Young age and high cost are associated with future preference for stopping tyrosine kinase inhibitor therapy in Chinese with chronic myeloid leukemia

Current and emerging tyrosine kinase inhibitors for the treatment of chronic myeloid leukemia in young adults

INTRODUCTION

Chronic myeloid leukemia (CML) is more common in older adults, but nearly 15-20% of the patients is between 15 and 39 years of age. In this age group, patients may seek clinical care a much later period of the disease and they may have a heavier burden of disease. In addition, young patients with CML may face unique challenges related to their age, such as concerns about health care, fertility, or careers. The current standard of care for CML is the use of tyrosine kinase inhibitors (TKIs), which induce remission in most young patients and can achieve long-term disease control.

AREAS COVERED

This review summarizes age-specific treatment-related conditions, as well as the effectiveness of TKI therapy in this age group. PubMed, Google Scholar, clinicaltrials.gov and other abstract databases were used while preparing this review. The period of 2001-2023 was chosen as the search window.

EXPERT OPINION

Although we do not have sufficient data, young adult population has a special importance for TKI treatment. Clinical features, efficacy of treatments, and specific conditions in this age group should attract more attention of clinicians and more intensive studies should be conducted in the future.

Quality-of-life, mental health, and perspective on TKI dose reduction as a prelude to discontinuation in chronic phase chronic myeloid leukemia

BACKGROUND

Treatment-free remission (TFR) has become the main target for chronic myeloid leukemia (CML). Tyrosine kinase inhibitors (TKI) dose optimization is crucial in managing adverse events, and improving adherence in clinical practice. In persons achieving a deep molecular response (DMR), some data suggest TKI dose reduction before discontinuation does not change success rate of achieving TFR, but this is controversial. However, data on quality-of-life (QoL) and mental health in CML patients with full-dose TKI, low-dose TKI, and TKI discontinuation are limited. Moreover, recent evidence indicating the feasibility of TKI dose reduction and discontinuation after dose reduction, which may change CML patients' perspectives on TKI discontinuation.

METHODS

We conducted a cross-sectional study using online questionnaires to explore the QoL, mental health in patients with diverse TKI dose, and perspective on TKI dose reduction as a prelude to discontinuation.

RESULTS

1450 responses were included in the analysis. 44.3% of respondents reported a moderate-to-severe impact of TKI treatment on their QoL. 17% of respondents had moderate-to-severe anxiety. 24.4% of respondents had moderate-to-severe depression. In 1326 patients who had not discontinued their medication, 1055 (79.6%) patients reported they would try TKI discontinuation because of concerns over side effects of long-term medication (67.9%), financial burden (68.7%), poor QoL (77.9%), pregnancy needs (11.6%), anxiety and depression while taking TKI (20.8%), inconvenience of TKI treatment (22.2%). 613 of 817 (75.0%) patients on full-dose TKI therapy indicated they preferred trying a dose reduction before discontinuing TKI therapy after dose reduction compared with 31 (3.8%) preferring no dose reduction before stopping.

CONCLUSIONS

TKI dose reduction showed a significant improvement of patients' QoL and mental health, comparable to the effect of TKI discontinuation. Most patients indicated they preferred dose reduction before stopping TKI therapy. In clinical practice, TKI dose reduction can be considered as a bridge from full-dose treatment to discontinuation. Our results showed that tyrosine kinase inhibitors (TKI) dose reduction showed a significant improvement of patients' quality-of-life and mental health, comparable to the effect of TKI discontinuation. Most patients desire to discontinue TKI in the future. TKI discontinuation after dose reduction is more acceptable compared to discontinuing it directly. In clinical practice, TKI dose reduction can be considered as a bridge from full-dose treatment to discontinuation. Please do not hesitate to contact me in case further clarification is needed with this submission.

[Survey and analysis of the concerns of patients with chronic myeloid leukemia in China in 2021]

Objective: To investigate the concerns of adult patients with chronic myeloid leukemia (CML) in the chronic phase receiving tyrosine kinase inhibitor (TKI) therapy in China. Methods: A cross-sectional questionnaire including 23 issues of concern was filled by patients with CML nationwide from August to September 2021. The results were compared with those from 2015 to 2016. Results: Data from 952 questionnaires were analyzed. The five most concerned issues were "TKI-related adverse effects and management" (66%) , "stopping TKI therapy" (46%) , "CML risk assessment" (46%) , "TKI dose reduction" (42%) , and "restrictions in daily life activities" (41%) . Compared with the results from 2015 to 2016, patients paid more attention to "TKI-related adverse effects and management" , "monitoring" , and "interpretation of laboratory reports" (all P<0.01) . Concerns of "TKI reimbursement policies" , "price reduction of TKIs" , and issues related to generic TKIs decreased significantly (all P<0.01) . Multivariate analysis showed that female patients (OR=1.8, 95% CI 1.4-2.5, P<0.001) , elderly patients (OR=1.0, 95% CI 1.0-1.0, P<0.001) , or patients with bachelor's degree or higher (OR=1.8, 95% CI 1.3-2.4, P<0.001) were more concerned with "TKI dose reduction" than others. Patients with a bachelor's degree or higher (OR=1.6, 95% CI 1.2-2.2, P=0.002) paid more attention to "CML risk assessment" , whereas those currently receiving a second- or third-generation TKI therapy (OR=1.9, 95% CI 1.3-2.6, P<0.001) were more concerned about "TKI resistance" . Conclusion: Patients with CML paid the most attention to "TKI-related adverse effects and management" , "stopping TKI therapy" , "CML risk assessment" , "TKI dose reduction" , and "restrictions in daily life activities" . Patients' sociodemographic covariates and treatment status were associated with their concerns.

Questions concerning tyrosine kinase-inhibitor therapy and transplants in chronic phase chronic myeloid leukaemia

In this provocative commentary, we consider several questions posed by the late chronic myeloid leukaemia (CML) expert Prof. Michele Baccarani, which he challenged us to address after his death. He noted only a small proportion of people with chronic phase CML receiving tyrosine kinase-inhibitor (TKI)-therapy are likely to achieve sustained therapy-free remission (TFR) and even fewer are likely to be cured. Persons most likely to fail TKItherapy can be identified at diagnosis or soon after starting TKI-therapy. These persons are likely to need lifetime TKI-therapy with attendant risks of adverse events, cost and psychological consequences. Allogeneic transplants achieve much higher rates of leukaemia-free survival compared with TKI-therapy but are associated with transplant-related adverse events including an almost 20 percent risk of transplant-related deaths within 1 year post-transplant and a compromised quality-of-life because of complications such as chronic graft-versus-host disease. Subject-, disease- and transplant-related co-variates associated with transplant outcomes are known with reasonable accuracy. Not everyone likely to fail TKI-therapy is a transplant candidate. However, in those who candidates are physicians and patients need to weigh benefits and risks of TKI-therapy versus a transplant. We suggest transplants should be more often considered in the metric when counseling people with chronic phase CML unlikely to achieve TFR with TKI-therapy. We question whether we are discounting a possible important therapy intervention; we think so.

Psychological Factors Affecting the Willingness to Accept a Possible Tyrosine Kinase Inhibitor (TKI) Discontinuation in Chronic Myeloid Leukaemia (CML) Patients

PURPOSE

Patients with chronic myeloid leukemia (CML) who present a sustained deep molecular response (DMR) for a stable period of time might benefit from discontinuing tyrosine kinase inhibitors (TKIs). A significant number of patients seem able to reach this stage due to the availability of TKIs. However, many patients remain reluctant about TKI discontinuation and may refuse treatment interruption. The purpose of this study was to explore the clinical and psycho-cognitive factors that may influence the decision to discontinue TKI therapy, thereby gaining a better understanding of patients' viewpoints on TKI discontinuation.

PATIENTS AND METHODS

One hundred and nineteen patients diagnosed with CML aged between 34 and 69 were enrolled (67 males and 52 females). Different clinical information and psycho-cognitive aspects such as attitude toward risk behaviours, risk preferences, need for cognitive closure, and tendency to resist to changes were assessed through the administration of a battery of questionnaires.

RESULTS

A higher tendency toward risk behaviours and the tendency to focus on possible gain in the short term rather than on losses might represent important predictors for the willingness to accept TKI discontinuation. Possible relapses following interruption of the therapy are the most common reason for concern. Furthermore, lower levels of resistance to change and having previously experienced the desire to interrupt the therapy might lead patients to accept a higher probability of relapse risk when facing such a decision.

CONCLUSION

TKI discontinuation appears appealing and challenging at the same time for many CML patients, and different factors may influence this decision. Psychology plays a crucial role in assisting physician-patient communication and informed decision-making.

Chronic myeloid leukemia stem cells: targeting therapeutic implications

Chronic myeloid leukemia (CML) is a clonal myeloproliferative neoplasm driven by BCR-ABL1 oncoprotein, which plays a pivotal role in CML pathology, diagnosis, and treatment as confirmed by the success of tyrosine kinase inhibitor (TKI) therapy. Despite advances in the development of more potent tyrosine kinase inhibitors, some mechanisms particularly in terms of CML leukemic stem cell (CML LSC) lead to intrinsic or acquired therapy resistance, relapse, and disease progression. In fact, the maintenance CML LSCs in patients who are resistance to TKI therapy indicates the role of CML LSCs in resistance to therapy through survival mechanisms that are not completely dependent on BCR-ABL activity. Targeting therapeutic approaches aim to eradicate CML LSCs through characterization and targeting genetic alteration and molecular pathways involving in CML LSC survival in a favorable leukemic microenvironment and resistance to apoptosis, with the hope of providing a functional cure. In other words, it is possible to develop the combination therapy of TKs with drugs targeting genes or molecules more specifically, which is required for survival mechanisms of CML LSCs, while sparing normal HSCs for clinical benefits along with TKIs.

Long-term treatment-free remission in patients with chronic myeloid leukemia after second-line nilotinib: ENESTop 5-year update

The ENESTop study evaluated treatment-free remission (TFR) in patients with chronic myeloid leukemia (CML) in chronic phase who had received ≥3 years of tyrosine kinase inhibitor therapy and achieved sustained deep molecular response only after switching from imatinib to nilotinib. After 1-year nilotinib consolidation, 126 patients attempted TFR. At 48 weeks (primary analysis), 57.9% (73/126) were in TFR. In the present analysis at 5 years, 42.9% (54/126) were in TFR. Since the 48-week analysis, among patients who left the TFR phase, 58% (11/19) did not have a loss of molecular response and discontinued for other reasons. Of the 59 patients who reinitiated nilotinib upon loss of major molecular response (MMR) or confirmed loss of MR⁴, 98.3% regained MMR, 94.9% regained MR⁴, and 93.2% regained MR^4.5. Overall adverse event rates decreased over the 5 years of TFR. In patients reinitiating nilotinib, there was a cumulative increase in cardiovascular events with longer nilotinib exposure. No disease progression or CML-related deaths were reported. Overall, these results confirm the durability and safety of TFR for patients receiving second-line nilotinib. Cardiovascular risk should be carefully managed, particularly when reinitiating treatment after TFR.

Economics influences therapy decisions in chronic myeloid leukaemia: should it?

The question whether economic considerations should influence therapy decisions in persons with chronic myeloid leukaemia (CML) is complex touching on many metrics other than medicine including the perceptions, attitudes, and motivations of physicians, patients, their families, and payors', allocation of health care resources, and others. We discuss metrics whereby physicians, patients, and payors make CML therapy choices in settings where cost and availability are or are not considerations. We conclude that economic considerations strongly influence therapy decisions in CML. Whether this should be so and what impact it has on outcomes is also considered. Absent definitive data proving which therapy strategy is best allowing economic considerations to operate may not be as unreasonable or unethical as it appears. In some settings, it may be the best approach. However, because TKIs markedly prolong survival and may even cure some persons with CML, TKI therapy should be available to everyone with CML.

Counterpoint: There is a best duration of deep molecular response for treatment-free remission, but it is patient-specific, and that is the challenge

There is considerable clinical and scientific interest in identifying reliable predictors of treatment-free remission in chronic myeloid leukaemia. Most predictors have been identified from non-randomized clinical trials or retrospective cohorts that could be subject to bias. The validity of predictive factors, such as duration of treatment or of deep molecular response, has been questioned. We briefly review the relevant data and the potential for bias, arguing that the risk of bias may be overstated, and that accumulating data strongly suggest that depth and duration of molecular response are critical factors to enable us to predict the probability of treatment-free remission.

Tyrosine kinase inhibitor treatment discontinuation in chronic myeloid leukemia: patient views

Patients with chronic myeloid leukemia (CML) in deep molecular remission may discontinue tyrosine kinase inhibitor (TKI) treatment without relapse. The present study aims to gain insight into the views of CML patients on TKI treatment discontinuation and identify factors that are associated with their willingness to discontinue treatment. A cross-sectional study, among adult Dutch CML patients was conducted to assess willingness and their views on benefits of and concerns about discontinuation. A total of 185 patients participated of whom 76% were willing to discontinue TKI-treatment. Patients considered the absence of side effects the most important benefit whereas fear of disease recurrence was their most prominent concern. Adequate monitoring was the most important prerequisite for TKI-treatment discontinuation. However, ambiguity with respect to perquisites indicate that patients on long-term TKI treatment should be adequately informed both on the possibility to discontinue treatment and on its benefits, risks, and measures that address risks.

Variables associated with self-reported anxiety and depression symptoms in patients with chronic myeloid leukemia receiving tyrosine kinase inhibitor therapy

Variables associated with self-reported anxiety and depression symptoms were explored in 1169 adults with chronic myeloid leukemia (CML) receiving tyrosine kinase inhibitor (TKI)-therapy. The Self-Rating Anxiety Scale and Self-Rating Depression Scale questionnaires were used to measure anxiety and depression symptoms. Two hundred and fifty-one (22.4%) and 415 (37.1%) respondents reported anxiety and depression, respectively. In multivariate analyses, female sex, lower education level, comorbidities, advanced-line TKI-therapy, and longer TKI-therapy duration were significantly associated with more severe anxiety and/or depression. It is concluded that socio-demographics, comorbidities, advanced-line TKI-therapy, and longer TKI-therapy duration were significantly associated with anxiety and/or depression symptoms in CML patients receiving TKI-therapy.

Treatment-free remission in patients with chronic myeloid leukaemia

In the past few years, international treatment guidelines for chronic myeloid leukaemia have incorporated recommendations for attempting discontinuation of treatment with tyrosine-kinase inhibitors (TKIs) outside of the setting of a clinical trial with the aim of a treatment-free remission (TFR). Physicians involved in the treatment of chronic myeloid leukaemia need to be sufficiently well informed to guide patients through decision-making about the discontinuation of treatment with TKIs targeting BCR-ABL1 by providing a balanced assessment of the potential risks and benefits of stopping or continuing therapy. These guidelines also seek to ensure that the risks associated with being off treatment are kept to a minimum. In this Review, we summarize the clinical studies of TFR and how their results can guide routine clinical practice with a focus on specific aspects such as molecular monitoring and the pregnancy-specific risks associated with a TFR attempt in female patients. We also address the development of predictors of outcome after TKI discontinuation and present strategies that warrant further consideration to enable more patients to enter TFR.

Feasibility Study of Switching to Nilotinib After First-line Imatinib in the Chronic Phase of Chronic Myeloid Leukemia

BACKGROUND

We investigated the real-life choice of first-line treatment in the chronic phase of chronic myeloid leukemia (CML-CP) and the feasibility of switching to nilotinib after first-line imatinib.

PATIENTS AND METHODS

We performed a retrospective analysis of the efficacy and safety of imatinib versus nilotinib as first-line therapy for patients with CML-CP. We also performed a comparative analysis of the efficacy of sustained imatinib versus a switch to nilotinib for patients with CML-CP with a warning or failure response or intolerance to imatinib. We also comparatively analyzed the efficacy between first-line nilotinib and first-line imatinib after standardized management in accordance with the European Leukemia Network (ELN) recommendations. A total of 344 patients were included in the present study.

RESULTS

The proportion of patients achieving a complete cytogenetic response (CCyR), major molecular response (MMR), and molecular response 4.0 (MR4.0) was greater with first-line nilotinib than with first-line imatinib at 0 to 24 and 0 to 36 months (P < .05). Of the 344 patients, 174 did not achieve an optimal response to first-line imatinib. A greater proportion of those patients who had switch to nilotinib had achieved a CCyR, MMR, and MR4.0 compared with those continuing imatinib for 12 months of subsequent treatment (P < .005). No difference was found in the proportion of patients with a CCyR, MMR, and MR4.0 between first-line nilotinib and first-line imatinib after standardized management in accordance with the ELN recommendations at 0 to 24 and 0 to 36 months (P > .05).

CONCLUSION

First-line imatinib can result in efficacy similar to that with first-line nilotinib after standardized management in accordance with the ELN recommendations. Treatment with imatinib as first-line treatment, with a switch to nilotinib after standardized management is feasible and effective.

Variables associated with patient-reported symptoms in persons with chronic phase chronic myeloid leukemia receiving tyrosine kinase inhibitor therapy

PURPOSE

The aim of this study was to evaluate the variables associated with patient-reported symptoms and the impact of symptoms on health-related quality-of-life (HRQoL) in patients with chronic myeloid leukemia (CML) receiving tyrosine kinase inhibitors (TKIs).

METHODS

Anonymous Chinese-language questionnaires were distributed to adults with chronic-phase CML (CML-CP) receiving TKIs therapy >3 months regarding symptoms' incidence, severity, and HRQoL. The multivariate cumulative logistic regression model was built to identify variables associated with the symptoms. General Linear Model was used to model the relationship between symptoms and HRQoL using stepwise-forward algorithm.

RESULTS

A total of 1142 respondents were included in this study. The top 10 common TKI-related symptoms were fatigue, periorbital and lower limb edema, chest distress and shortness of breath, memory deterioration, skin color change, alopecia, muscle cramp, weight gain and musculoskeletal pain, and itchy skin. One hundred forty-one (50%) females ≤50 years reported menstrual disorders. Female, married, therapy duration 1 to 3 years, and foreign generic TKIs were associated with increased symptoms' frequency and severity. In contrast, receiving nilotinib or dasatinib, and achieving a complete cytogenetic response but not complete molecular response were associated with fewer and milder symptoms. Chest distress and shortness of breath and loss of appetite were associated with both lower physical component summary (PCS) and mental component summary (MCS) scores; fatigue, musculoskeletal pain, dizziness and abdominal pain, were associated with lower PCS score; anxiety-depression, was associated with lower MCS score in multivariate analyses.

CONCLUSIONS

Demographic and social variables, type of TKI-therapy, therapy duration, and depth of response were associated with patient-reported symptoms in persons with chronic phase CML. Certain symptoms have adverse impact on HRQoL.

Interruption or Discontinuation of Tyrosine Kinase Inhibitor Treatment in Chronic Myeloid Leukaemia: A Retrospective Cohort Study (SPARKLE) in Belgium

OBJECTIVES

To assess interruptions/discontinuations of tyrosine kinase inhibitor (TKI) treatment in Belgian patients with chronic myeloid leukaemia (CML).

METHODS

This retrospective study included patients with TKI interruptions/discontinuations of ≥4 continuous weeks (no clinical trial context) between May 2013 and May 2016. Data collection took place between October 2016 and February 2017.

RESULTS

All 60 participants (69 interruptions/discontinuations) had chronic-phase CML and 75% had at least a major molecular response (≥MMR) at interruption/discontinuation. Most interruptions/discontinuations occurred while on imatinib (36/69; 49%) and dasatinib (20/69; 29%). Most interruptions/discontinuations occurred due to side effects/intolerance (46/69; 67%); other reasons included a wish to conceive (6/69; 9%) and attempts to achieve treatment-free remission (TFR) (6/69; 9%). Interruptions due to side effects occurred later for imatinib- or dasatinib-treated patients than for those on nilotinib or ponatinib. Treatment was re-initiated in 62% (43/69) of cases. Most interruptions caused by side effects/intolerance were followed by treatment changes. All 4 patients with ≥MR 4.5 at interruption/discontinuation and ≥11-month follow-up who had not restarted treatment maintained the response.

CONCLUSION

Although TKIs are used for long-term CML treatment, physicians sometimes recommend interruptions/discontinuations. In this study, interruptions/discontinuations were mainly caused by side effects or intolerance, rather than TFR attempts.

Monitoring and Analysis of Chinese Chronic Myeloid Leukemia Patients Who Have Stopped Tyrosine Kinase Inhibitor Therapy

Discontinuation of tyrosine kinase inhibitor (TKI) therapy after achieving a persistent deep molecular response (DMR) is an urgently needed treatment goal for chronic myeloid leukemia (CML) patients and has been included in the National Comprehensive Cancer Network (NCCN) guidelines (version 2.2017) for CML. Indeed, various studies have confirmed the feasibility of discontinuing TKI therapy. In this study, we analyzed data from 45 CML patients who had discontinued TKI therapy. Univariate analysis was performed to predict factors that were potentially related to treatment-free remission (TFR) and identify the differences between early relapse and late relapse. Out of the 45 patients, 20 exhibited molecular relapse after a median follow-up of 18 months (range, 1-54 months), and the estimated TFR at 24 months was 40%. The univariate analysis revealed that a high Sokal score and interruptions or dose reductions during TKI treatment were the only baseline factors associated with poor outcomes. Our results indicate that TKI discontinuation could be successfully put into practice in China.

Exploring Patient Decision Making Regarding Discontinuation of Tyrosine Kinase Inhibitors for Chronic Myeloid Leukemia

BACKGROUND

The standard treatment for chronic phase chronic myeloid leukemia (CML) is lifelong oral tyrosine kinase inhibitor (TKI) therapy. Multiple clinical trials have demonstrated that some patients with a sustained deep molecular response to TKI therapy can safely stop therapy and remain in a treatment-free remission. TKI discontinuation is now offered to select patients in routine clinical care. In order to better support patient decision making, we explored patients' views on TKI discontinuation and the factors patients consider when making this decision.

MATERIALS AND METHODS

Patients were recruited from three U.S. academic cancer centers. Qualitative interviews were recorded, transcribed, and content analyzed.

RESULTS

We interviewed 22 patients, half of whom wanted to try TKI discontinuation. Eleven factors relevant to the decision emerged, and patients weighed these factors differently. Commonly mentioned factors included perceived risk of relapse, TKI side effects, financial considerations, polypharmacy, and willingness to change something that was working (status quo). There were notable differences in patients' understanding of the likelihood of achieving a treatment-free remission, with patients who did not want to stop TKIs more accurately reporting the risk of relapse than patients who wanted to stop.

CONCLUSION

This is a novel decision that will become more common as the prevalence of patients with well-controlled CML continues to increase. These results highlight the need for patient education and decision support so that patients and providers can make shared decisions that are informed and values based.

IMPLICATIONS FOR PRACTICE

The standard treatment for chronic phase chronic myeloid leukemia (CML) is lifelong oral tyrosine kinase inhibitor (TKI) therapy. Clinical trials have shown that some patients with a sustained deep molecular response to TKI therapy can safely stop therapy and remain in a treatment-free remission. TKI discontinuation is now being offered to patients outside of clinical trials. This study explored factors that patients who are eligible to try TKI discontinuation considered when making this decision. Factors relevant to the decision included risk of relapse, side effects, financial considerations, polypharmacy, and willingness to change something that was working. This is a novel decision that will become more common as the prevalence of patients with well-controlled CML continues to increase. These results highlight the need for decision support and outline the factors that should be included so that patients and providers can make shared decisions that are informed and values based.

CML Hematopoietic Stem Cells Expressing IL1RAP Can Be Targeted by Chimeric Antigen Receptor-Engineered T Cells

Chronic myeloid leukemia (CML) is a chronic disease resulting in myeloid cell expansion through expression of the BCR-ABL1 fusion transcript. Tyrosine kinase inhibitors (TKI) have significantly increased survival of patients with CML, and deep responders may consider stopping the treatment. However, more than 50% of patients relapse and restart TKI, subsequently suffering unknown toxicity. Because CML is a model immune system-sensitive disease, we hypothesize that chimeric antigen receptor (CAR) T cells targeting IL1 receptor-associated protein (IL1RAP) in quiescent CML stem cells may offer an opportunity for a permanent cure. In this study, we produced and molecularly characterized a specific monoclonal anti-IL1RAP antibody from which fragment antigen-binding nucleotide coding sequences were cloned as a single chain into a lentiviral backbone and secured with the suicide gene iCASP9/rimiducid system. Our CAR T-cell therapy exhibited cytotoxicity against both leukemic stem cells and, to a lesser extent, monocytes expressing IL1RAP, with no apparent effect on the hematopoietic system, including CD34⁺ stem cells. This suggests IL1RAP as a tumor-associated antigen for immunotherapy cell targeting. IL1RAP CAR T cells were activated in the presence of IL1RAP⁺ cell lines or primary CML cells, resulting in secretion of proinflammatory cytokines and specifically killing in vitro and in a xenograft murine model. Overall, we demonstrate the proof of concept of a CAR T-cell immunotherapy approach in the context of CML that is applicable for young patients and primary TKI-resistant, intolerant, or allograft candidate patients. SIGNIFICANCE: These findings present the first characterization and proof of concept of a chimeric antigen receptor directed against IL1RAP expressed by leukemic stem cells in the context of CML.

Achieving optimal response at 12 months is associated with a better health-related quality of life in patients with chronic myeloid leukemia: a prospective, longitudinal, single center study

Background

To assess the relationship between responses within 1 year and health-related quality of life (HRQoL) outcomes by exploring profiles of patients with CML-CP who were treated with front-line imatinib or nilotinib.

Methods

A prospective, longitudinal, single-center study was conducted to assess the response to treatment with imatinib or nilotinib and the HRQoL profile of patients who were newly diagnosed with CML in chronic phase enrolled in the ENESTchina study.

Results

Fifty-nine patients were randomized to receive imatinib (n = 31) or nilotinib (n = 28). With a median follow-up of 5 years, there was no difference in HRQoL profile observed between patients receiving imatinib and nilotinib. Achieving optimal response at 12 months was associated with better role limitations due to physical health problems (RP; P = 0.0019) and emotional problems (RE; P = 0.0110) and was the sole factor associated with significantly improving physical component summary over time (PCS; P = 0.0160). Achieving optimal response at 6 months had high probability of better physical functioning (PF; P = 0.0674), better social functioning (SF; P = 0.0571), and reduced role limitations due to emotional problems (RE; P = 0.0916). In addition, factors including age < 40 years, female gender, and higher level of education were also associated with better HRQoL subscale scores. However, optimal response at 3 months had no impact on HRQoL profile. The proportions of patients with failure-free survival and PFS at 5 years were significantly higher among patients who achieved optimal response at 3, 6, or 12 months than among those who did not achieve optimal response (warning or failure), and the OS rate at 5 years was significantly higher among those who achieved optimal response at 12 months. In a multivariate analysis, treatment received (nilotinib vs imatinib) was identified as an independent factor for the achievement of optimal response at both 6 months (OR, 3.9; 95% CI, 1.0–14.9) and 12 months (OR, 5.6; 95% CI, 1.7–17.9).

Conclusions

Achieving optimal response at 12 months was not only associated with longer OS and reduced treatment failure rates and disease progression but also better HRQoL in newly diagnosed patients with CML-CP receiving front-line tyrosine kinase inhibitor treatment.

Trial registration

Chinese Clinical Trial Registry (http://www.chictr.org.cn): ChiCTR-OCH-11001699.

[Comorbidity profile and its impact on reported outcome in Chinese patients with chronic myeloid leukemia in chronic phase receiving tyrosine kinase-inhibitor therapy]

Objectives: To explore the comorbidity profile and its impact on reported outcome of patients with chronic myeloid leukemia in chronic phase (CML-CP) receiving tyrosine kinase-inhibitor (TKI) therapy in China. Methods: From September 2015 to March 2016, anonymous questionnaires were distributed to adult CML patients who were receiving TKI treatment in China. The questionnaires included demographics, comorbidity(ies), TKI(s) therapy, annual out-of-pocket expense for TKIs, treatment responses, health-related quality of life (HRQoL) measured by the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), satisfaction with therapy, impact of TKI therapy on work and daily life. Results: Data from 1 108 respondents in CML-CP were analyzed, 701 (63.6%) were male, median age was 42 years (range, 18-88 years), 76.4% were currently on imatinib, median TKI-therapy-duration was 29 months (range, 3-178 months). Of them, 300 (27.1%) had ≥1 comorbidity(ies), including hypertension(30.3%), diabetes (21.0%), coronary heart disease (12.3%), gastro-intestinal disease (12.3%), liver disease (11.7%), kidney disease (8.3%), cerebrovascular disease (6.7%) and lung diseases (5.7%), thrombosis (1.3%), other benign diseases (15.3%) and other cancer (8.0%), and 74 (24.7%) had ≥2 comorbidities. Multivariate analyses showed the comorbidity profile of other benign diseases was significantly associated with lower HRQoL score and TKI therapy affecting work and daily life, but it did not significantly affect patients' satisfaction with TKI treatment. Female and no complete cytogenetic response (CCyR) were associated with lower HRQoL score, education level ≥bachelor degree and TKI-therapy duration ≥3 years were associated with higher HRQoL score. Switching between first and second generation TKIs and no CCyR were associated with dis-satisfaction or extreme dis-satisfaction with TKI therapy, free out-of-pocket expense for TKI was associated with better satisfaction. Age<60 years and no CCyR were associated with TKI therapy affecting work and daily life. Conclusions: The survey showed that 27.1% Chinese adult patients with CML-CP receiving TKI-therapy had comorbidity(ies). Different comorbidity profile had different impact on patients' HRQoL and different impact of TKI therapy on work and daily life.

Durable treatment-free remission in patients with chronic myeloid leukemia in chronic phase following frontline nilotinib: 96-week update of the ENESTfreedom study

PURPOSE

ENESTfreedom is evaluating treatment-free remission (TFR) following frontline nilotinib in patients with chronic myeloid leukemia (CML) in chronic phase. Following our primary analysis at 48 weeks, we here provide an updated 96-week analysis.

METHODS

Attempting TFR required ≥ 3 years of nilotinib, a molecular response of MR4.5 [BCR-ABL1 ≤ 0.0032% on the International Scale (BCR-ABL1IS)], and sustained deep molecular response (DMR) during a 1-year consolidation phase. Patients restarted nilotinib following loss of major molecular response (MMR; BCR-ABL1IS ≤ 0.1%).

RESULTS

Ninety-six weeks after stopping treatment (3.6-year median prior nilotinib duration), 93 of 190 patients (48.9%) remained in TFR. Of 88 patients who restarted nilotinib following loss of MMR, 87 regained MMR and 81 regained MR4.5 by the data cut-off. Ninety-six-week TFR rates were 61.3, 50.0, and 28.6% in patients with low, intermediate, and high Sokal risk scores at diagnosis, respectively. Patients consistently in MR4.5 during consolidation had higher TFR rates (50.6%) than patients with ≥ 1 assessment without MR4.5 during consolidation (35.0%). In a landmark analysis, 96-week TFR rates for patients with MR4.5, MR4 (BCR-ABL1IS ≤ 0.01%) but not MR4.5, and MMR but not MR4 at TFR week 12 were 82.6, 23.1, and 0%, respectively. There were no reports of disease progression or death due to CML; overall adverse event frequency decreased following TFR. Within the follow-up period, TFR did not adversely affect disease outcomes.

CONCLUSIONS

These results demonstrate the feasibility and durability of TFR following frontline nilotinib and emphasize the importance of sustained DMR for TFR.

Patients' and hematologists' concerns regarding tyrosine kinase-inhibitor therapy in chronic myeloid leukemia

PURPOSE

To explore patients' and hematologists' concerns regarding tyrosine kinaseinhibitor (TKI)-therapy and identify variables associated these concerns. Methods A cross-sectional questionnaire including 16 common issues related to TKI-therapy was distributed to adults with chronic myeloid leukemia (CML) receiving TKIs and hematologists treating CML patients and answered anonymously.

RESULTS

Data from 1518 patient respondents receiving TKI-therapy ≥ 3 months were analyzed. 939 (62%) were male. Median age was 42 years. 72% were receiving imatinib. Median TKI-therapy duration was 27 months. Data from 259 hematologist respondents were analyzable. 154 (59%) treated > 5 persons with CML per month. Median number of concerns was 5 (range 0-16) for both patients and hematologists. The top five issues for both cohorts were new drug development, stopping TKI-therapy, TKI-reimbursement policies, TKI-related adverse effects and long-term efficacy of TKIs. 12 issues attracted proportionally discordant attention between patients and hematologists. Patients were more concerned with TKI-reimbursement policies, price reduction of TKIs, TKI-related adverse effects, restrictions to daily life, CML knowledge and interpretation of laboratory data, whereas hematologists were more concerned with stopping TKI-therapy, TKI choice, monitoring, TKI dose-adjustment, quality of generics and switching between branded and generic TKIs. In multivariate analyses female sex [OR = 1.4 (1.1-1.7); p = 0.008], education level ≥ bachelor e[OR = 1.8 (1.4-2.2); p < 0.001], TKI-therapy duration 36-< 60 months [OR = 1.4 (1.0-1.9); p = 0.049] and having adverse impact on daily life and work [OR = 1.5 (1.2-1.8]; p = 0.001] were associated with greater numbers of patients' concerns.

CONCLUSIONS

Our data suggested hematologists need to be aware of CML patients' concerns to improve their quality-of-life and patient-hematologist communication.

Chronic myeloid leukemia patients and treatment-free remission attitudes: a multicenter survey

BACKGROUND

Treatment-free remission (TFR) is becoming an essential goal for chronic myeloid leukemia (CML) patients in clinical practice. Few studies have emphasized patient attitudes or preferences about discontinuing tyrosine kinase inhibitors treatment. This study aimed to evaluate the characteristics of Chinese CML patients and their views and perspectives on TFR.

METHODS

A total of 329 CML patients participated in this multicenter, questionnaire-based, standardized, semi-structured, interview-guided, open-ended, cross-sectional study. Information about demographics, diagnosis information, treatment history, quality of life (QoL), and TFR preference was collected.

RESULTS

The adherence rate was 50% (N=163) and sex dependent (males, OR=2.24, 95% CI=1.40-3.58). Physical activity, symptom burden, mood impact, and daily impact were found to be better among adherent patients. Thirty-four percent of the patients were willing to attempt TFR positively. The reasons for preferring TFR were due to side effects (56%) followed by high cost (52%), inconvenience (42%), and pregnancy need (41%). Multivariate analysis indicated that patients who were younger (OR=0.96, 95% CI=0.94-0.99) with shorter disease duration (OR=0.90, 95% CI=0.82-0.98) and higher disease symptom burden (OR=1.08, 95% CI=0.98-1.21) were more likely positive about TFR.

CONCLUSION

Patients who were younger with shorter disease duration and higher disease symptom burden were more likely to try TFR. They expressed several perceived noncost factors of TFR. Our data may help promote the management of CML and designing of clinical trials for TFR in some developed regions of China.

Considerations for Successful Treatment-free Remission in Chronic Myeloid Leukemia

BCR-ABL1 tyrosine kinase inhibitors have dramatically improved outcomes for patients with chronic myeloid leukemia, and current studies are investigating whether some patients may be able to suspend therapy yet maintain response in a state known as "treatment-free remission" (TFR). Results from ongoing studies suggest that ≈ 40% to 60% of patients in sustained (generally ≥ 2 years) deep molecular response (defined as a 4-log or deeper reduction in BCR-ABL1 transcripts, depending on the study) who attempt TFR may successfully remain off treatment. Results from TFR clinical trials, patient considerations for attempting TFR, and potential predictive factors associated with successful TFR are reviewed herein.

[Analysis on tyrosine kinase inhibitor discontinuation in patients with chronic myeloid leukemia in the real world: experience from single center]

Objective: To explore status of tyrosine kinase inhibitor (TKI) discontinuation in patients with chronic myeloid leukemia (CML) in the chronic phase (CP) in the real world, to analyze causes, factors and outcomes associated with TKI discontinuation and the possibility of pursuit treatment-free remission (TFR) in China. Methods: From January 2013 to August 2016, data of CML-CP patients in Peking University People's Hospital which were not enrolled in clinical trials were retrospectively collected and analyzed. Results: Data of 662 CML-CP patients were collected. With a median follow-up after TKI-therapy of 26 months (range, 3-187 months) , 187 patients (28.2%) experienced TKI cessation of at least 2 weeks. Causes of TKI discontinuation included hematologic adverse events 57.8% (n=108) , non-hematologic adverse events 30.4% (n=57) , financial burden 25.1% (n=47) , and others 7.0% (n= 13) . Multivariate analyses showed female, ≥40 years, no co-morbidity, and interval from diagnosis to TKI initiation ≥6 months, TKI switch and patients from other hospitals were factors associated with TKI discontinuation because of hematologic adverse effects. Female and patients from other hospitals were factors associated with TKI discontinuation because of non-hematologic adverse effect. TKI switch, generic TKI used and patients from other hospitals were factors associated with TKI discontinuation because of financial toxicity. Patients TKI discontinuation because of hematologic, non-hematologic or financial toxicity achieved a lower complete cytogenetic response or complete molecular response (CMR) than those with uninterrupted TKI-therapy. Patients with TKI discontinuation because of hematologic or financial toxicity had a shorter progression-free survival than those with uninterrupted TKI-therapy. 5 of 7 patients who obtained sustained CMR and discontinued TKI-therapy experienced disease recurrence with a median duration of 3 months (range, 2-32 months) . In 39 patients from other hospitals who aimed to confirm their optimal response of sustained CMR in Peking University People's Hospital, 21 (53.8%) were BCR-ABL positive. Conclusion: In the real world in China, half of CML-CP patients who discontinued TKI-therapy were incurred to TKI-related hematologic adverse effect, and both a quarter of them, TKI-related non-hematologic toxicities and financial toxicity, respectively. Discontinued TKI-therapy due to hematologic adverse events or financial toxicity was associated with lower TKI-therapy response rates. Nowadays, based on the Chinese situation, it is too early to talk about TFR.

Higher out-of-pocket expenses for tyrosine kinase-inhibitor therapy is associated with worse health-related quality-of-life in persons with chronic myeloid leukemia

PURPOSE

To explore health-related quality-of-life (HRQoL) profiles and identify socio-demographic and clinical variables associated with HRQoL in persons with chronic myeloid leukemia (CML) receiving tyrosine kinase inhibitors (TKIs).

METHODS

A cross-sectional questionnaire was distributed to adults with chronic-phase CML receiving tyrosine kinase-inhibitor (TKI) therapy >3 months in complete cytogenetic response (CCyR). Respondents were anonymous. SF-36 Health Survey was used to measure HRQoL.

RESULTS

Data from 828 respondents were analyzable. 524 (63%) were male. Median age was 42 years (range 18-88 years). 648 (78%) were receiving imatinib. Median TKI-therapy duration was 36 months (range 3-178 months). 638 (77%) paid some or all of their TKI costs. Annual out-of-pocket expenses >$4600 USD was associated with lower physical component summary (PCS; -2.8 to -3.8; P = 0.0081 and 0.0009) and mental component summary (MCS; -2.1 to -4.3; P = 0.0394 and 0.0080) in multivariate analyses. Other variables significantly associated with a lower PCS and/or MCS included: (1) female sex; (2) increasing age; (3) education level < bachelor degree; (4) co-morbidity(ies); and (5) generic drug use. TKI-therapy duration 3-5 years was associated with higher PCS and MCS.

CONCLUSIONS

Higher out-of-pocket expense for TKI therapy is significantly associated with worse HRQoL in persons with chronic-phase CML in CCyR receiving TKI therapy. These data indicate the importance of drug cost and health insurance policies on people's HRQoL.

Patient perceptions of treatment-free remission in chronic myeloid leukemia

Around half of patients with chronic myeloid leukemia (CML) who achieve a stable deep molecular response would remain in treatment-free remission (TFR) if their tyrosine kinase inhibitors (TKIs) were stopped. TFR is increasingly becoming a goal of treatment. Eighty-seven patients answered a survey exploring patient perceptions of TFR, incorporating CML-specific factors (disease history, treatment toxicity, and adherence) and questions concerning health beliefs. 81% of participants (95% CI: 72%-89%) indicated that they would be willing to attempt TFR. No demographic or CML-related variable in the survey was significantly associated with willingness. In qualitative analysis, the commonest motivations for TFR included TKI toxicity (n = 26) and convenience (n = 18). The leading reason for reluctance was fear of consequences of stopping TKI (n = 16). Reluctance was often associated with needs for additional information or incomplete understanding of the current data. Understanding patient motivations and concerns is important if TFR is to become a part of CML management.

[A survey on tyrosine kinase inhibitor treatment in patients with chronic myeloid leukemia in China: from patients'perspective]

OBJECTIVES

To assess tyrosine kinase inhibitor (TKI) treatment status in patients with chronic myeloid leukemia (CML) in China and analyze the response-associated factors.

METHODS

From May to November in 2014, anonymous questionnaires were distributed to adult CML patients who were receiving TKI treatment all over China.

RESULTS

1 038 questionnaires were collected, 949 questionnaires were evaluable. Of the 949 evaluable respondents, 549 (58%) were male with the median age of 41 years (range, 18 to 88 years). 623 (66%) respondents lived in an urban area and 449 (47%) had an education level ≥ a bachelor degree. 888 (94%) respondents were in the chronic phase at diagnosis, and 690 (78%) of them started TKI treatment within one year after diagnosis. 794 (84%) respondents were on imatinib, 768 (81%) on the branded. With a median TKI treatment duration of 3 years (range, <1 to 13 years), 708 of 834 (85%) evaluable respondents achieved Ph- negative (i.e. complete cytogenetic response, CCyR), and 497 of 859 (46% ) BCR- ABL negative (i.e. complete molecular response, CMR). Multivariate analyses showed that female (OR=1.8, 95% CI 1.1-2.8,P=0.019 andOR=1.5, 95% CI 1.1-2.0,P=0.015), TKI treatment duration >3 years (OR=4.1, 95% CI 2.6- 6.5,P<0.001 andOR=3.7, 95% CI 2.7- 5.1,P< 0.001) and imatinib taken (OR=2.1, 95% CI 1.2-3.7,P=0.007 andOR=3.3, 95% CI 2.1-5.1,P<0.001) were factors affecting achieving both CCyR and CMR. In addition, higher education level (OR=2.0, 95% CI 1.3- 3.1,P=0.003), starting TKI treatment <1 year (OR=2.4, 95% CI 1.5- 3.8,P<0.001) and branded drugs received (OR=2.4, 95% CI 1.4- 4.0,P=0.001) were factors affecting achieving a CCyR. In 884 respondents, 534 (62%) reported " heavy financial burden" as the biggest treatment impediment, only 152 (17%) reported " poor quality of life related to adverse effects of TKI".

CONCLUSIONS

The survey showed that majority of the Chinese CML patients received imatinib as a TKI therapy, and most of the patients achieved satisfied responses by TKI. Financial burden became the major obstacle during TKI treatment.

Deep molecular responses for treatment-free remission in chronic myeloid leukemia

Several clinical trials have demonstrated that some patients with chronic myeloid leukemia in chronic phase (CML-CP) who achieve sustained deep molecular responses on tyrosine kinase inhibitor (TKI) therapy can safely suspend therapy and attempt treatment-free remission (TFR). Many TFR studies to date have enrolled imatinib-treated patients; however, the feasibility of TFR following nilotinib or dasatinib has also been demonstrated. In this review, we discuss available data from TFR trials and what these data reveal about the molecular biology of TFR. With an increasing number of ongoing TFR clinical trials, TFR may become an achievable goal for patients with CML-CP.