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Vu M, Degeling K, Thompson ER, Blombery P, Westerman D, IJzerman MJ. Cost Effectiveness of Molecular Diagnostic Testing Algorithms for the Treatment Selection of Frontline Ibrutinib for Patients with Chronic Lymphocytic Leukemia in Australia. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:107-122. [PMID: 37608228 PMCID: PMC10761538 DOI: 10.1007/s40258-023-00826-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Clinical indications for ibrutinib reimbursement in Australia should consider the inclusion of patients with chronic lymphocytic leukemia (CLL) harboring prognostically unfavorable TP53/IGHV genomic aberrations. This study assessed the cost effectiveness of five first-line treatment strategies in CLL for young (aged ≤ 65 years), fit patients without significant comorbidities: (1) no testing (fludarabine, cyclophosphamide and rituximab [FCR] for all), (2) test for del(17p) only, (3) test for TP53 gene mutation status, (4) test for TP53 and IGHV gene mutation status and (5) no testing (ibrutinib for all). METHOD A decision analytic model (decision tree and partitioned survival model) was developed from the Australian healthcare system perspective with a lifetime horizon. Comparative treatment effects were estimated from indirect treatment comparisons and survival analysis using several studies. Costs, utility and adverse events were derived from public literature sources. Deterministic and probabilistic sensitivity analyses explored the impact of modeling uncertainties on outcomes. RESULTS Strategy 1 was associated with 5.69 quality-adjusted life-years (QALYs) and cost 458,836 Australian dollars (AUD). All other strategies had greater effectiveness but were more expensive than Strategy 1. At the willingness-to-pay (WTP) threshold of 100,000 AUD per QALY gained, Strategy 1 was most cost effective with an estimated probability of 68.8%. Strategy 4 was cost effective between thresholds 155,000-432,300 AUD per QALY gained, and Strategy 5 >432,300 AUD per QALY gained. CONCLUSION Population targeting using mutation testing for TP53 and IGHV when performed with del(17p) testing specifically in the context of frontline ibrutinib choice does not make a cost-ineffective treatment into a cost-effective treatment.
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Affiliation(s)
- Martin Vu
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, 305 Grattan Street, Melbourne, VIC, 3000, Australia
- Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Koen Degeling
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, 305 Grattan Street, Melbourne, VIC, 3000, Australia
- Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Ella R Thompson
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
| | - Piers Blombery
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Melbourne, Australia
| | - David Westerman
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia
- Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Melbourne, Australia
| | - Maarten J IJzerman
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, 305 Grattan Street, Melbourne, VIC, 3000, Australia.
- Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia.
- Erasmus School of Health Policy and Management, Rotterdam, The Netherlands.
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Mulligan EA, Tudhope SJ, Hunter JE, Clift AEG, Elliott SL, Summerfield GP, Wallis J, Pepper CJ, Durkacz B, Veuger S, Willmore E. Expression and Activity of the NF-κB Subunits in Chronic Lymphocytic Leukaemia: A Role for RelB and Non-Canonical Signalling. Cancers (Basel) 2023; 15:4736. [PMID: 37835430 PMCID: PMC10571822 DOI: 10.3390/cancers15194736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/14/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Canonical NF-κB signalling by p65 (RelA) confers chemo-resistance and poor survival in chronic lymphocytic leukaemia (CLL). The role of non-canonical NF-κB signalling (leading to RelB and p52 subunit activation) in CLL is less understood, but given its importance in other B-cell tumour types, we theorised that RelB and p52 may also contribute to the pathology of CLL. METHODS DNA binding activity of all five NF-kB subunits, p65, p50, RelB, p52, and c-Rel, was quantified using ELISA and correlated to ex vivo chemoresistance, CD40L-stimulated signalling (to mimic the lymph node microenvironment), and clinical data. RESULTS Importantly, we show for the first time that high basal levels of RelB DNA binding correlate with nuclear RelB protein expression and are associated with del(11q), ATM dysfunction, unmutated IGHV genes, and shorter survival. High levels of nuclear p65 are prevalent in del(17p) cases (including treatment-naïve patients) and also correlate with the outcome. CD40L-stimulation resulted in rapid RelB activation, phosphorylation and processing of p100, and subsequent CLL cell proliferation. CONCLUSIONS These data highlight a role for RelB in driving CLL cell tumour growth in a subset of patients and therefore strategies designed to inhibit non-canonical NF-κB signalling represent a novel approach that will have therapeutic benefit in CLL.
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Affiliation(s)
- Evan A. Mulligan
- Cancer Research UK Drug Discovery Unit, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Susan J. Tudhope
- Cancer Research UK Drug Discovery Unit, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Jill E. Hunter
- Cancer Research UK Drug Discovery Unit, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Arabella E. G. Clift
- Cancer Research UK Drug Discovery Unit, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Sarah L. Elliott
- Cancer Research UK Drug Discovery Unit, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | | | - Jonathan Wallis
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK
| | - Chris J. Pepper
- Medical Research Building, Brighton and Sussex Medical School, University of Sussex, Brighton BN1 9PX, UK
| | - Barabara Durkacz
- Cancer Research UK Drug Discovery Unit, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Stephany Veuger
- Department of Applied Sciences, Northumbria University, Newcastle upon Tyne NE7 7XA, UK
| | - Elaine Willmore
- Cancer Research UK Drug Discovery Unit, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
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Griffin J, Wu Y, Mu Q, Li X, Ho RJY. Design and Characterization of a Novel Venetoclax-Zanubrutinib Nano-Combination for Enhancing Leukemic Cell Uptake and Long-Acting Plasma Exposure. Pharmaceutics 2023; 15:pharmaceutics15031016. [PMID: 36986876 PMCID: PMC10051515 DOI: 10.3390/pharmaceutics15031016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Leukemia remains incurable partly due to difficulties in reaching and maintaining therapeutic drug concentrations in the target tissues and cells. Next-generation drugs targeted to multiple cell checkpoints, including the orally active venetoclax (Bcl-2 target) and zanubrutinib (BTK target), are effective and have improved safety and tolerability compared to conventional, nontargeted chemotherapies. However, dosing with a single agent frequently leads to drug resistance; asynchronous coverage due to the peak-and-trough time-course of two or more oral drugs has prevented drug combinations from simultaneously knocking out the respective drugs' targets for sustained leukemia suppression. Higher doses of the drugs may potentially overcome asynchronous drug exposure in leukemic cells by saturating target occupancy, but higher doses often cause dose-limiting toxicities. To synchronize multiple drug target knockout, we have developed and characterized a drug combination nanoparticle (DcNP), which enables the transformation of two short-acting, orally active leukemic drugs, venetoclax and zanubrutinib, into long-acting nanoformulations (VZ-DCNPs). VZ-DCNPs exhibit synchronized and enhanced cell uptake and plasma exposure of both venetoclax and zanubrutinib. Both drugs are stabilized by lipid excipients to produce the VZ-DcNP nanoparticulate (d ~ 40 nm) product in suspension. The VZ-DcNP formulation has enhanced uptake of the two drugs (VZ) in immortalized leukemic cells (HL-60), threefold over that of its free drug counterpart. Additionally, drug-target selectivity of VZ was noted with MOLT-4 and K562 cells that overexpress each target. When given subcutaneously to mice, the half-lives of venetoclax and zanubrutinib were extended by approximately 43- and 5-fold, respectively, compared to an equivalent free VZ. Collectively, these data suggest that VZ in VZ-DcNP warrant consideration for preclinical and clinical development as a synchronized and long-acting drug-combination for the treatment of leukemia.
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Affiliation(s)
- James Griffin
- Departments of Pharmaceutics, University of Washington, Seattle, WA 98195, USA
| | - Yan Wu
- Departments of Bioengineering, University of Washington, Seattle, WA 98195, USA
| | - Qingxin Mu
- Departments of Pharmaceutics, University of Washington, Seattle, WA 98195, USA
| | - Xinyan Li
- Departments of Pharmaceutics, University of Washington, Seattle, WA 98195, USA
- School of Pharmacy, China Pharmaceutical University, Nanjing 210009, China
| | - Rodney J Y Ho
- Departments of Pharmaceutics, University of Washington, Seattle, WA 98195, USA
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Pathobiology and Therapeutic Relevance of GSK-3 in Chronic Hematological Malignancies. Cells 2022; 11:cells11111812. [PMID: 35681507 PMCID: PMC9180032 DOI: 10.3390/cells11111812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 05/28/2022] [Accepted: 05/29/2022] [Indexed: 12/10/2022] Open
Abstract
Glycogen synthase kinase-3 (GSK-3) is an evolutionarily conserved, ubiquitously expressed, multifunctional serine/threonine protein kinase involved in the regulation of a variety of physiological processes. GSK-3 comprises two isoforms (α and β) which were originally discovered in 1980 as enzymes involved in glucose metabolism via inhibitory phosphorylation of glycogen synthase. Differently from other proteins kinases, GSK-3 isoforms are constitutively active in resting cells, and their modulation mainly involves inhibition through upstream regulatory networks. In the early 1990s, GSK-3 isoforms were implicated as key players in cancer cell pathobiology. Active GSK-3 facilitates the destruction of multiple oncogenic proteins which include β-catenin and Master regulator of cell cycle entry and proliferative metabolism (c-Myc). Therefore, GSK-3 was initially considered to be a tumor suppressor. Consistently, GSK-3 is often inactivated in cancer cells through dysregulated upstream signaling pathways. However, over the past 10–15 years, a growing number of studies highlighted that in some cancer settings GSK-3 isoforms inhibit tumor suppressing pathways and therefore act as tumor promoters. In this article, we will discuss the multiple and often enigmatic roles played by GSK-3 isoforms in some chronic hematological malignancies (chronic myelogenous leukemia, chronic lymphocytic leukemia, multiple myeloma, and B-cell non-Hodgkin’s lymphomas) which are among the most common blood cancer cell types. We will also summarize possible novel strategies targeting GSK-3 for innovative therapies of these disorders.
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