Patient characteristics, treatment patterns, and mortality in elderly patients newly diagnosed with ALL

Advances in the treatment of Philadelphia chromosome negative acute lymphoblastic leukemia

There have been major paradigm shifts in the treatment of Philadelphia chromosome negative (Ph-) acute lymphoblastic leukemia (ALL) in the last decade with the introduction of new immunotherapies and targeted agents, adoption of pediatric-type chemotherapy protocols in younger adults as well as chemotherapy light approaches in older adults and the incorporation of measurable residual disease (MRD) testing to inform clinical decision making. With this, treatment outcomes in adult Ph- ALL have improved across all age groups. However, a subset of patients will still develop relapsed disease, which can be challenging to treat and associated with poor outcomes. Here we review the treatment of Ph- ALL in both younger and older adults, including the latest advancements and future directions.

SOHO State of the Art Updates and Next Questions | Approach to Older Adults With Phildadelphia-Chromosome Negative Acute Lymphoblastic Leukemia

Philadelphia-chromosome-negative (Ph-neg) acute lymphoblastic leukemia (ALL) has historically been associated with poor outcomes in older patients due to adverse disease biology, as well as inferior tolerance of conventional chemotherapy. Fortunately, novel therapies, including inotuzumab ozogamicin, blinatumomab, and venetoclax, are now being incorporated into first-line therapy to improve efficacy and decrease toxicity of initial therapy. Inotuzumab ozogamicin, alone or in combination with low intensity chemotherapy, appears to be best suited for the induction phase of treatment due to efficacy in the setting of high tumor burden. In contrast, blinatumomab may be best suited for consolidation due to superior efficacy in setting of morphologic remission, with or without measurable residual disease (MRD). Venetoclax is being investigated in combination with chemotherapy and can be used for treatment of older adults with both B-cell and T-cell ALL. Ongoing trials incorporating inotuzumab, blinatumomab, and venetoclax demonstrate high rates of MRD-negative complete remissions with low early mortality. Long-term outcomes have been less favorable so far, with several trials reporting nonrelapse mortality during subsequent treatment. Unanswered questions remain regarding the optimal treatment of older adults with Ph-neg ALL, including central nervous system (CNS) prophylaxis, the most appropriate consolidation to minimize toxicity without compromising efficacy, and the role of transplant and cellular therapy. T-cell ALL remains an area of unmet need and effort is required to ensure that therapeutic advances benefit all populations equitably. In this manuscript, we review current data and ongoing trials regarding the treatment of older adults with Ph-neg ALL and define topics for further research.

Mini-hyper-CVD plus inotuzumab ozogamicin, with or without blinatumomab, in the subgroup of older patients with newly diagnosed Philadelphia chromosome-negative B-cell acute lymphocytic leukaemia: long-term results of an open-label phase 2 trial

BACKGROUND

The outcome of older patients with B-cell acute lymphocytic leukaemia is inferior to that in younger patients due to the adverse disease biology and their inability to tolerate intensive therapy. We aimed to study the long-term outcomes of inotuzumab ozogamicin with or without blinatumomab in combination with low-intensity chemotherapy in these patients.

METHODS

For this open-label phase 2 trial, patients aged 60 years or older with newly diagnosed, Philadelphia-chromosome negative, B-cell acute lymphocytic leukaemia, and an ECOG performance status of 3 or lower were eligible. This study was conducted at the University of Texas MD Anderson Cancer Center. The induction chemotherapy consisted of mini-hyper-CVD and has been published before; inotuzumab ozogamicin was administered intravenously on day 3 of the first four cycles at a dose of 1·3-1·8 mg/m2 in cycle 1, followed by 1·0-1·3 mg/m2 in subsequent cycles (cycles 2-4). Maintenance therapy with dose-reduced POMP (6-mercaptopurine, vincristine, methotrexate, and prednisone) was given for 3 years. From patient 50 onwards, the study protocol was amended to fractionate inotuzumab ozogamicin to a maximum cumulative dose of 2·7 mg/m2 (0·9 mg/m2 during cycle 1 fractionated into 0·6 mg/m2 on day 2 and 0·3 mg/m2 on day 8 of cycle 1, and 0·6 mg/m2 in cycles 2-4 fractionated into 0·3 mg/m2 on day 2 and 0·3 mg/m2 on day 8) followed by blinatumomab for four cycles (cycles 5-8). POMP maintenance was shortened to 12 cycles with one cycle of blinatumomab administered by continuous infusion after every three cycles of POMP. The primary endpoint was progression-free survival and was analysed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov (NCT01371630) and the present data is from the newly diagnosed, older subgroup of patients treated on the phase 2 portion of this trial; the trial is still enrolling patients.

RESULTS

Between Nov 11, 2011, and March 31, 2022, 80 patients were enrolled and treated (32 female and 48 male patients; median age 68 years [IQR 63-72]), 31 of whom were treated after the protocol amendment. With a median follow-up of 92·8 months (IQR 8·8-67·4), the 2-year progression-free survival was 58·2% (95% CI 46·7-68·2) and 5-year progression-free survival was 44·0% (31·2-54·3). At a median follow-up of 104·4 months (IQR 6·6-89·2) for the patients treated before the protocol amendment and 29·7 months (8·8-41·0) for those treated after the protocol amendment, median progression-free survival did not differ significantly between the two groups (34·7 months [95% CI 15·0-68·3] vs 56·4 months [11·3-69·7]; p=0·77). The most common grade 3-4 events were thrombocytopenia in 62 (78%) patients and febrile neutropenia in 26 (32%) patients. Six (8%) patients developed hepatic sinusoidal obstruction syndrome. There were eight (10%) deaths due to infectious complications, nine (11%) from complications related to secondary myeloid malignancy, and four (5%) from sinusoidal obstruction syndrome.

INTERPRETATION

Inotuzumab ozogamicin with or without blinatumomab added to low-intensity chemotherapy showed promising activity in terms of progression-free survival in older patients with B-cell acute lymphocytic leukaemia. Further attenuation of the chemotherapy regimen might improve tolerability while maintaining efficacy in older patients.

FUNDING

Pfizer and Amgen.

Real-world outcomes of adult patients with acute lymphoblastic leukemia treated with a modified CALGB 10102 regimen

Acute lymphoblastic leukemia (ALL) is an aggressive bone marrow cancer with disparate outcomes. Data on patient outcomes in real world settings outside of clinical trials is limited. The current study reports on outcomes for 137 ALL patients who received an adult induction and consolidation regimen derived from the CALGB 10102 trial modified without alemtuzumab. Of the 137 patients, 32 were < 40 years old, 52 were between 40 and 59, and 53 were ≥ 60 years old. Overall, 109 (79.6%) patients achieved a complete remission (< 40: 96.1%, 40-59: 86.5%, and 62.3% ≥ 60 (p = 0.0002)). Progression free survival for the entire cohort was 13.5 months and by age was 19.8 months for less than 40, 23.4 months for 40 to 59 and 6.7 months for ≥ 60; p = 0.0002. Median survival was 22.1 months for the entire cohort (32.9 months for ages < 40, 26.6 months ages 40-59, 7.8 months ≥ 60, p < 0.001).

SOHO State of the Art Updates and Next Questions: Mini-Hyper-CVD Combinations for Older Adults: Results of Recent Trials and a Glimpse into the Future

Acute lymphoblastic leukemia (ALL) is an aggressive blood cancer that affects both children and adults. Although the majority of children diagnosed with ALL are now cured and outcomes are improving for younger adults, older adults diagnosed with ALL usually succumb to their disease. Traditional chemotherapy regimens are poorly tolerated and ineffective in most older adults. Recently, novel chemotherapy agents such as inotuzumab ozogamicin and venetoclax have been successfully combined with dose reduced chemotherapy (mini-hyper-CVD) with promising results. Further study is needed to define the optimal combination and sequencing of novel agents and chemotherapy for different patient populations. This review discusses the challenge of treating older adults with traditional chemotherapy, experience to date with novel agents in combination with mini-hyper-CVD, as well as future directions and unanswered questions.

Innovative Approaches to the Management of Acute Lymphoblastic Leukemia Across the Age Spectrum

Adults compose nearly half of all patients diagnosed with acute lymphoblastic leukemia (ALL) and historically have had poor survival compared with pediatric patients. Recently approved therapies, such as monoclonal antibodies, CAR T-cell constructs, and next-generation tyrosine kinase inhibitors, have improved survival in relapsed and refractory ALL, and studies are now examining incorporating these treatments and others into the upfront setting. In adolescent and young adult patients, use of pediatric-based regimens has already improved survival compared with historical controls, and the addition of monoclonal antibodies, such as inotuzumab ozogamicin and blinatumomab, may further enhance this survival benefit. In older adults, approaches have centered on minimizing conventional chemotherapy to decrease toxicity by incorporating monoclonal antibodies and other novel therapies to increase efficacy. With the addition of tyrosine kinase inhibitors to chemotherapy for patients with Philadelphia chromosome-positive ALL, survival of this once poor-prognosis ALL subtype now approaches or exceeds outcomes of other subtypes of adult ALL. Further refinements in the backbone treatment regimen and optimal consolidation approaches will likely improve survival further. Although allogeneic hematopoietic stem cell transplant was previously routinely used as consolidation for adults with ALL, incorporation of measurable residual disease and other risk stratification strategies has enabled better identification of patients who will benefit from allogeneic hematopoietic stem cell transplant. Ongoing clinical trials investigating these approaches will continue the evolution of treatment approaches for adults with ALL, with further improvement in outcomes anticipated.

Characteristics and Outcome of Elderly Patients (>55 years) with Acute Lymphoblastic Leukemia

Simple Summary

Disease-specific mortality of acute lymphoblastic leukemia (ALL) increases with age. So far, only a few analyses have investigated disease characteristics of elderly patients (>55 years) with newly diagnosed ALL. The aim of our retrospective study was to evaluate the treatment results of 93 elderly patients who received intensive chemotherapy between May 2003 and October 2020. We identify poor performance status and older age at the time of diagnosis as risk factors for inferior outcomes, while ALL immunophenotype, BCR::ABL1 status, the complexity of karyotype, and intensity of treatment did not significantly affect overall survival (OS). With 17.3% of patients dying while in complete remission (CR), an event-free survival (EFS) and OS of 32.9% and 47.3% at 3 years, our data suggest that intensive treatment of elderly ALL patients is feasible but associated with significant toxicity. These results underline the need for novel, less toxic treatment approaches for this vulnerable cohort of patients.

Abstract

Prognosis of elderly ALL patients remains dismal. Here, we retrospectively analyzed the course of 93 patients > 55 years with B-precursor (n = 88) or T-ALL (n = 5), who received age-adapted, pediatric-inspired chemotherapy regimens at our center between May 2003 and October 2020. The median age at diagnosis was 65.7 years, and surviving patients had a median follow-up of 3.7 years. CR after induction therapy was documented in 76.5%, while the rate of treatment-related death within 100 days was 6.4%. The OS of the entire cohort at 1 and 3 year(s) was 75.2% (95% CI: 66.4–84.0%) and 47.3% (95% CI: 36.8–57.7%), respectively, while the EFS at 1 and 3 years(s) was 59.0% (95% CI: 48.9–69.0%) and 32.9% (95% CI: 23.0–42.8%), respectively. At 3 years, the cumulative incidence (CI) of relapse was 48.3% (95% CI: 38.9–59.9%), and the CI rate of death in CR was 17.3% (95% CI: 10.9–27.5%). Older age and an ECOG > 2 represented risk factors for inferior OS, while BCR::ABL1 status, immunophenotype, and intensity of chemotherapy did not significantly affect OS. We conclude that intensive treatment is feasible in selected elderly ALL patients, but high rates of relapse and death in CR underline the need for novel therapeutic strategies.

Acute lymphoblastic leukemia in older adults: curtain call for conventional chemotherapy?

Unlike younger adults with acute lymphoblastic leukemia (ALL), older adults are rarely cured due to a combination of intrinsic disease resistance and treatment-related toxicities. Novel therapeutics such as inotuzumab ozogamicin, blinatumomab, venetoclax, and ABL kinase inhibitors have high activity in ALL and are well tolerated by older adults. Frontline treatment regimens for older adults using novel therapeutics with reduction or omission of conventional chemotherapy are being developed with early results demonstrating high remission rates and lower toxicity, but long-term efficacy and toxicity data are lacking. Collaboration between academic and pharmaceutical stakeholders is needed to develop clinical trials to define the optimal treatment regimens for older adults with ALL.

Targeted therapy paves the way for the cure of acute lymphoblastic leukaemia

The past decade has witnessed tremendous progress in the treatment of acute lymphoblastic leukaemia (ALL), primarily due to the development of targeted therapies, including tyrosine kinase inhibitors targeting BCR-ABL1 tyrosine kinase, monoclonal antibodies targeting cell surface antigens (CD19, CD20 and CD22), bispecific antibodies and chimeric antigen receptor T- cell therapy. A number of new therapies have been approved by the US Food and Drug Administration in the past 5 years, including blinatumomab in 2014, inotuzumab ozagamicin in 2017 and tisagenlecleucel in 2017 for relapsed/refractory ALL. This has led to tremendous improvement in long-term survival, of more than 50% in patients with precursor B-ALL [50-70% in patients with Philadelphia chromosome (Ph)-positive ALL)], 50-60% in T-ALL and 80% in mature B-ALL. Research is ongoing to optimize the benefit of targeted therapeutics with the goal of decreasing the use of cytotoxic therapies.