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Graff Z, Wachter F, Eapen M, Lehmann L, Cooper T. Navigating Treatment Options and Communication in Relapsed Pediatric AML. Am Soc Clin Oncol Educ Book 2024; 44:e438690. [PMID: 38862135 DOI: 10.1200/edbk_438690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Despite improved outcomes in newly diagnosed pediatric AML, relapsed disease remains a therapeutic challenge. Factors contributing to slow progress in improving outcomes include inherent challenges in pediatric clinical trial accrual and the scarcity of novel targeted/immunotherapy agents available for pediatric development. This paradigm is changing, however, as international collaboration grows in parallel with the development of promising targeted agents. In this review, we discuss the therapeutic landscape of relapsed pediatric AML, including conventional chemotherapy, targeted therapies, and the challenges of drug approvals in this patient population. We highlight current efforts to improve communication among academia, industry, and regulatory authorities and discuss the importance of international collaboration to improve access to new therapies. Among the therapeutic options, we highlight the approach to second hematopoietic stem cell transplant (HSCT) and discuss which patients are most likely to benefit from this potentially curative intervention. Importantly, we acknowledge the challenges in providing these high-risk interventions to our patients and their families and the importance of shared communication and decision making when considering early-phase clinical trials and second HSCT.
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Affiliation(s)
- Zachary Graff
- Department of Pediatrics, Division of Hematology, Oncology, and BMT, Medical College of Wisconsin, Milwaukee, WI
| | - Franziska Wachter
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mary Eapen
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Leslie Lehmann
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Todd Cooper
- Department of Pediatrics, Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, WA
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Ceolin V, Ishimaru S, Karol SE, Bautista F, Goemans BF, Gueguen G, Willemse M, Di Laurenzio L, Lukin J, van Tinteren H, Locatelli F, Petit A, Tomizawa D, Norton A, Kaspers G, Reinhardt D, Tasian SK, Nichols G, Kolb EA, Zwaan CM, Cooper TM. The PedAL/EuPAL Project: A Global Initiative to Address the Unmet Medical Needs of Pediatric Patients with Relapsed or Refractory Acute Myeloid Leukemia. Cancers (Basel) 2023; 16:78. [PMID: 38201506 PMCID: PMC10778551 DOI: 10.3390/cancers16010078] [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: 11/20/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
The prognosis of children with acute myeloid leukemia (AML) has improved incrementally over the last few decades. However, at relapse, overall survival (OS) is approximately 40-50% and is even lower for patients with chemo-refractory disease. Effective and less toxic therapies are urgently needed for these children. The Pediatric Acute Leukemia (PedAL) program is a strategic global initiative that aims to overcome the obstacles in treating children with relapsed/refractory acute leukemia and is supported by the Leukemia and Lymphoma Society in collaboration with the Children's Oncology Group, the Innovative Therapies for Children with Cancer consortium, and the European Pediatric Acute Leukemia (EuPAL) foundation, amongst others. In Europe, the study is set up as a complex clinical trial with a stratification approach to allocate patients to sub-trials of targeted inhibitors at relapse and employing harmonized response and safety definitions across sub-trials. The PedAL/EuPAL international collaboration aims to determine new standards of care for AML in a first and second relapse, using biology-based selection markers for treatment stratification, and deliver essential data to move drugs to front-line pediatric AML studies. An overview of potential treatment targets in pediatric AML, focused on drugs that are planned to be included in the PedAL/EuPAL project, is provided in this manuscript.
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Affiliation(s)
- Valeria Ceolin
- Princess Máxima Center for Pediatric Oncology, 3584 Utrecht, The Netherlands; (V.C.); (S.I.); (F.B.); (B.F.G.); (M.W.); (H.v.T.); (G.K.)
- Department of Pediatric Hematology/Oncology, Regina Margherita Children’s Hospital, University of Turin, 10126 Turin, Italy
| | - Sae Ishimaru
- Princess Máxima Center for Pediatric Oncology, 3584 Utrecht, The Netherlands; (V.C.); (S.I.); (F.B.); (B.F.G.); (M.W.); (H.v.T.); (G.K.)
| | - Seth E. Karol
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
| | - Francisco Bautista
- Princess Máxima Center for Pediatric Oncology, 3584 Utrecht, The Netherlands; (V.C.); (S.I.); (F.B.); (B.F.G.); (M.W.); (H.v.T.); (G.K.)
- The Innovative Therapies for Children with Cancer (ITCC) Consortium, 94805 Paris, France
| | - Bianca Frederika Goemans
- Princess Máxima Center for Pediatric Oncology, 3584 Utrecht, The Netherlands; (V.C.); (S.I.); (F.B.); (B.F.G.); (M.W.); (H.v.T.); (G.K.)
| | - Gwenaëlle Gueguen
- Center of Clinical Investigations, INSERM CIC 1426, Robert Debre Hospital, University of Paris, 75019 Paris, France;
| | - Marieke Willemse
- Princess Máxima Center for Pediatric Oncology, 3584 Utrecht, The Netherlands; (V.C.); (S.I.); (F.B.); (B.F.G.); (M.W.); (H.v.T.); (G.K.)
| | - Laura Di Laurenzio
- Leukemia & Lymphoma Society, Rye Brook, NY 10573, USA; (L.D.L.); (J.L.); (G.N.)
| | - Jennifer Lukin
- Leukemia & Lymphoma Society, Rye Brook, NY 10573, USA; (L.D.L.); (J.L.); (G.N.)
| | - Harm van Tinteren
- Princess Máxima Center for Pediatric Oncology, 3584 Utrecht, The Netherlands; (V.C.); (S.I.); (F.B.); (B.F.G.); (M.W.); (H.v.T.); (G.K.)
| | - Franco Locatelli
- Department of Hematology/Oncology and Cell and Gene Therapy, IRCCS Bambino Gesù Children’s Hospital, Catholic University of the Sacred Heart, 00163 Rome, Italy;
| | - Arnaud Petit
- Department of Pediatric Hematology and Oncology, Hôpital Armand Trousseau, Assistance Publique Hôpitaux de Paris, APHP Sorbonne Université, 75012 Paris, France;
| | - Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children’s Cancer Center, National Center for Child Health and Development, Tokyo 104-0045, Japan;
| | - Alice Norton
- Birmingham Children’s Hospital, Birmingham B4 6NH, UK;
| | - Gertjan Kaspers
- Princess Máxima Center for Pediatric Oncology, 3584 Utrecht, The Netherlands; (V.C.); (S.I.); (F.B.); (B.F.G.); (M.W.); (H.v.T.); (G.K.)
- Emma Children’s Hospital, Amsterdam UMC, Vrije Universiteit, 1105 Amsterdam, The Netherlands
| | - Dirk Reinhardt
- Department of Pediatric Hematology/Oncology, Pediatrics III, University Hospital of Essen, 45147 Essen, Germany;
| | - Sarah K. Tasian
- Division of Oncology, Children’s Hospital of Philadelphia, Department of Pediatrics, School of Medicine, Center for Childhood Cancer Research, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Gwen Nichols
- Leukemia & Lymphoma Society, Rye Brook, NY 10573, USA; (L.D.L.); (J.L.); (G.N.)
| | - Edward Anders Kolb
- Leukemia & Lymphoma Society, Rye Brook, NY 10573, USA; (L.D.L.); (J.L.); (G.N.)
| | - Christian Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, 3584 Utrecht, The Netherlands; (V.C.); (S.I.); (F.B.); (B.F.G.); (M.W.); (H.v.T.); (G.K.)
- The Innovative Therapies for Children with Cancer (ITCC) Consortium, 94805 Paris, France
- Department of Pediatric Hematology/Oncology, Erasmus University MC-Sophia Children’s Hospital, 3015 Rotterdam, The Netherlands
| | - Todd Michael Cooper
- Division of Hematology/Oncology, Seattle Children’s Hospital, University of Washington, Seattle, DC 98105, USA;
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Pearson ADJ, Zwaan CM, Kolb EA, Karres D, Guillot J, Kim SY, Marshall L, Tasian SK, Smith M, Cooper T, Adamson PC, Barry E, Benettaib B, Binlich F, Borgman A, Brivio E, Capdeville R, Delgado D, Faller D, Fogelstrand L, Fraenkel PG, Hasle H, Heenen D, Kaspers G, Kieran M, Klusmann JH, Lesa G, Ligas F, Mappa S, Mohamed H, Moore A, Morris J, Nottage K, Reinhardt D, Scobie N, Simko S, Winkler T, Norga K, Reaman G, Vassal G. Paediatric Strategy Forum for medicinal product development for acute myeloid leukaemia in children and adolescents: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration. Eur J Cancer 2020; 136:116-129. [PMID: 32688206 PMCID: PMC7789799 DOI: 10.1016/j.ejca.2020.04.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Abstract
Purpose: The current standard-of-care for front-line therapy for acute myeloid leukaemia (AML) results in short-term and long-term toxicity, but still approximately 40% of children relapse. Therefore, there is a major need to accelerate the evaluation of innovative medicines, yet drug development continues to be adult-focused. Furthermore, the large number of competing agents in rare patient populations requires coordinated prioritisation, within the global regulatory framework and cooperative group initiatives. Methods: The fourth multi-stakeholder Paediatric Strategy Forum focused on AML in children and adolescents. Results: CD123 is a high priority target and the paediatric development should be accelerated as a proof-of-concept. Efforts must be coordinated, however, as there are a limited number of studies that can be delivered. Studies of FLT3 inhibitors in agreed paediatric investigation plans present challenges to be completed because they require enrolment of a larger number of patients than actually exist. A consensus was developed by industry and academia of optimised clinical trials. For AML with rare mutations that are more frequent in adolescents than in children, adult trials should enrol adolescents and when scientifically justified, efficacy data could be extrapolated. Methodologies and definitions of minimal residual disease need to be standardised internationally and validated as a new response criterion. Industry supported, academic sponsored platform trials could identify products to be further developed. The Leukaemia and Lymphoma Society PedAL/EUpAL initiative has the potential to be a major advance in the field. Conclusion: These initiatives continue to accelerate drug development for children with AML and ultimately improve clinical outcomes.
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Affiliation(s)
| | - C Michel Zwaan
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | - Julie Guillot
- Fred Hutchinson Cancer Research Center, Leukaemia Lymphoma Society, Target Paediatric AML, USA
| | | | - Lynley Marshall
- Royal Marsden Hospital, The Institute of Cancer Research, UK
| | - Sarah K Tasian
- Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, USA
| | - Malcolm Smith
- National Institutes of Health, National Cancer Institute, USA
| | | | - Peter C Adamson
- Sanofi US, Emeritus Professor of Paediatrics & Pharmacology, Perelman School of Medicine, University of Pennsylvania, USA
| | | | | | | | | | - Erica Brivio
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | | | - Linda Fogelstrand
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | | | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital, Denmark
| | | | - Gertjan Kaspers
- Princess Máxima Center, Utrecht, the Netherlands; Erasmus MC, Rotterdam, the Netherlands; ITCC, the Netherlands
| | | | | | - Giovanni Lesa
- European Medicines Agency, Amsterdam, the Netherlands
| | - Franca Ligas
- European Medicines Agency, Amsterdam, the Netherlands
| | | | | | - Andrew Moore
- Queensland Children's Hospital, Brisbane, Australia
| | | | | | | | | | | | | | - Koen Norga
- Universitair Ziekenhuis Antwerpen, FAMHP, Belgium
| | | | - Gilles Vassal
- ACCELERATE/ITCC, Belgium; Gustave Roussy Cancer Centre, France
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