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Treating Older Patients with Chronic Lymphocytic Leukemia: A Personalized Approach. Drugs Aging 2019; 36:841-851. [PMID: 31055788 DOI: 10.1007/s40266-019-00678-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Median age at diagnosis for patients with chronic lymphocytic leukemia (CLL) is 72 years, and the number of older individuals affected by this condition is predicted to increase in the future as populations age. Contrary to common assumptions, CLL significantly affects the life expectancy of older individuals, frequently presenting at a more advanced stage and with more unfavorable features than in the younger population. Therefore, identifying the optimal treatment for these patients is a priority. Older patients with CLL are usually classified as fit, non-fit, or frail based on performance status and comorbidities, and several assessment tools can be used to make these evaluations. While supportive care is appropriate for frail patients, the remaining patients should be treated when indication criteria are met. Treatment options include chemoimmunotherapy, monoclonal antibody-based approaches (such as the use of rituximab, ofatumumab, or obinutuzumab) and, more recently, small molecules (such as ibrutinib, idelalisib, and venetoclax). The choice of treatment is guided by the patient's performance status and co-morbidities and by the disease characteristics, such as chromosomal and molecular abnormalities, and in patients with recurrent disease also by the type of prior regimen, their tolerability, and duration of response.
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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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Kocsik AS, Klein DE, Liedke M, Kaunzner UW, Nealon NM, Gauthier SA, Vartanian T, Perumal JS. Induction of disease remission with one cycle of alemtuzumab in relapsing–remitting MS. J Neurol 2018; 265:1226-1229. [DOI: 10.1007/s00415-018-8845-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/21/2018] [Accepted: 03/22/2018] [Indexed: 12/16/2022]
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Tallantyre EC, Whittam DH, Jolles S, Paling D, Constantinescu C, Robertson NP, Jacob A. Correction to: Secondary antibody deficiency: a complication of anti-CD20 therapy for neuroinflammation. J Neurol 2018; 265:1123. [PMID: 29627939 PMCID: PMC5937881 DOI: 10.1007/s00415-018-8833-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- E C Tallantyre
- University Hospital of Wales, Cardiff, UK.,Cardiff University School of Medicine, Cardiff, UK
| | - D H Whittam
- The Walton Centre NHS Trust, Liverpool, L97LJ, UK.,University of Liverpool, Liverpool, UK
| | - S Jolles
- University Hospital of Wales, Cardiff, UK.,Cardiff University School of Medicine, Cardiff, UK
| | - D Paling
- NIHR Sheffield Biomedical Research Centre (Translational Neuroscience), Sheffield, UK.,Royal Hallamshire Hospital, Sheffield, UK
| | | | - N P Robertson
- University Hospital of Wales, Cardiff, UK.,Cardiff University School of Medicine, Cardiff, UK
| | - A Jacob
- The Walton Centre NHS Trust, Liverpool, L97LJ, UK. .,University of Liverpool, Liverpool, UK.
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Korycka-Wołowiec A, Wołowiec D, Robak T. The safety profile of monoclonal antibodies for chronic lymphocytic leukemia. Expert Opin Drug Saf 2016; 16:185-201. [PMID: 27880061 DOI: 10.1080/14740338.2017.1264387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Monoclonal antibodies (MoAbs), non-chemotherapeutic agents targeting the antigens present on chronic lymphocytic leukemia (CLL) lymphocytes, are being implemented increasingly more often as treatment options. Areas covered: This article reviews the similarities and differences in the structure, mechanism of action, efficacy and safety profile of commercially-available MoAbs and prevents new agents potentially useful for CLL treatment. Publications in English before June 2016 were surveyed on the MEDLINE database for articles. Proceedings of the American Society of Hematology held during the last five years were also included. Expert opinion: MoAbs, especially those targeting CD20, are highly effective biological options for first-line and salvage treatment of CLL, particularly in chemoimmunotherapy, and possibly also as maintenance therapy. Treatment with MoAbs is associated with reduced risk of such adverse events as cytopenias, infections and secondary neoplasias and is generally well tolerated. Depending on antibody type, the most common adverse events are usually transient and limited to grade 1 and 2 infusion-related reactions. In addition to commercially available MoAbs, several other antibodies exist which are targeted against different antigens studied in the clinical trials.
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Affiliation(s)
| | - Dariusz Wołowiec
- b Department of Hematology , Medical University of Wroclaw , Wroclaw , Poland
| | - Tadeusz Robak
- a Department of Hematology Medical , University of Lodz , Lodz , Poland
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Asklid A, Winqvist M, Eketorp Sylvan S, Mattsson A, Björgvinsson E, Søltoft F, Repits J, Diels J, Österborg A, Hansson L. Outcomes of second-line treatment in chronic lymphocytic leukemia - a population-based study from a well defined geographical region between 2003 and 2013. Leuk Lymphoma 2016; 58:1219-1223. [PMID: 27894205 DOI: 10.1080/10428194.2016.1246727] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Anna Asklid
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,b Department of Oncology , Karolinska University Hospital , Stockholm , Sweden
| | - Maria Winqvist
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,d Department of Hematology , Karolinska University Hospital Solna , Stockholm , Sweden
| | | | - Agnes Mattsson
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,c Department of Internal Medicine , Södersjukhuset , Stockholm , Sweden
| | - Einar Björgvinsson
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,b Department of Oncology , Karolinska University Hospital , Stockholm , Sweden
| | | | | | | | - Anders Österborg
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,d Department of Hematology , Karolinska University Hospital Solna , Stockholm , Sweden
| | - Lotta Hansson
- a Department of Oncology-Pathology , Karolinska Institutet , Stockholm , Sweden.,d Department of Hematology , Karolinska University Hospital Solna , Stockholm , Sweden
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Vojdeman FJ, Van't Veer MB, Tjønnfjord GE, Itälä-Remes M, Kimby E, Polliack A, Wu KL, Doorduijn JK, Alemayehu WG, Wittebol S, Kozak T, Walewski J, Abrahamse-Testroote MCJ, van Oers MHJ, Geisler CH. The HOVON68 CLL trial revisited: performance status and comorbidity affect survival in elderly patients with chronic lymphocytic leukemia. Leuk Lymphoma 2016; 58:594-600. [PMID: 27484290 DOI: 10.1080/10428194.2016.1213831] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In the HOVON68 CLL trial, patients 65 to 75 years of age had no survival benefit from the addition of low-dose alemtuzumab to fludarabine and cyclophosphamide (FC) in contrast to younger patients. The reasons are explored in this 5-year trial update using both survival analysis and competing risk analysis on non-CLL-related mortality. Elderly FCA patients died more frequently from causes not related to CLL, and more often related to comorbidity (mostly cardiovascular) than to infection. In a Cox multivariate analysis, del(17p), performance status >0, and comorbidity were associated with a higher non-CLL-related mortality in the elderly independent of the treatment modality. Thus, while the 'fit' elderly with no comorbidity or performance status of 0 might potentially benefit from chemo-immunotherapy with FC, caution is warranted, when considering alemtuzumab treatment in elderly patients with cardiovascular comorbidity.
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Affiliation(s)
| | - Mars B Van't Veer
- b Department of Hematology , Leiden University Medical Centre , Leiden , The Netherlands
| | - Geir E Tjønnfjord
- c Department of Hematology , Oslo University Hospital and Institute of Clinical Medicine, University of Oslo , Oslo , Norway
| | | | - Eva Kimby
- e Division of Hematology, Department of Medicine at Huddinge , Karolinska Institute , Stockholm , Sweden
| | - Aaron Polliack
- f Department of Hematology , Hadassah University Hospital, Hebrew University Medical School , Jerusalem , Israel
| | - Ka L Wu
- g Department of Hematology , Stuivenberg Hospital , Antwerpen , Belgium
| | - Jeanette K Doorduijn
- h Department of Hematology , Erasmus MC Cancer Center , Rotterdam , The Netherlands
| | | | - Shulamiet Wittebol
- j Department of Internal Medicine , Gelderse Vallei, Amersfoot , The Netherlands
| | - Tomas Kozak
- k Department of Clinical Hematology, Third Faculty of Medicine , Charles University Hospital Kralovske Vinohrady , Prague , Czech Republic
| | - Jan Walewski
- l Lymphoid Malignancies , Maria Sklodowska-Curie Memorial Institute and Oncology Centre , Warszawa , Poland
| | | | - Marinus H J van Oers
- m Department of Hematology , Academisch Medisch Centrum , Amsterdam , The Netherlands
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