Advance and stagnation in the treatment of patients with lymphoma and myeloma: Analysis using population-based cancer registry data in Japan from 1993 to 2006

Mediation of Ferroptosis Suppressor Protein 1 Expression via 4-Hydroxy-2-Nonenal Accumulation Contributes to Acquisition of Resistance to Apoptosis and Ferroptosis in Diffuse Large B-Cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma. New therapeutic strategies are needed for the treatment of refractory DLBCL. 4-Hydroxy-2-nonenal (4-HNE) is a cytotoxic lipid peroxidation marker, which alters intracellular signaling and induces genetic mutations. Lipid peroxidation is associated with nonapoptotic cell death, called ferroptosis. However, the relationship between 4-HNE accumulation and feroptotic regulators in DLBCL has not been fully evaluated. Here, we aimed to evaluate the accumulation of lipid peroxide and the expression of ferroptosis suppressor protein 1 (FSP1) in DLBCL using immunohistochemistry. We found a significant increase in the expression of FSP1 in cases with nuclear 4-HNE accumulation (P = .021). Both nuclear and cytoplasmic 4-HNE accumulation and FSP1 positivity were independent predictors of worse prognosis. In vitro exposure to 4-HNE resulted in its concentration- and time-dependent intracellular accumulation and increased expression of FSP1. Furthermore, short-term (0.25 and 1.0 μM) or long-term (0.25 μM) exposure to 4-HNE induced resistance to not only apoptosis but also ferroptosis. Taken together, regulation of FSP1 through 4-HNE accumulation may attenuate resistance to cell death in treatment-resistant DLBCL and might help develop novel therapeutic strategies for refractory DLBCL.

The combination of brentuximab vedotin and chidamide synergistically suppresses the proliferation of T-cell lymphoma cells through the enhancement of apoptosis

PURPOSE

Peripheral T-cell lymphoma (PTCL) is an aggressive disease with a poor prognosis. Brentuximab vedotin (BV), an anti-CD30 monoclonal antibody linked to a microtubule-disrupting agent, has been approved for the treatment of PTCL. We evaluated a new effective combination partner of BV using non-clinical approaches that could potentially identify agents capable of improving survival times for patients with PTCL.

METHODS

A high-throughput screening test was used to select the most synergistic partner of BV from 14 candidate drugs that were under development or available in clinical practice for PTCL. HH cells, originating from an aggressive cutaneous T-cell lymphoma, were used as an experimental model of PTCL. Apoptotic effects of the synergistic partner of BV were further investigated in vitro and in vivo using HH-cell xenograft mice.

RESULTS

Chidamide (tucidinostat), a novel histone deacetylase inhibitor, was found to have the greatest synergistic effect with BV on HH cells. The combined effects of chidamide and BV were demonstrated in a study of HH-cell xenograft mice; mean tumor size following combined treatment was 22% of that observed in the control group, compared with 71% and 58% following chidamide and BV monotherapy, respectively. Further investigations in vitro and in vivo revealed that the levels of an anti-apoptotic protein, Bcl-2, and a rate-limiting factor of DNA replication, CDC45, were reduced in HH cells treated with chidamide combined with BV compared with the control group.

CONCLUSION

The use of chidamide in conjunction with BV may positively affect and enhance T-cellular apoptotic pathways without offsetting each other.

Conditional survival in multiple myeloma and impact of prognostic factors over time

Overall survival estimates from diagnosis are valuable for guiding treatment, but do not consider the years already survived. Conditional survival (CS) provides dynamic survival predictions over time. This study was conducted to estimate CS at 1-8 years from diagnosis and the impact of baseline prognostic factors on CS in multiple myeloma (MM) patients. This is a retrospective study including 2556 MM patients diagnosed between 2004 and 2019. CS (t | s) was defined as the probability of surviving t years given survival of s years. Median age was 64 years. Median follow-up was 6.2 years and median overall survival from diagnosis was 7.5 years. The 5-year CS estimates at s = 0, 1, 2, 3, and 5 years were 0.64, 0.61, 0.61, 0.61, and 0.58, respectively. On multivariate analysis, age ≥ 65 and proteasome inhibitor+immunomodulatory-based induction were associated with decreased survival and increased survival, respectively, retained at 5 years. The adverse impact of 1q gain/amplification, high-risk IgH translocation, and ISS-3 was significant at 1 and 3 years but not 5 years. Chromosome 17 abnormality was associated with decreased survival only at 1 year. Among MM patients, 5-year CS was stable at 1-5 years from diagnosis. The prognostic impact of high-risk cytogenetic factors decreased with additional years survived.

Epidemiological Characteristics of Peripheral T-Cell Lymphoma: A Population-Based Study

Objects

The aim of this study is to explore the epidemiological characteristics of peripheral T-cell lymphoma in Beijing.

Methods

 All data were extracted from the Beijing Cancer Registry database from January 1, 2007, to December 31, 2018. Segi’s World Standard Population was used to estimate the age-standardized rate (ASR). Changes in trends were examined using joinpoint regression analysis. The observed survival was estimated by the Kaplan–Meier method. Relative survival was calculated using Ederer II and standardized using the Brenner method and International Cancer Survival Standard (ICSS) group 1 age structure. Stratified by gender, area, and histological type, incidence, mortality, and age of onset trends were observed in Beijing.

Results

 In Beijing, there were 801 new cases and 463 deaths of T-cell lymphoma from 2007 to 2018. Peripheral T-cell lymphoma not otherwise specified (PTCL-NOS) was the most prevalent subtype (37.45%), followed by angioimmunoblastic T-cell lymphoma (AITL; 20.35%), NK/T-cell lymphoma (NK/TCL; 17.60%), and anaplastic large cell lymphoma (ALCL; 10.24%). The crude incidence and mortality rates were 0.52 and 0.30 per 100,000 person-years, respectively, whereas the age-standardized incidence and mortality rates (ASIR and ASMR) were 0.35 and 0.18 per 100,000 person-years, respectively. Both ASIR and ASMR were more prevalent in men (0.48 and 0.24 per 100,000) and urban area (0.38 and 0.19 per 100,000) than in women (0.22 and 0.11 per 100,000) and rural area (0.30 and 0.15 per 100,000). The average annual percentage change (AAPC) of ASIR and ASMR was 5.72% (95% confidence interval (CI): 1.79%–9.81%) and 4.35% (95% CI: −0.09%–8.99%), respectively. The age-specific incidence rate increased with age and peaked at the age groups of 10–14 and 80–84. The mean and median age of onset increased between 2007 and 2018. In addition, it decreased after the age of onset was age standardization (β = −0.41, P = 0.26). The 5-year age-standardized relative survival was 39.02% for all patients, 58.14% for NK/TCL, 57.60% for ALCL, 31.38% for AITL, and 29.18% for PTCL-NOS.

Conclusions

 T-cell lymphoma incidence was rising, but survival was dismal in Beijing, indicating the need for improved early diagnosis and standardized treatment.

Cost drivers associated with diffuse large B-cell lymphoma (DLBCL) in Japan: A structural equation model (SEM) analysis

Diffuse large B-cell lymphoma (DLBCL) is an aggressive non-Hodgkin’s lymphoma of increasing prevalence in Japan. However, patients with relapsed or refractory disease to first line treatment (rrDLBCL) have been found to shoulder greater economic burden and have poor survival with subsequent lines of therapy. The relative impact of individual patient attributes on total medical cost among patients with rrDLBCL receiving second or third line (2L/3L) therapy was assessed. Structural equation modelling was used to identify potential cost drivers of total medical costs incurred by treatment and procedures in a Japanese retrospective claims database. From the database, rrDLBCL patients on 2L or 3L of treatment were grouped into respective cohorts. The mean [median] (SD) total medical cost of care for the 2L cohort was 73,296.40 [58,223.11] (58,409.79) US dollars (USD) and 75,238.35 [60,477.31] (59,583.66) USD for the 3L cohort. The largest total effect on medical cost in both cohorts was length of hospital stay (LOS) (β: 0.750 [95%CI: 0.728, 0.772] vs β: 0.762 [95%CI: 0.729, 0.794]). Length of hospital stay and potential heart disease complications due to line of treatment were the primary drivers of total cost for patients who had received at least 2L or 3L therapy for rrDLBCL.

Increased incidence of adult T cell leukemia-lymphoma and peripheral T cell lymphoma-not otherwise specified with limited improvement in overall survival: a retrospective analysis using data from the population-based Osaka Cancer Registry

Peripheral T cell lymphomas (PTCL) are a heterogeneous group of non-Hodgkin lymphomas with poor outcomes. Adult T cell leukemia-lymphoma (ATL) and PTCL-not otherwise specified (PTCL-NOS)-are 2 common mature T cell lymphomas in Japan. Since it is unclear whether novel agents and treatment strategies incorporating hematopoietic cell transplantation have contributed to improved clinical outcomes in the real world, we performed a retrospective analysis using data from the population-based Osaka Cancer Registry. From 1977 to 2014, 1274 and 1143 patients were diagnosed with ATL or PTCL-NOS, respectively. Recently, the incidence of both diseases has gradually increased, and the age at diagnosis has risen. The 3-year overall survival (OS) rates in ATL patients were 12.0% in era 1 (1977-1999), 12.4% in era 2 (2000-2008), and 17.5% in era 3 (2009-2014) (P < 0.001). The 3-year OS rates in PTCL-NOS patients were 27.6% in era 1, 36.2% in era 2, and 35.0% in era 3 (P = 0.049). In conclusion, the incidences of ATL and PTCL-NOS have been increasing, particularly in elderly individuals. Clinical outcomes have improved in recent decades but are still unsatisfactory in both diseases. Thus, effective new treatment strategies incorporating novel agents are needed to further improve clinical outcomes in patients with ATL and PTCL-NOS.

Nationwide claims database analysis of treatment patterns, costs and survival of Japanese patients with diffuse large B-cell lymphoma

Limited data are available regarding treatment patterns, healthcare resource utilization (HCRU), treatment costs and clinical outcomes for patients with diffuse large B-cell lymphoma (DLBCL) in Japan. This retrospective database study analyzed the Medical Data Vision database for DLBCL patients who received treatment during the identification period from October 1 2008 to December 31 2017. Among 6,965 eligible DLBCL patients, 5,541 patients (79.6%) received first-line (1L) rituximab (R)-based therapy, and then were gradually switched to chemotherapy without R in subsequent lines of therapy. In each treatment regimen, 1L treatment cost was the highest among all lines of therapy. The major cost drivers i.e. total direct medical costs until death or censoring across all regimens and lines of therapy were from the 1L regimen and inpatient costs. During the follow-up period, DLBCL patients who received a 1L R-CHOP regimen achieved the highest survival rate and longest time-to-next-treatment, with a relatively low mean treatment cost due to lower inpatient healthcare resource utilization and fewer lines of therapy compared to other 1L regimens. Our retrospective analysis of clinical practices in Japanese DLBCL patients demonstrated that 1L treatment and inpatient costs were major cost contributors and that the use of 1L R-CHOP was associated with better clinical outcomes at a relatively low mean treatment cost.

Risk of disease recurrence and survival in patients with multiple myeloma: A German Study Group analysis using a conditional survival approach with long-term follow-up of 815 patients

BACKGROUND

Unlike the traditional method of overall survival prediction in patients with cancer, conditional survival predicts the survival of patients dynamically throughout the course of disease, identifying how a prognosis evolves over time.

METHODS

The authors assessed 815 consecutive patients with multiple myeloma through the German Study Group on Multiple Myeloma (Deutsche Studiengruppe Multiples Myelom; DSMM) incentive. Over 10 variables, including patient-specific and multiple myeloma-specific parameters, were analyzed at the time of initial diagnosis and repeatedly during follow-up. The probability of survival for another 5 years was calculated according to disease-related and host-related risks. Multivariate Cox models were used to determine baseline and updated prognostic factors for survival.

RESULTS

The median follow-up and overall survival were 10.3 years and 5.1 years, respectively. When comparing 5-year conditional survival probabilities from the data derived at the time of initial diagnosis with those updated over time, substantially differing prognoses were observed when follow-up data were used. Multivariate Cox regression models for cohorts surviving 0 to 5 years demonstrated hazard ratios (HRs) for patients aged <60 years, 60 to 69 years, and >70 years of 1, 1.68, and 3.17, respectively. These HRs for age were found to decline for patients surviving 5 years, as well as for those with advanced stages of disease (II/III) and unfavorable cytogenetics, whereas progressive disease remained an important factor in patients surviving 1 year, 3 years, and 5 years, with HRs of 1.85, 2.11, and 2.14, respectively.

CONCLUSIONS

To the authors' knowledge, the current study is the first analysis of conditional survival in patients with multiple myeloma using both baseline and follow-up risk parameters, demonstrating that regular risk assessment throughout the course of disease and complete follow-up provide a more reliable conditional survival estimation than baseline assessment alone.

Analysis of Japanese patients from the AUGMENT phase III study of lenalidomide + rituximab (R2) vs. rituximab + placebo in relapsed/refractory indolent non-Hodgkin lymphoma

Patients with indolent non-Hodgkin lymphoma (iNHL) typically respond to first-line immunochemotherapy, but relapse is common. Treatment options for relapsed iNHL include chemotherapy ± rituximab and rituximab monotherapy. Lenalidomide plus rituximab (R²) is an immunomodulatory regimen that enhances rituximab-mediated cytotoxicity and improves clinical activity in iNHL. AUGMENT was a double-blind phase III randomized trial of R² vs. rituximab + placebo (R-placebo) in patients with relapsed/refractory follicular lymphoma or marginal zone lymphoma who were not refractory to rituximab. The primary endpoint was progression-free survival (PFS). Data reported here focus on Japanese patients from AUGMENT and reflect 36 patients (n = 18, each group). PFS was superior in the R² group, HR = 0.32 (95% CI 0.11-0.96). Median PFS was not reached (95% CI 19.7-NE) in the R² group vs. 16.5 months (95% CI 11.3-30.6) in the R-placebo group. Grade 3/4 adverse events were more frequent in patients treated with R² (67%) than with R-placebo (22%), primarily attributable to increased neutropenia (50% vs 17%). R² resulted in significantly longer median PFS than R-placebo in Japanese patients with R/R iNHL, and the efficacy and the safety profile of R² were similar to those reported in the global population.

Rapidly changing myeloma epidemiology in the general population: Increased incidence, older patients, and longer survival

The incidence of multiple myeloma is characterized by a steep increase with advancing age. Dramatic improvements in survival have been reported in clinical trials; however, elderly patients are generally underrepresented in these. The aims of this study are to review patterns of incidence and survival in multiple myeloma in the general population. We searched PubMed for population-based studies on trends in incidence and survival published between January 1, 2000 and June 30, 2017 and based on regional or national cancer registries and report the following results of the review. The age-adjusted incidence of multiple myeloma has increased during the second half of the twentieth century in some countries but remained stable in areas with high case ascertainment and access to universal medical care. The crude incidence is increasing globally due to an aging population. Survival rates have improved, and 5-year relative survival rates are now around 50% and over 60% in patients 65-70 years or younger. Preliminary data suggest a 3-fold increase in the prevalence of multiple myeloma. We conclude that the number of multiple myeloma patients is increasing in the general population due to (i) aging populations and (ii) more patients living longer due to modern drugs.

[Comparison of allogeneic or autologous hematopoietic stem cell transplant for high-risk peripheral T cell lymphomas]

Objective: To evaluate the efficacy of auto-HSCT and allo-HSCT in the treatment of high risk peripheral T cell lymphoma (PTCL). Methods: From July 2007 to July 2014, 60 cases of high risk PTCL were analyzed retrospectively. Results: All 60 patients were at high risk group (carried with IPI≥3), with a median age of 31 (12-58) years old. Of the 60 cases, 22 were PTCL-not otherwise specified (PTCL-NOS), 22 ALK negative anaplastic large cell lymphoma (ALK-negative ALCL) and 16 angioimmunoblastic T-cell lymphoma (AITL). Twenty-one patients (21/60) received allo-HSCT, and thirty-nine (39/60) auto-HSCT. Before receiving transplantation, 40/60 patients were in complete remission (CR), 2/60 patients partial remission (PR) and 18/60 patients not remission (NR). In the 40 CR patients before transplant, 10 patients received allo-HSCT and 30 patients auto-HSCT, respectively. In the 20 PR/NR patients before transplant, 11 patients received allo-HSCT and 9 patients auto-HSCT, respectively. After a median follow-up of 39 (range 1-96) months, the K-M analysis showed that the 5-year PFS by auto-HSCT and allo-HSCT were 61% and 60% (P=0.724) , respectively. The 5-year OS by auto-HSCT and allo-HSCT were 62% and 61% (P=0.724) , respectively. There were no statistically significant differences between auto-HSCT and allo-HSCT. And the cumulative TRM of auto-HSCT and allo-HSCT were 22.7% and 41.8% (P=0.250) , respectively within 5-years after transplantation. At the end of the last follow-up, 7 and 2 patients relapsed in auto-HSCT and allo-HSCT groups respectively, the 5-year cumulative recurrence rates of auto-HSCT and allo-HSCT transplantation were 37.2% and 10.1% (P=0.298), respectively. Conclusion: There was no significant difference in the long-term survival between auto-HSCT and allo-HSCT for high risk PTCL patients. Outcome by allo-HSCT may be better for NR patients.

Contributions of Subtypes of Non-Hodgkin Lymphoma to Mortality Trends

BACKGROUND

Non-Hodgkin lymphoma (NHL) comprises distinct tumor subtypes. Although mortality from NHL overall has changed dramatically in the United States over time, little is known about trends for subtypes, because death certificates do not record this information.

METHODS

Using data from U.S. Surveillance, Epidemiology, and End Results (SEER) areas, we assessed NHL mortality rates and mapped NHL deaths to incident NHL cases in SEER cancer registries. This allowed us to evaluate population-level mortality trends attributed to specific NHL subtypes (incidence-based mortality; IBM). We also describe NHL incidence and survival after NHL diagnosis by calendar year. We used Joinpoint to identify years when IBM and incidence rate trends changed slope.

RESULTS

Overall NHL mortality rates increased during 1975-1997, peaking at 10.9 per 100,000 person-years, then decreased subsequently in 1997-2011. Overall IBM rates mirror this trend during 1990-2011. For B-cell NHL subtypes, IBM rates decreased beginning in the mid-1990s, with yearly declines of -3.0% for diffuse large B-cell lymphoma (DLBCL), -2.7% for chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), and -5.3% for follicular lymphoma. Incidence rates for these subtypes did not decrease until after 2003. Corresponding 5-year cancer-specific survival increased dramatically over time for DLBCL (from 37%-66%), CLL/SLL (69%-84%), and follicular lymphoma (69%-82%). IBM for peripheral T-cell lymphoma was flat during 2006-2011, although incidence increased.

CONCLUSIONS

Mortality due to three common B-cell NHL subtypes has fallen over time in the United States.

IMPACT

This decline reflects better survival after NHL diagnosis, likely from improved therapies, because the decline in NHL incidence occurred later.