokr
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Maximilian Stahl
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Alexander B Pine
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA
| | - Amer M Zeidan
- a Division of Hematology/Medical Oncology, Department of Medicine , Yale University School of Medicine , New Haven , USA.,b Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center , Yale University , New Haven , USA
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Counseling patients with higher-risk MDS regarding survival with azacitidine therapy: are we using realistic estimates? Blood Cancer J 2018; 8:55. [PMID: 29891916 PMCID: PMC5995881 DOI: 10.1038/s41408-018-0081-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 03/21/2018] [Accepted: 04/03/2018] [Indexed: 11/30/2022] Open
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Shallis RM, Zeidan AM. More is less, less is more, or does it really matter? The curious case of impact of azacitidine administration schedules on outcomes in patients with myelodysplastic syndromes. BMC HEMATOLOGY 2018; 18:4. [PMID: 29435332 PMCID: PMC5796398 DOI: 10.1186/s12878-018-0095-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 01/04/2018] [Indexed: 12/16/2022]
Abstract
Myelodysplastic syndromes (MDS) encompass a diverse group of hematologic disorders characterized by ineffective and malignant hematopoiesis, peripheral cytopenias and significantly increased risk of progression to acute myeloid leukemia (AML). The hypomethylating agents (HMA) azacitidine and decitabine induce meaningful clinical responses in a significant subset of patients with MDS. Though never compared directly with decitabine, only azacitidine has improved overall survival (OS) compared to conventional care in a randomized trial in patients with higher-risk MDS. The azacitidine regimen used in this pivotal trial AZA-001 included administration at 75 mg/m2/day for 7 consecutive days in 28-day cycles (7-0 regimen). Given the logistical difficulties of weekend administration in the 7-0 regimen, as well as in efforts to improve response rates, alternative dosing schedules have been used. In a typical 28-day cycle, administration schedules of 3, 5, 10, and (with the oral version of azacitidine) 14 and 21 days have been used in clinical trials. Most trials that evaluated alternative administration schedules of azacitidine did so in lower-risk MDS and did not directly compare to the 7-0 schedule. Given the lack of randomized prospective studies comparing the 7-0 schedule to the other regimens of azacitidine in MDS, Shapiro et al. conducted a systematic review in an attempt to answer this question. Here we place the findings of this important work in clinical context and review the current knowledge and unresolved issues regarding the impact of administration schedules of azacitidine on outcomes of patients with both lower-risk and higher-risk MDS.
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Affiliation(s)
- Rory M. Shallis
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT USA
- Section of Hematology, Department of Internal Medicine, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT 06520-8028 USA
| | - Amer M. Zeidan
- Department of Internal Medicine, School of Medicine, Yale University, New Haven, CT USA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT USA
- Section of Hematology, Department of Internal Medicine, Yale University, 333 Cedar Street, PO Box 208028, New Haven, CT 06520-8028 USA
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Long-term survival of older patients with MDS treated with HMA therapy without subsequent stem cell transplantation. Blood 2017; 131:818-821. [PMID: 29259002 DOI: 10.1182/blood-2017-10-811729] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/15/2017] [Indexed: 12/23/2022] Open
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Zeidan AM. Hypomethylating agents in myelodysplastic syndromes and population-level outcomes: a changing landscape or a small dent? Leuk Lymphoma 2017; 59:1030-1032. [PMID: 28952833 DOI: 10.1080/10428194.2017.1382700] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Amer M Zeidan
- a Department of Internal Medicine, School of Medicine , Yale University , New Haven , CT , USA.,b Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University , New Haven , CT , USA
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