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Sánchez Suárez MDM, Martín Roldán A, Alarcón-Payer C, Rodríguez-Gil MÁ, Poquet-Jornet JE, Puerta Puerta JM, Jiménez Morales A. Treatment of Chronic Lymphocytic Leukemia in the Personalized Medicine Era. Pharmaceutics 2023; 16:55. [PMID: 38258066 PMCID: PMC10818903 DOI: 10.3390/pharmaceutics16010055] [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: 10/16/2023] [Revised: 11/26/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024] Open
Abstract
Chronic lymphocytic leukemia is a lymphoproliferative disorder marked by the expansion of monoclonal, mature CD5+CD23+ B cells in peripheral blood, secondary lymphoid tissues, and bone marrow. The disease exhibits significant heterogeneity, with numerous somatic genetic alterations identified in the neoplastic clone, notably mutated TP53 and immunoglobulin heavy chain mutational statuses. Recent studies emphasize the pivotal roles of genetics and patient fragility in treatment decisions. This complexity underscores the need for a personalized approach, tailoring interventions to individual genetic profiles for heightened efficacy. The era of personalized treatment in CLL signifies a transformative shift, holding the potential for improved outcomes in the conquest of this intricate hematologic disorder. This review plays a role in elucidating the evolving CLL treatment landscape, encompassing all reported genetic factors. Through a comprehensive historical analysis, it provides insights into the evolution of CLL management. Beyond its retrospective nature, this review could be a valuable resource for clinicians, researchers, and stakeholders, offering a window into the latest advancements. In essence, it serves as a dynamic exploration of our current position and the promising prospects on the horizon.
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Affiliation(s)
- María Del Mar Sánchez Suárez
- Servicio de Farmacia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.D.M.S.S.); (A.M.R.); (A.J.M.)
| | - Alicia Martín Roldán
- Servicio de Farmacia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.D.M.S.S.); (A.M.R.); (A.J.M.)
| | - Carolina Alarcón-Payer
- Servicio de Farmacia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.D.M.S.S.); (A.M.R.); (A.J.M.)
| | - Miguel Ángel Rodríguez-Gil
- Unidad de Gestión Clínica Hematología y Hemoterapia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.Á.R.-G.); (J.M.P.P.)
| | | | - José Manuel Puerta Puerta
- Unidad de Gestión Clínica Hematología y Hemoterapia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.Á.R.-G.); (J.M.P.P.)
| | - Alberto Jiménez Morales
- Servicio de Farmacia, Hospital Universitario Virgen de las Nieves, 18014 Granada, Granada, Spain; (M.D.M.S.S.); (A.M.R.); (A.J.M.)
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Welch BM, Manso BA, Gwin KA, Lothert PK, Parikh SA, Kay NE, Medina KL. Comparison of the blood immune repertoire with clinical features in chronic lymphocytic leukemia patients treated with chemoimmunotherapy or ibrutinib. Front Oncol 2023; 13:1302038. [PMID: 38111528 PMCID: PMC10725910 DOI: 10.3389/fonc.2023.1302038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/20/2023] [Indexed: 12/20/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is characterized by the accumulation of CD19+ CD5+ clonal B lymphocytes in the blood, bone marrow, and peripheral lymphoid organs. Treatment options for patients range from historical chemoimmunotherapy (CIT) to small molecule inhibitors targeting pro-survival pathways in leukemic B cells, such as the Bruton's tyrosine kinase inhibitor ibrutinib (IBR). Using biobanked blood samples obtained pre-therapy and at standard response evaluation timepoints, we performed an in-depth evaluation of the blood innate and adaptive immune compartments between pentostatin-based CIT and IBR and looked for correlations with clinical sequelae. CD4+ conventional T cells and CD8+ cytotoxic T cells responded similarly to CIT and IBR, although exhaustion status differed. Both treatments dramatically increased the prevalence and functional status of monocyte, dendritic cell, and natural killer cell subsets. As expected, both regimens reduced clonal B cell levels however, we observed no substantial recovery of normal B cells. Although improvements in most immune subsets were observed with CIT and IBR at response evaluation, both patient groups remained susceptible to infections and secondary malignancies during the study.
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Affiliation(s)
- Baustin M. Welch
- Department of Immunology, Mayo Clinic, Rochester, MN, United States
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN, United States
| | - Bryce A. Manso
- Department of Immunology, Mayo Clinic, Rochester, MN, United States
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN, United States
- Department of Biomolecular Engineering, University of California, Santa Cruz, Santa Cruz, CA, United States
| | - Kimberly A. Gwin
- Department of Immunology, Mayo Clinic, Rochester, MN, United States
| | - Petra K. Lothert
- Department of Immunology, Mayo Clinic, Rochester, MN, United States
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN, United States
| | - Sameer A. Parikh
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Neil E. Kay
- Department of Immunology, Mayo Clinic, Rochester, MN, United States
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Kay L. Medina
- Department of Immunology, Mayo Clinic, Rochester, MN, United States
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Baratè C, Sanna A, Benedetti E, Bocchia M, Capochiani E, Danesi R, Moretti S, Occhini U, Santini S, Galimberti S, Gozzetti A. Real-life diagnostic and therapeutic approach to CLL: a 2022 update from an expert panel in Tuscany. Clin Exp Med 2023; 23:4251-4264. [PMID: 37979127 DOI: 10.1007/s10238-023-01244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 10/26/2023] [Indexed: 11/19/2023]
Abstract
A panel of chronic lymphocytic leukemia (CLL) experts from Tuscany propose a real-life diagnostic and therapeutic approach CLL that considers the role of genomic and somatic prognostic factors in risk stratification and treatment decisions. Safety and efficacy of new agents has been demonstrated now not only in clinical trials but also in many real-world series. The BTK inhibitors, ibrutinib and acalabrutinib, and BH3 mimetic venetoclax are now indicated as first-line therapy and chemoimmunotherapy can be spared to the majority of CLL patients, thus preventing unnecessary hematological and non-hematological toxicity and second primary tumors. For treatment, FISH for 17 p and P53 mutational status are essential. IGHV mutation can be done at diagnosis or before treatment. Echography is the gold standard radiological investigation in CLL, at both diagnosis and response evaluation. Chemotherapy is virtually abandoned. Age, genetic risk, and patient comorbidities have to be carefully evaluated for treatment decision. With the availability of different drugs, there is a need for a uniform and shared approach in daily therapeutic choice. The proposed approach is based on current evidence and guidelines as well as results from clinical trials and daily clinical experience.
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Affiliation(s)
- Claudia Baratè
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Alessandro Sanna
- Hematology Unit, Department of Oncology, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
| | - Edoardo Benedetti
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
- Italian School of Basic and Emergency Ultrasound (SIUMB), Pisa, Italy
| | - Monica Bocchia
- Hematology Unit, Azienda USL, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Enrico Capochiani
- Hematology Unit, Department of Internal Medicine, Toscana Nord Ovest, Leghorn, Italy
| | - Romano Danesi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | | | | | | | - Sara Galimberti
- Department of Clinical and Experimental Medicine, UO Hematology, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alessandro Gozzetti
- Hematology Unit, Azienda USL, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
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van der Straten L, Stege CAM, Kersting S, Nasserinejad K, Dubois J, Dobber JA, Mellink CHM, van der Kevie-Kersemaekers AMF, Evers LM, de Boer F, Koene HR, Schreurs J, van der Klift M, Velders GA, van der Spek E, van der Straaten HM, Hoogendoorn M, van Gelder M, Posthuma EFM, Visser HPJ, Houtenbos I, Idink CAM, Issa DE, Dompeling EC, van Zaanen HCT, Veelken JH, Levenga H, Tick LW, Terpstra WE, Tonino SH, Westerweel PE, Langerak AW, Kater AP, Levin MD. Fixed-duration venetoclax plus obinutuzumab improves quality of life and geriatric impairments in FCR-unfit patients with CLL. Blood 2023; 142:1131-1142. [PMID: 37363833 DOI: 10.1182/blood.2023020195] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/26/2023] [Accepted: 05/29/2023] [Indexed: 06/28/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL)-related symptoms and morbidity related to the advanced age at diagnosis impairs the well-being of older adult patients. Therefore, it is essential to tailor treatment according to geriatric characteristics and aim for an improvement in health-related quality of life (HRQoL) as a primary treatment goal. In the HOVON139/GiVe trial, 12 cycles of fixed-duration venetoclax plus obinutuzumab (Ven-O) were shown to be effective and tolerable in FCR (fludarabine, cyclophosphamide, rituximab)-unfit patients with CLL (n = 67). However, prolonged venetoclax exposure as consolidation treatment led to increased toxicity with limited effect on minimal residual disease. To assess the impact of geriatric assessment on treatment outcomes and the patients' HRQoL, patient-reported outcomes (PROs), including function, depression, cognition, nutrition, physical performance, muscle parameters, comorbidities, and the European Organization for Research and Treatment of Cancer C30 and CLL17 questionnaires were assessed. At baseline, geriatric impairments were present in >90% of patients and ≥2 impairments present in 60% of patients predicted grade ≥3 nonhematological toxicity. During treatment, the number of geriatric impairments diminished significantly and clinically relevant improvements in HRQoL subscales were reached for global health status, physical functioning, role functioning, emotional functioning, fatigue, dyspnea, physical condition or fatigue, and worries or fears related to health and functioning. These improvements were comparable for patients receiving venetoclax consolidation and patients in whom treatment could mostly be discontinued. Collectively, frontline fixed-duration Ven-O improves overall PROs in older, unfit patients with CLL with and without geriatric impairments. This study was registered at EudraCT as 2015-004985-27 and the Netherlands Trial Register as NTR6043.
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Affiliation(s)
- Lina van der Straten
- Department of Immunology, Erasmus MC, Rotterdam, The Netherlands
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - Claudia A M Stege
- Department of Hematology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam-Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Sabina Kersting
- Department of Hematology, HAGA Teaching Hospital, The Hague, The Netherlands
| | - Kazem Nasserinejad
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Julie Dubois
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam, The Netherlands
| | - Johan A Dobber
- Department of Laboratory Special Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Clemens H M Mellink
- Department of Human Genetics, Section Cytogenetics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Ludo M Evers
- Department of Laboratory Special Hematology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Fransien de Boer
- Department of Internal Medicine, Ikazia Hospital, Rotterdam, The Netherlands
| | - Harry R Koene
- Department of Hematology, Antonius Hospital, Nieuwegein, The Netherlands
| | - John Schreurs
- Department of Internal Medicine, Martini Hospital, Groningen, The Netherlands
| | | | - Gerjo A Velders
- Department of Internal Medicine, Gelderland Valley Hospital, Ede, The Netherlands
| | - Ellen van der Spek
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Mels Hoogendoorn
- Department of Internal Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Michel van Gelder
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Eduardus F M Posthuma
- Department of Internal Medicine, Reinier The Graaf Hospital, Delft, The Netherlands
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hein P J Visser
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Ilse Houtenbos
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Cecile A M Idink
- Department of Internal Medicine, ZorgSaam Hospital, Terneuzen, The Netherlands
| | - Djamila E Issa
- Department of Internal Medicine, Jeroen Bosch Hospital, s-Hertogenbosch, The Netherlands
| | | | - Henk C T van Zaanen
- Department of Internal Medicine, St Franciscus Hospital, Rotterdam, The Netherlands
| | - J Hendrik Veelken
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henriette Levenga
- Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
| | - Lidwine W Tick
- Department of Internal Medicine, Maxima Medical Center, Eindhoven, The Netherlands
| | - Wim E Terpstra
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Sanne H Tonino
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam, The Netherlands
| | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Anton W Langerak
- Department of Immunology, Erasmus MC, Rotterdam, The Netherlands
| | - Arnon P Kater
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam, The Netherlands
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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Anderson MA, Bennett R, Badoux X, Best G, Chia N, Cochrane T, Cull G, Crassini K, Harrup R, Jackson S, Kuss B, Lasica M, Lew TE, Marlton P, Opat S, Palfreyman E, Polizzotto MN, Ratnasingam S, Seymour JF, Soosapilla A, Talaulikar D, Tam CS, Weinkove R, Wight J, Mulligan SP. Chronic lymphocytic leukaemia Australasian consensus practice statement. Intern Med J 2023; 53:1678-1691. [PMID: 37743239 DOI: 10.1111/imj.16207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 07/30/2023] [Indexed: 09/26/2023]
Abstract
Chronic lymphocytic leukaemia (CLL) is the most common haematological malignancy in Australia and New Zealand (ANZ). Considerable changes to diagnostic and management algorithms have occurred within the last decade. The availability of next-generation sequencing and measurable residual disease assessment by flow cytometry allow for advanced prognostication and response assessments. Novel therapies, including inhibitors of Bruton's tyrosine kinase (BTKi) and B-cell lymphoma 2 (BCL2) inhibitors, have transformed the treatment landscape for both treatment-naïve and relapsed/refractory disease, particularly for patients with high-risk genetic aberrations. Recommendations regarding appropriate supportive management continue to evolve, and special considerations are required for patients with CLL with respect to the global SARS-CoV-2 pandemic. The unique funding and treatment environments in Australasia highlight the need for specific local guidance with respect to the investigation and management of CLL. This consensus practice statement was developed by a broadly representative group of ANZ experts in CLL with endorsement by peak haematology bodies, with a view to providing this standardised guidance.
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Affiliation(s)
- Mary A Anderson
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rory Bennett
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Xavier Badoux
- St George Hospital, Sydney, New South Wales, Australia
| | - Giles Best
- Flinders University and Medical Centre, Adelaide, South Australia, Australia
| | - Nicole Chia
- Genomic Diagnostics, Healius Pathology, Brisbane, Queensland, Australia
| | - Tara Cochrane
- Gold Coast University Hospital, Griffith University, Gold Coast, Queensland, Australia
| | - Gavin Cull
- Sir Charles Gairdner Hospital, PathWest Laboratory Medicine and University of Western Australia, Perth, Western Australia, Australia
| | - Kyle Crassini
- Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Rosemary Harrup
- Cancer and Blood Services Royal Hobart Hospital, Hobart, Tasmania, Australia
- Menzies Research Institute, University of Tasmania, Hobart, Tasmania, Australia
| | - Sharon Jackson
- Te Whatu Ora health New Zealand Counties Manukau, Auckland, New Zealand
| | - Bryone Kuss
- Flinders University and Medical Centre, Adelaide, South Australia, Australia
| | - Masa Lasica
- St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Thomas E Lew
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, Melbourne, Victoria, Australia
- Department of Medical Biology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Paula Marlton
- Department of Haematology, Princess Alexandra Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Stephen Opat
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Emma Palfreyman
- Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Mark N Polizzotto
- Department of Clinical Haematology, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Clinical Hub for Interventional Research, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Sumita Ratnasingam
- St John of God Hospital Geelong, Geelong, Victoria, Australia
- University Hospital Geelong, Geelong, Victoria, Australia
- School of Medicine, Geelong Clinical School, Deakin University, Geelong, Victoria, Australia
| | - John F Seymour
- Department of Clinical Haematology, The Royal Melbourne Hospital and The Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Asha Soosapilla
- Flow Cytometry, Healius Pathology, Sydney, New South Wales, Australia
| | - Dipti Talaulikar
- Department of Diagnostic Genomics, ACT Pathology, Canberra Health Services, Canberra, Australian Capital Territory, Australia
- Department of Haematology, ACT Pathology, Canberra Health Services, Canberra, Australian Capital Territory, Australia
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Constantine S Tam
- Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Robert Weinkove
- Te Rerenga Ora Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
| | - Joel Wight
- Department of Haematology and Bone Marrow Transplantation, Townsville University Hospital, Townsville, Queensland, Australia
- James Cook University, School of Medicine, Townsville, Queensland, Australia
| | - Stephen P Mulligan
- Royal North Shore Hospital, Sydney, New South Wales, Australia
- Healius Pathology, Sydney, New South Wales, Australia
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Bennett R, Anderson MA, Seymour JF. Unresolved questions in selection of therapies for treatment-naïve chronic lymphocytic leukemia. J Hematol Oncol 2023; 16:72. [PMID: 37422670 PMCID: PMC10329329 DOI: 10.1186/s13045-023-01469-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 06/19/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND The treatment landscape for chronic lymphocytic leukemia (CLL) continues to undergo considerable evolution. Optimal selection of initial therapy from multiple effective options provides a major challenge for clinicians, who need to consider both disease and patient factors in conjunction with a view to sequencing available therapies in event of disease relapse. REVIEW We explore the most topical clinically relevant unresolved questions through discussion of important available pertinent literature and propose expert opinion based on these data. (1) Shrinking role of chemoimmunotherapy (CIT); while novel therapies are generally superior, we highlight the utility of FCR for IGHV-mutated CLL. (2) Choosing between inhibitors of Bruton's tyrosine kinase (BTKi); while efficacy between agents is likely similar there are important differences in toxicity profiles, including the incidence of cardiac arrhythmia and hypertension. (3) BTKi with or without anti-CD20 monoclonal antibodies (mAb); while obinutuzumab-acalabrutinib (AO) may confer superior progression-free survival to acalabrutinib (Acala), this is not true of rituximab (Ritux) to ibrutinib (Ib)-we highlight that potential for increased side effects should be carefully considered. (4) Continuous BTKi versus time-limited venetoclax-obinutuzumab (VenO); we propose that venetoclax (Ven)-based therapy is generally preferable to BTKi with exception of TP53 aberrant disease. (5) BTKi-Ven versus VenO as preferred time-limited therapy; we discuss comparable efficacies and the concerns about simultaneous 1L exposure to both BTKi and Ven drug classes. (6) Utility of triplet therapy (BTKi-Ven-antiCD20 mAb) versus VenO; similar rates of complete response are observed yet with greater potential for adverse events. (7) Optimal therapy for TP53 aberrant CLL; while limited data are available, there are likely effective novel therapy combinations for TP53 aberrant disease including BTKi, BTKi-Ven ± antiCD20 mAb. CONCLUSION Frontline therapy for CLL should be selected based on efficacy considering the patient specific biologic profile of their disease and potential toxicities, considering patient comorbidities and preferences. With the present paradigm of sequencing effective agents, 1L combinations of novel therapies should be used with caution in view of potential adverse events and theoretical resistance mechanism concerns in the absence of compelling randomized data to support augmented efficacy.
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Affiliation(s)
- Rory Bennett
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
| | - Mary Ann Anderson
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia
- Division of Blood Cells and Blood Cancer, The Walter and Eliza Hall Institute, 1G, Royal Parade, Parkville, Melbourne, VIC, 3052, Australia
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia
| | - John F Seymour
- Department of Clinical Haematology, Royal Melbourne Hospital and Peter MacCallum Cancer Centre, 305 Grattan St, Parkville, Melbourne, VIC, 3000, Australia.
- University of Melbourne, Grattan St, Parkville, Melbourne, VIC, 3010, Australia.
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Abstract
IMPORTANCE Chronic lymphocytic leukemia (CLL), defined by a minimum of 5 × 109/L monoclonal B cells in the blood, affects more than 200 000 people and is associated with approximately 4410 deaths in the US annually. CLL is associated with an immunocompromised state and an increased rate of complications from infections. OBSERVATIONS At the time of diagnosis, the median age of patients with CLL is 70 years, and an estimated 95% of patients have at least 1 medical comorbidity. Approximately 70% to 80% of patients with CLL are asymptomatic at the time of diagnosis, and one-third will never require treatment for CLL. Prognostic models have been developed to estimate the time to first treatment and the overall survival, but for patients who are asymptomatic, irrespective of disease risk category, clinical observation is the standard of care. Patients with symptomatic disease who have bulky or progressive lymphadenopathy or hepatosplenomegaly and those with a low neutrophil count, anemia, or thrombocytopenia and/or symptoms of fever, drenching night sweats, and weight loss (B symptoms) should be offered treatment. For these patients, first-line treatment consists of a regimen containing either a covalent Bruton tyrosine kinase (BTK) inhibitor (acalabrutinib, zanubrutinib, or ibrutinib) or a B-cell leukemia/lymphoma 2 (BCL2) inhibitor (venetoclax). There is no evidence that starting either class before the other improves outcomes. The covalent BTK inhibitors are typically used indefinitely. Survival rates are approximately 88% at 4 years for acalabrutinib, 94% at 2 years for zanubrutinib, and 78% at 7 years for ibrutinib. Venetoclax is prescribed in combination with obinutuzumab, a monoclonal anti-CD20 antibody, in first-line treatment for 1 year (overall survival, 82% at 5-year follow-up). A noncovalent BTK inhibitor, pitobrutinib, has shown an overall response rate of more than 70% after failure of covalent BTK inhibitors and venetoclax. Phosphoinositide 3'-kinase (PI3K) inhibitors (idelalisib and duvelisib) can be prescribed for disease that progresses with BTK inhibitors and venetoclax, but patients require close monitoring for adverse events such as autoimmune conditions and infections. In patients with multiple relapses, chimeric antigen receptor T-cell (CAR-T) therapy with lisocabtagene maraleucel was associated with a 45% complete response rate. The only potential cure for CLL is allogeneic hematopoietic cell transplant, which remains an option after use of targeted agents. CONCLUSIONS AND RELEVANCE More than 200 000 people in the US are living with a CLL diagnosis, and CLL causes approximately 4410 deaths each year in the US. Approximately two-thirds of patients eventually need treatment. Highly effective novel targeted agents include BTK inhibitors such as acalabrutinib, zanubrutinib, ibrutinib, and pirtobrutinib or BCL2 inhibitors such as venetoclax.
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Affiliation(s)
- Mazyar Shadman
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Medical Oncology Division, University of Washington, Seattle
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8
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Owen C, Banerji V, Johnson N, Gerrie A, Aw A, Chen C, Robinson S. Canadian evidence-based guideline for frontline treatment of chronic lymphocytic leukemia: 2022 update. Leuk Res 2023; 125:107016. [PMID: 36634577 DOI: 10.1016/j.leukres.2023.107016] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023]
Abstract
Chronic lymphocytic leukemia (cll) is the most common adult leukemia in North America. In 2018, the first unified national guideline in Canada was developed for the front-line treatment of cll that helped guide treatment across the country. As an update in 2022, a group of clinical experts from across Canada came together to provide input and guidance that included new and innovative treatments and approaches that will continue to provide health care professionals with clear guidance on the first-line management of cll. Recommendations were provided in consensus based on available evidence for the first-line treatment of cll.
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Affiliation(s)
- Carolyn Owen
- Division of Hematology and Hematological Malignancies, Foothills Medical Centre, Calgary, AB T2N 4N2, Canada.
| | - Versha Banerji
- Department of Hematology and Medical Oncology, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Nathalie Johnson
- Department of Medicine, Jewish General Hospital, Montréal, QC H3T 1E2, Canada
| | - Alina Gerrie
- Division of Medical Oncology, Centre for Lymphoid Cancer, BC Cancer, Vancouver, BC V5Z 4E6, Canada
| | - Andrew Aw
- Division of Hematology, The Ottawa Hospital, Ottawa, Ontario K1Y 4E9, Canada
| | - Christine Chen
- Department of Medical Oncology, University of Toronto, and Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada
| | - Sue Robinson
- Division of Hematology, Dalhousie University, and qeii Health Sciences Centre, Halifax, NS B3H 2Y9, Canada
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9
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Huang M, Luo J, Ji X, Hu M, Xue Y, Liu Q. Deficiency of tumor-expressed B7-H3 augments anti-tumor efficacy of anti-PD-L1 monotherapy rather than the combined chemoimmunotherapy in ovarian cancer. Pharmacol Res 2022; 186:106512. [DOI: 10.1016/j.phrs.2022.106512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/12/2022] [Accepted: 10/12/2022] [Indexed: 11/27/2022]
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10
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Is unmeasurable residual disease (uMRD) the best surrogate endpoint for clinical trials, regulatory approvals and therapy decisions in chronic lymphocytic leukaemia (CLL)? Leukemia 2022; 36:2743-2747. [PMID: 36100641 DOI: 10.1038/s41375-022-01699-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 11/08/2022]
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11
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Kutsch N, Fink AM, Fischer K. Management of front line chronic lymphocytic leukemia. Am J Hematol 2022; 97 Suppl 2:S3-S10. [PMID: 36125035 DOI: 10.1002/ajh.26677] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/06/2022] [Accepted: 08/01/2022] [Indexed: 11/11/2022]
Abstract
Treatment options with targeted agents have changed the treatment landscape of CLL profoundly. Besides chemoimmunotherapy, treatment regimen approved for frontline therapy include continuous treatment with BTK inhibitors like ibrutinib and acalabrutinib or fixed-duration regimen like venetoclax-obinutuzumab with the approval of venetoclax-ibrutinib to be awaited. Although these agents have usually manageable side effects, toxicities might limit choices for the individual patient. We here discuss latest trial data and propose a treatment algorithm for frontline treatment of CLL according to fitness and relevant genetic risk factors like IGHV mutational status and TP53 aberrations.
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Affiliation(s)
- Nadine Kutsch
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Duesseldorf and German CLL Study Group, University of Cologne, Cologne, Germany
| | - Anna Maria Fink
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Duesseldorf and German CLL Study Group, University of Cologne, Cologne, Germany
| | - Kirsten Fischer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne, Duesseldorf and German CLL Study Group, University of Cologne, Cologne, Germany
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12
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Ghilardi G, Chong EA, Svoboda J, Wohlfarth P, Nasta SD, Williamson S, Landsburg JD, Gerson JN, Barta SK, Pajarillo R, Myers J, Chen AI, Schachter L, Yelton R, Ballard HJ, Hodges Dwinal A, Gier S, Victoriano D, Weber E, Napier E, Garfall A, Porter DL, Jäger U, Maziarz RT, Ruella M, Schuster SJ. Bendamustine is safe and effective for lymphodepletion before tisagenlecleucel in patients with refractory or relapsed large B-cell lymphomas. Ann Oncol 2022; 33:916-928. [PMID: 35690221 DOI: 10.1016/j.annonc.2022.05.521] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Anti-CD19 chimeric antigen receptor T-cell immunotherapy (CAR-T) is now a standard treatment of relapsed or refractory B-cell non-Hodgkin lymphomas; however, a significant portion of patients do not respond to CAR-T and/or experience toxicities. Lymphodepleting chemotherapy is a critical component of CAR-T that enhances CAR-T-cell engraftment, expansion, cytotoxicity, and persistence. We hypothesized that the lymphodepletion regimen might affect the safety and efficacy of CAR-T. PATIENTS AND METHODS We compared the safety and efficacy of lymphodepletion using either fludarabine/cyclophosphamide (n = 42) or bendamustine (n = 90) before tisagenlecleucel in two cohorts of patients with relapsed or refractory large B-cell lymphomas treated consecutively at three academic institutions in the United States (University of Pennsylvania, n = 90; Oregon Health & Science University, n = 35) and Europe (University of Vienna, n = 7). Response was assessed using the Lugano 2014 criteria and toxicities were assessed by the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 and, when possible, the American Society for Transplantation and Cellular Therapy (ASTCT) consensus grading. RESULTS Fludarabine/cyclophosphamide led to more profound lymphocytopenia after tisagenlecleucel infusion compared with bendamustine, although the efficacy of tisagenlecleucel was similar between the two groups. We observed significant differences, however, in the frequency and severity of adverse events. In particular, patients treated with bendamustine had lower rates of cytokine release syndrome and neurotoxicity. In addition, higher rates of hematological toxicities were observed in patients receiving fludarabine/cyclophosphamide. Bendamustine-treated patients had higher nadir neutrophil counts, hemoglobin levels, and platelet counts, as well as a shorter time to blood count recovery, and received fewer platelet and red cell transfusions. Fewer episodes of infection, neutropenic fever, and post-infusion hospitalization were observed in the bendamustine cohort compared with patients receiving fludarabine/cyclophosphamide. CONCLUSIONS Bendamustine for lymphodepletion before tisagenlecleucel has efficacy similar to fludarabine/cyclophosphamide with reduced toxicities, including cytokine release syndrome, neurotoxicity, infectious and hematological toxicities, as well as reduced hospital utilization.
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Affiliation(s)
- G Ghilardi
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - E A Chong
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - J Svoboda
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - P Wohlfarth
- Medical University of Vienna, Division of Hematology and Hemostaseology, Department of Medicine I Wien, Comprehensive Cancer Center, Vienna, Austria
| | - S D Nasta
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - S Williamson
- Oregon Health & Science University Knight Cancer Institute, Adult Blood and Marrow Stem Cell Transplant & Cell Therapy Program, Portland, USA
| | - J D Landsburg
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - J N Gerson
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - S K Barta
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - R Pajarillo
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - J Myers
- Oregon Health & Science University Knight Cancer Institute, Adult Blood and Marrow Stem Cell Transplant & Cell Therapy Program, Portland, USA
| | - A I Chen
- Oregon Health & Science University Knight Cancer Institute, Adult Blood and Marrow Stem Cell Transplant & Cell Therapy Program, Portland, USA
| | - L Schachter
- Oregon Health & Science University Knight Cancer Institute, Adult Blood and Marrow Stem Cell Transplant & Cell Therapy Program, Portland, USA
| | - R Yelton
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA
| | - H J Ballard
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - A Hodges Dwinal
- Oregon Health & Science University Knight Cancer Institute, Adult Blood and Marrow Stem Cell Transplant & Cell Therapy Program, Portland, USA
| | - S Gier
- Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - D Victoriano
- Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - E Weber
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - E Napier
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - A Garfall
- Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - D L Porter
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - U Jäger
- Medical University of Vienna, Division of Hematology and Hemostaseology, Department of Medicine I Wien, Comprehensive Cancer Center, Vienna, Austria
| | - R T Maziarz
- Oregon Health & Science University Knight Cancer Institute, Adult Blood and Marrow Stem Cell Transplant & Cell Therapy Program, Portland, USA
| | - M Ruella
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - S J Schuster
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; Center for Cellular Immunotherapies and Cellular Therapy and Transplant, University of Pennsylvania, Philadelphia, USA; Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, USA.
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13
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Shanafelt TD, Wang XV, Hanson CA, Paietta EM, O'Brien S, Barrientos J, Jelinek DF, Braggio E, Leis JF, Zhang CC, Coutre SE, Barr PM, Cashen AF, Mato AR, Singh AK, Mullane MP, Little RF, Erba H, Stone RM, Litzow M, Tallman M, Kay NE. Long-term outcomes for ibrutinib-rituximab and chemoimmunotherapy in CLL: updated results of the E1912 trial. Blood 2022; 140:112-120. [PMID: 35427411 PMCID: PMC9283968 DOI: 10.1182/blood.2021014960] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/25/2022] [Indexed: 01/14/2023] Open
Abstract
Herein, we present the long-term follow-up of the randomized E1912 trial comparing the long-term efficacy of ibrutinib-rituximab (IR) therapy to fludarabine, cyclophosphamide, and rituximab (FCR) and describe the tolerability of continuous ibrutinib. The E1912 trial enrolled 529 treatment-naïve patients aged ≤70 years with chronic lymphocytic leukemia (CLL). Patients were randomly assigned (2:1 ratio) to receive IR or 6 cycles of FCR. With a median follow-up of 5.8 years, median progression-free survival (PFS) is superior for IR (hazard ratio [HR], 0.37; P < .001). IR improved PFS relative to FCR in patients with both immunoglobulin heavy chain variable region (IGHV) gene mutated CLL (HR: 0.27; P < .001) and IGHV unmutated CLL (HR: 0.27; P < .001). Among the 354 patients randomized to IR, 214 (60.5%) currently remain on ibrutinib. Among the 138 IR-treated patients who discontinued treatment, 37 (10.5% of patients who started IR) discontinued therapy due to disease progression or death, 77 (21.9% of patients who started IR) discontinued therapy for adverse events (AEs)/complications, and 24 (6.8% of patients who started IR) withdrew for other reasons. Progression was uncommon among patients able to remain on ibrutinib. The median time from ibrutinib discontinuation to disease progression or death among those who discontinued treatment for a reason other than progression was 25 months. Sustained improvement in overall survival (OS) was observed for patients in the IR arm (HR, 0.47; P = .018). In conclusion, IR therapy offers superior PFS relative to FCR in patients with IGHV mutated or unmutated CLL, as well as superior OS. Continuous ibrutinib therapy is tolerated beyond 5 years in the majority of CLL patients. This trial was registered at www.clinicaltrials.gov as #NCT02048813.
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Affiliation(s)
| | | | | | | | - Susan O'Brien
- University of California Irvine Medical Center, Irvine, CA
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14
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Hanna KS, Fijalka A, Watson I, Brown O, Ojulu A. Long-term follow-up and future direction on the management of chronic lymphocytic leukemia/small lymphocytic leukemia. J Oncol Pharm Pract 2022; 28:1869-1884. [PMID: 35635742 DOI: 10.1177/10781552221103820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Chronic lymphocytic leukemia and small lymphocytic lymphoma remain the most prevalent adult leukemia in Western countries. Novel therapeutics have established long-term efficacy and have changed the landscape in patient management. In contrast, novel approaches pose opportunities for patients to be treated for finite durations. In this manuscript, we highlight long-term safety and efficacy data with Bruton's tyrosine kinase inhibitors and combination BCL2 + anti-CD20 therapies. We also offer key considerations for treatment selection and outline ongoing trials which may continue to expand therapeutic options and approaches. Data sources An electronic search of the PubMed database was performed to obtain key literature in chronic lymphocytic leukemia and small lymphocytic lymphoma published using the following search terms: chronic lymphocytic leukemia/small lymphocytic lymphoma, Richter syndrome, and histologic transformation. The search results were narrowed by selecting studies in humans published in English. Results were confined to the following article types: Clinical Trial, Phase II; Clinical Trial, Phase III; Clinical Trial, Phase IV; Guideline; Randomized Controlled Trial; Meta-Analysis; Systematic Reviews; and Validation Studies. Data summary Chronic lymphocytic leukemia and small lymphocytic lymphoma are different manifestations of the same disease and are managed in much the same way. Bruton's tyrosine kinase inhibitors have demonstrated long and durable efficacy benefits in patients with newly diagnosed chronic lymphocytic leukemia/small lymphocytic lymphoma and in the relapsed/refractory setting. Despite these benefits, long terms adverse events have posed challenges for patients and have led to treatment discontinuations. Additionally, the use of monotherapy Bruton's tyrosine kinase inhibitor's requires chronic use of the medications leading to added financial implications. BCL2 inhibition with venetoclax in combination with anti-CD20 monoclonal antibodies has offered a novel and finite treatment approach in frontline and relapsed chronic lymphocytic leukemia/small lymphocytic lymphoma. Ongoing clinical trials are in investigating this modality further to enhance durable responses utilizing a combination Bruton's tyrosine kinase inhibitor's and BCL2 inhibitors. Conclusion The treatment armamentarium of chronic lymphocytic leukemia/small lymphocytic lymphoma continues to evolve. Despite the long term, durable responses with Bruton's tyrosine kinase inhibitor's, it is likely that finite treatment durations could become the standard of care as a result of continued, long-term responses.
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Affiliation(s)
- Kirollos S Hanna
- Department of Pharmacy, Mayo Clinic College of Medicine, Rochester, MN, USA
- M Health Fairview Maple Grove, Maple Grove, MN, USA
| | - Andrew Fijalka
- M Health Fairview University of Minnesota Medical Center - West Bank, Minneapolis, MN, USA
| | - Ian Watson
- M Health Fairview University of Minnesota Medical Center - West Bank, Minneapolis, MN, USA
| | - Olivia Brown
- M Health Fairview University of Minnesota Medical Center - West Bank, Minneapolis, MN, USA
| | - Apiew Ojulu
- M Health Fairview University of Minnesota Medical Center - West Bank, Minneapolis, MN, USA
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15
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Weis TM, Gutierrez J, Kabel CC, King AC, Daley RJ, Stump SE. Real-world management of targeted therapies in chronic lymphocytic leukemia. J Oncol Pharm Pract 2022; 28:1411-1433. [PMID: 35350909 DOI: 10.1177/10781552221090869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The advent of novel targeted therapies, including B-cell receptor (BCR) pathway and B-cell lymphoma 2 (BCL2) inhibitors, has substantially changed the treatment paradigm for chronic lymphocytic leukemia (CLL). Although targeted therapies have improved outcomes compared to traditional chemoimmunotherapy in the front-line and relapsed or refractory settings, they are associated with resistance mutations and suboptimal outcomes in certain high-risk patients. Additionally, targeted therapies are associated with drug interactions and unique adverse effect profiles which can be challenging for patients and clinicians to manage. Ongoing studies continue to address questions regarding optimal sequencing of therapies, the role of treatment combinations, and the efficacy of next-generation novel agents. This review provides a comprehensive overview regarding the clinical management of targeted therapies for CLL and applies current literature to clinical practice.
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Affiliation(s)
- Taylor M Weis
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Jillian Gutierrez
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Charlene C Kabel
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Amber C King
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Ryan J Daley
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
| | - Sarah E Stump
- Department of Pharmacy, Leukemia Service, 5803Memorial Sloan Kettering Cancer Center, NY, USA
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16
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Oerlemans S, Efficace F, Kieffer JM, Kyriakou C, Xochelli A, Levedahl K, Petranovic D, Borges FC, Bredart A, Shamieh O, Gziskevicius L, Lehmann J, Scholz CW, Caocci G, Molica S, Stamatopoulos K, Panteliadou AK, Papaioannou M, Alrjoob W, Baliakas P, Rosenquist R, Malak S, Miranda A, Cocks K, van de Poll-Franse L. International validation of the EORTC QLQ-CLL17 questionnaire for assessment of health-related quality of life for patients with chronic lymphocytic leukaemia. Br J Haematol 2022; 197:431-441. [PMID: 35255152 DOI: 10.1111/bjh.18072] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 11/26/2022]
Abstract
Selecting the most appropriate chronic lymphocytic leukaemia (CLL) treatment is challenging. Patient-reported health-related quality of life (HRQoL) is therefore a critical aspect to consider. This international study by the European Organization for Research and Treatment of Cancer (EORTC) tested the psychometric properties of a newly developed measure for CLL patients: the EORTC QLQ-CLL17 to supplement the core questionnaire (EORTC QLQ-C30). Patients with CLL (n = 341) from 12 countries completed the QLQ-C30, QLQ-CLL17 and a debriefing questionnaire. Sociodemographic and clinical data were recorded from medical records. A high percentage (30%-66%) reported symptoms and/or worries (e.g. aches/pains in muscles, lack of energy and worry/fears about health). Confirmatory factor analysis showed an acceptable to good fit of the 17 items on the three scales (i.e. symptom burden, physical condition/fatigue and worries/fears about health and functioning). Completion took on average 8 min. Test-retest and convergent validity was demonstrated. The QLQ-CLL17 differentiated between patients with an Eastern Cooperative Oncology group (ECOG) performance of 0 versus 1-3 (p's < 0.01 and clinically relevant). The newly developed EORTC QLQ-CLL17 will increase sensitivity of HRQoL assessment in patients with CLL. Implementation of this questionnaire both in clinical research and practice will help to generate unique clinically relevant data to better inform CLL treatment decision-making.
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Affiliation(s)
- Simone Oerlemans
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Fabio Efficace
- Health Outcomes Research Unit, Italian Group for Adult Hematologic Diseases (GIMEMA) Data Centre, Rome, Italy
| | - Jacobien M Kieffer
- Department of Psychosocial Research & Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Aliki Xochelli
- Institute of Applied Biosciences, Center for Research and Technology Hellas, Thessaloniki, Greece
| | - Kerstin Levedahl
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Duska Petranovic
- Clinical Hospital Center Rijeka, University of Rijeka, Rijeka, Croatia
| | - Fabio Cardoso Borges
- Department of Epidemiology and National Cancer Registry (RON), Instituto Português de Oncologia de Lisboa Francisco Gentil, E.P.E, Lisbon, Portugal
| | - Anne Bredart
- Institut Curie - Psycho-Oncology Unit, Paris University, Paris, France.,Psychopathology and Health Process Laboratory (LPPS) (UR 4057), PSL University, Paris, France
| | - Omar Shamieh
- Department of Palliative Medicine, King Hussein Cancer Center, Amman, Jordan
| | | | - Jens Lehmann
- University Hospital of Psychiatry II, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Giovanni Caocci
- Hematology, Businco Hospital, University of Cagliari, Cagliari, Italy
| | | | - Kostas Stamatopoulos
- Institute of Applied Biosciences, Center for Research and Technology Hellas, Thessaloniki, Greece
| | | | - Maria Papaioannou
- Hematology Unit, 1st Dept of Internal Medicine, AUTH, AHEPA Hospital, Thessaloniki, Greece
| | - Waleed Alrjoob
- Department of Palliative Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Panagiotis Baliakas
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Richard Rosenquist
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Sandra Malak
- Hôpital René Huguenin-Institut Curie - Hématologie, Saint-Cloud, France
| | - Ana Miranda
- Department of Epidemiology and National Cancer Registry (RON), Instituto Português de Oncologia de Lisboa Francisco Gentil, E.P.E, Lisbon, Portugal
| | - Kim Cocks
- York Trials Unit, University of York, York & Adelphi Values, Cheshire, UK
| | - Lonneke van de Poll-Franse
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,Department of Psychosocial Research & Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
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17
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Csanádi M, Ágh T, Tordai A, Tapprich C, Vokó Z, Stamatopoulos K. Secondary primary malignancies after treatment with chemo-immunotherapy in treatment-naïve patients with CLL: a systematic literature review. Expert Rev Hematol 2022; 15:273-284. [PMID: 35168449 DOI: 10.1080/17474086.2022.2042246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES In chronic lymphocytic leukemia (CLL), therapy-related cytotoxicity and the resulting immunodeficiency are thought to contribute to the development of secondary primary malignancies (SPM). Here we analyzed clinical trial data on the occurrence of SPM following chemo-immunotherapy (CIT) regimens in treatment-naïve CLL patients. METHODS A systematic literature search was conducted covering multiple databases between 2003-2019. Data from relevant clinical trials on the proportion of patients with SPMs were extracted. Then the number of SPM patients/person-years was calculated by taking into account the trials' follow-up time. Finally, a random-effects meta-analysis to pool the rates from individual studies was performed. RESULTS We identified 22 studies reporting SPM data available for analysis. Random-effects meta-analysis estimated that the number of SPM patients/1000 person-years was 24 (95%CI: 19-29). Results from trials with cancer-specific data indicated 19 (95%CI: 14-26) solid and 9 (95%CI: 6-12) hematological SPM patients/1000 person-years. These estimations did not change significantly when sub-groups were analysed by CIT regimens. CONCLUSION Although pooling data with the intention to analyze adverse event rates is challenging, our study concluded that in case of CIT regimens, SPM should be considered an important adverse outcome. Different regimens showed similar trends; however, other clinical and demographic factors have a profound impact in this respect.
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Affiliation(s)
| | - Tamás Ágh
- Syreon Research Institute, Budapest, Hungary
| | - Attila Tordai
- Department of Transfusion Medicine, Semmelweis University, Budapest, Hungary
| | | | - Zoltán Vokó
- Syreon Research Institute, Budapest, Hungary.,Center for Health Technology Assessment, Semmelweis University, Hungary
| | - Kostas Stamatopoulos
- Institute of Applied Biosciences, Centre for Research and Technology Hellas, Thessaloniki, Greece
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18
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Ranti J, Perkonoja K, Kauko T, Loponen H, Joensuu EI, Järvinen TM. Characterization of real‐world treatment practices and outcomes among patients with chronic lymphocytic leukemia treated in a Finnish tertiary center. EJHAEM 2022; 3:291-300. [PMID: 35846189 PMCID: PMC9176063 DOI: 10.1002/jha2.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Juha Ranti
- Department of Hematology and Stem Cell Transplantation Unit Division of Medicine Turku University Hospital Turku Finland
| | - Katariina Perkonoja
- Auria Clinical Informatics Turku University Hospital, Hospital District of Southwest Finland Turku Finland
| | - Tommi Kauko
- Auria Clinical Informatics Turku University Hospital, Hospital District of Southwest Finland Turku Finland
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19
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Moreno C, Muñoz C, Terol MJ, Hernández-Rivas JÁ, Villanueva M. Restoration of the immune function as a complementary strategy to treat Chronic Lymphocytic Leukemia effectively. J Exp Clin Cancer Res 2021; 40:321. [PMID: 34654437 PMCID: PMC8517318 DOI: 10.1186/s13046-021-02115-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 09/24/2021] [Indexed: 12/02/2022] Open
Abstract
Chronic Lymphocytic Leukemia (CLL) is a hematological malignancy characterized by uncontrolled proliferation of B-cells and severe immune dysfunction. Chemo(immuno)therapies (CIT) have traditionally aimed to reduce tumor burden without fully understanding their effects on the immune system. As a consequence, CIT are usually associated with higher risk of infections, secondary neoplasms and autoimmune disorders. A better understanding of the biology of the disease has led to the development of therapeutic strategies which not only act against malignant B-cells but also reactivate and enhance the patient's own anti-tumor immune response. Here, we review the current understanding of the underlying interplay between the malignant cells and non-malignant immune cells that may promote tumor survival and proliferation. In addition, we review the available evidence on how different treatment options for CLL including CIT regimens, small molecular inhibitors (i.e, BTK inhibitors, PI3K inhibitors, BCL-2 inhibitors) and T-cell therapies, affect the immune system and their clinical consequences. Finally, we propose that a dual therapeutic approach, acting directly against malignant B-cells and restoring the immune function is clinically relevant and should be considered when developing future strategies to treat patients with CLL.
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Affiliation(s)
| | - Cecilia Muñoz
- Hospital Universitario de la Princesa, Madrid, Spain
| | | | - José-Ángel Hernández-Rivas
- Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, Spain.
- Servicio de Hematología y Hemoterapia, Hospital Universitario Infanta Leonor, Departamento de Medicina, Universidad Complutense de Madrid, Madrid, España.
- , C/ Gran Vía del Este 80, 28031, Madrid, Spain.
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Improvements in Health-related Quality of Life and Symptoms in Patients With Previously Untreated Chronic Lymphocytic Leukemia: Final Results From the Phase II GIBB Study of the Combination of Obinutuzumab and Bendamustine. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:121-128. [PMID: 34674981 DOI: 10.1016/j.clml.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/02/2021] [Accepted: 09/08/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND We evaluated health-related quality of life (HRQoL) in patients with chronic lymphocytic leukemia (CLL) receiving first-line chemoimmunotherapy in the GIBB single-arm, Phase II study of obinutuzumab plus bendamustine (BG). MATERIALS AND METHODS Patients received six 28-day cycles of BG and were followed for up to 27 months. HRQoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Core 30 (EORTC QLQ-C30) and EORTC QLQ Chronic Lymphocytic Leukemia 16 (QLQ-CLL16) questionnaires. Scores were linear-transformed to a 100-point scale, with clinically meaningful responses defined as a ≥ 10-point change from baseline. RESULTS The patient-reported outcome (PRO) population comprised 98 patients (68.4% male; median age 61 years). EORTC QLQ-C30 global health status improvements were noted at all follow-up visits and were clinically meaningful 2 to 3 months after induction and at 3- and 27-months' follow-up. Clinically meaningful improvements were also observed for the EORTC QLQ-C30 role functioning, emotional functioning, fatigue and insomnia scales and the EORTC QLQ-CLL16 fatigue, disease symptoms and future health worries scales. Global health status was maintained throughout follow-up, and no clinically relevant deterioration in other HRQoL parameters was observed. CONCLUSION PRO data from the GIBB study show improved overall HRQoL in patients with CLL who received first-line chemoimmunotherapy with BG.
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Al‐Sawaf O, Gentile B, Devine J, Zhang C, Sail K, Tandon M, Fink A, Kutsch N, Wendtner C, Eichhorst B, Hallek M, Fischer K. Health-related quality of life with fixed-duration venetoclax-obinutuzumab for previously untreated chronic lymphocytic leukemia: Results from the randomized, phase 3 CLL14 trial. Am J Hematol 2021; 96:1112-1119. [PMID: 34050972 DOI: 10.1002/ajh.26260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/24/2021] [Accepted: 05/24/2021] [Indexed: 11/11/2022]
Abstract
Chronic lymphocytic leukemia (CLL)-related symptoms impair the well-being of patients, making improvement of health-related quality of life (QoL) a goal of treatment. The CLL14 trial demonstrated higher efficacy of fixed-duration venetoclax-obinutuzumab (Ven-Obi) compared to chlorambucil-obinutuzumab (Clb-Obi) in patients with previously untreated CLL. To assess patients' QoL, the following patient-reported outcomes (PRO) measures were assessed: the M.D. Anderson Symptom Inventory (MDASI) core instrument and CLL module and the EORTC Quality of Life Questionnaire Core 30 (EORTC QLQ-C30). At treatment start, physical functioning (mean 75.9 [standard deviation (SD) ± 20.1] in the Clb-Obi arm and 76.9 [±19.4] in the Ven-Obi arm), role functioning (73.6 [±27.86] and 72.6 [±26.9]) and GHS/QoL (63.6 [±21.0] and 60.3 [±20.5]) were comparable between treatment arms per EORTC QLQ-C30 scale scores. Baseline levels of physical and role functioning were maintained throughout treatment and follow-up, with no relevant improvement or deterioration. On average, patients treated with Ven-Obi showed a meaningful improvement of GHS/QoL during treatment and follow-up by at least eight points at cycle three, whereas improvement was delayed until cycle eight with Clb-Obi. According to MDASI scores, CLL symptoms (1.5 [±1.2] and 1.6 [±1.3]), core cancer symptoms (1.5 [±1.4] and 1.8 [±1.7]) and symptom interference (2.1 [±2.3] and 2.3 [±2.3]) were generally low and comparable between treatment arms at baseline and were maintained throughout treatment and follow-up. This analysis demonstrates that the higher efficacy of Ven-Obi is not associated with QoL impairment and that Ven-Obi achieves early relief of CLL-related symptoms in elderly unfit patients.
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Affiliation(s)
- Othman Al‐Sawaf
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf; German CLL Study Group University of Cologne Cologne Germany
| | | | - Jacob Devine
- Genentech Inc South San Francisco California USA
| | - Can Zhang
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf; German CLL Study Group University of Cologne Cologne Germany
| | | | | | - Anna‐Maria Fink
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf; German CLL Study Group University of Cologne Cologne Germany
| | - Nadine Kutsch
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf; German CLL Study Group University of Cologne Cologne Germany
| | - Clemens‐Martin Wendtner
- Department of Hematology, Oncology, Immunology, Palliative Care, Infectious Diseases and Tropical Medicine Klinikum Schwabing Munich Germany
| | - Barbara Eichhorst
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf; German CLL Study Group University of Cologne Cologne Germany
| | - Michael Hallek
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf; German CLL Study Group University of Cologne Cologne Germany
| | - Kirsten Fischer
- Department I of Internal Medicine and Center of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf; German CLL Study Group University of Cologne Cologne Germany
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van Gelder M, Tournilhac O, Te Raa D, Visser HPJ. Front-line chemo-immunotherapy is not inferior to ibrutinib in CLL. Ann Oncol 2021; 32:1442-1443. [PMID: 34428511 DOI: 10.1016/j.annonc.2021.08.1990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/02/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- M van Gelder
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands.
| | - O Tournilhac
- Service for Cell Therapy and Clinic for Hematology, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - D Te Raa
- Department of Internal Medicine, Gelderse Vallei Hospital, Ede, the Netherlands
| | - H P J Visser
- Northwest Oncology Center, Northwest Hospital Group, Alkmaar, the Netherlands
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Abstract
ABSTRACT Over the last 2 decades, treatment of chronic lymphocytic leukemia (CLL) therapy has drastically changed, resulting in greatly improved survival and treatment tolerance with current targeted therapies. First, the transition from chemotherapy (alkylating agents, nucleoside analogs) to chemoimmunotherapy with the addition of anti-CD20 antibodies resulted in deeper and more complete remissions, with an improvement in progression-free and overall survival. Over the last few years, chemoimmunotherapy has gradually been replaced by new targeted agents, based on further improvement in survival, especially in patients with high-risk CLL, and fewer adverse effects, that is, a lack of myelosuppression and lack of DNA damage and associated risk of secondary acute myeloid leukemia/myelodysplastic syndrome. The most active targeted treatments for CLL patients are the kinase inhibitors, which inhibit signaling of surface receptors, especially the B-cell antigen receptor, and the BCL-2 antagonist venetoclax. Among the kinase inhibitors, Bruton tyrosine kinase inhibitors are highly effective and generally well-tolerated and induce durable responses in the vast majority of patients. PI3 kinase inhibitors are alternatives for patients with intolerance to Bruton tyrosine kinase inhibitors. This review discusses the rationale for the transition from chemotherapy-based treatment to the novel agents, the activity, adverse effects, sequencing, and combinations of the novel agents and provides an outlook into future CLL therapy for the next decade.
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Abstract
ABSTRACT In this article, we carry out an overview on the management options available for chronic lymphocytic leukemia (CLL) patients and discuss possible treatment decisions, taking into account the issue of sustainability and availability. Targeted agents have shown to be superior compared with chemoimmunotherapy (CIT) in terms of progression-free survival in high-risk CLL. In the majority of studies, however, continuous treatment was compared with fixed-duration CIT and no overall survival or progression-free survival-2 (time from randomization to second progression or death) advantage could be documented. Meanwhile, a substantial financial burden on both patients and payers has raised issues about affordability and adherence to treatment. Therefore, value-based pricing of new drugs has been used to set up price negotiation policies in several countries, and fixed-duration therapy has shown to be less costly than continuous treatment. Thus, CIT continues to have a role in the treatment of CLL patients with a favorable genetic profile, that is, with a mutated IGHV gene profile and a wild-type TP53. Targeted treatment represents the preferred choice in patients with an unmutated IGHV gene configuration and/or a TP53 disruption, provided that adherence to treatment is guaranteed and bearing in mind that should costly drugs not be available for frontline treatment, new agents can be very effective as first salvage treatment.
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Smolej L, Vodárek P, Écsiová D, Šimkovič M. Chemoimmunotherapy in the First-Line Treatment of Chronic Lymphocytic Leukaemia: Dead Yet, or Alive and Kicking? Cancers (Basel) 2021; 13:3134. [PMID: 34201565 PMCID: PMC8267736 DOI: 10.3390/cancers13133134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/13/2021] [Accepted: 06/20/2021] [Indexed: 12/23/2022] Open
Abstract
The paradigm of first-line treatment of chronic lymphocytic leukaemia (CLL) is currently undergoing a radical change. On the basis of several randomised phase III trials showing prolongation of progression-free survival, chemoimmunotherapy is being replaced by treatment based on novel, orally available targeted inhibitors such as Bruton tyrosine kinase inhibitors ibrutinib and acalabrutinib or bcl-2 inhibitor venetoclax. However, the use of these agents may be associated with other disadvantages. First, with the exception of one trial in younger/fit patients, no studies have so far demonstrated benefit regarding the ultimate endpoint of overall survival. Second, oral inhibitors are extremely expensive and thus currently unavailable due to the absence of reimbursement in some countries. Third, treatment with ibrutinib and acalabrutinib necessitates long-term administration until progression; this may be associated with accumulation of late side effects, problems with patient compliance, and selection of resistant clones. Therefore, the identification of a subset of patients who could benefit from chemoimmunotherapy would be ideal. Current data suggest that patients with the mutated variable region of the immunoglobulin heavy chain (IGHV) achieve fairly durable remissions, especially when treated with fludarabine, cyclophosphamide, and rituximab (FCR) regimen. This review discusses current options for treatment-naïve patients with CLL.
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Affiliation(s)
- Lukáš Smolej
- 4th Department of Internal Medicine–Hematology, Faculty of Medicine, University Hospital, Charles University, 50005 Hradec Králové, Czech Republic; (P.V.); (D.É.); (M.Š.)
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Ibrutinib, fludarabine, cyclophosphamide, and obinutuzumab (iFCG) regimen for chronic lymphocytic leukemia (CLL) with mutated IGHV and without TP53 aberrations. Leukemia 2021; 35:3421-3429. [PMID: 34007049 DOI: 10.1038/s41375-021-01280-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 04/20/2021] [Accepted: 04/30/2021] [Indexed: 12/16/2022]
Abstract
Chemoimmunotherapy with combined fludarabine, cyclophosphamide and rituximab (FCR) has been an effective treatment for patients with chronic lymphocytic leukemia (CLL). We initiated a phase II trial for previously untreated patients with CLL with mutated IGHV and absence of del(17p)/TP53 mutation. Patients received ibrutinib, fludarabine, cyclophosphamide, and obinutuzumab (iFCG) for three cycles. Patients who achieved complete remission (CR)/CR with incomplete count recvoery (CRi) with marrow undetectable measurable residual disease (U-MRD) received additional nine cycles of ibrutinib with three cycles of obinutuzumab; all others received nine additional cycles of ibrutinib and obinutuzumab. Patients in marrow U-MRD remission after cycle 12 discontinued all treatment, including ibrutinib. Forty-five patients were treated. The median follow-up is 41.3 months. Among the total 45 treated patients, after three cycles, 38% achieved CR/CRi and 87% achieved marrow U-MRD. After cycle 12, the corresponding numbers were 67% and 91%, respectively. Overall, 44/45 (98%) patients achieved marrow U-MRD as best response. No patient had CLL progression. The 3-year progression-free survival (PFS) and overall survival (OS) were 98% and 98%, respectively. Per trial design, all patients who completed cycle 12 discontinued ibrutinib, providing for a time-limited therapy. Grade 3-4 neutropenia and thrombocytopenia occurred in 58% and 40% patients, respectively. The iFCG regimen with only 3 cycles of chemotherapy is an effective, time-limited regimen for patients with CLL with mutated IGHV and without del(17p)/TP53 mutation.
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Gianfelici V, Levato L, Molica S. The Evolution of Targeted Therapies in Chronic Lymphocytic Leukaemia. Curr Hematol Malig Rep 2020; 15:343-349. [PMID: 32500413 DOI: 10.1007/s11899-020-00586-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW The treatment landscape for chronic lymphocytic leukaemia (CLL) is rapidly evolving, with several targeted agents recently approved. These compounds have dramatically changed the natural history of the disease. RECENT FINDINGS However, with the array of effective therapies commercially available, the challenge is to define tailored treatment strategies able to realize a balance between treatment efficacy and toxicity or tolerance. New algorithms of treatment are being developed, and it appears that minimal residual disease (MRD) directed therapy will become the norm in the future. Clinical trials are looking at various combinations of novel therapies given with a defined, fixed-period of treatment based on MRD analysis. This approach enables patients to have a period of treatment-free remission instead of continuous therapy. In this review, we summarize this evolution of targeted therapies in CLL.
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Affiliation(s)
- Valentina Gianfelici
- Department Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, 88100, Catanzaro, Italy
| | - Luciano Levato
- Department Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, 88100, Catanzaro, Italy
| | - Stefano Molica
- Department Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, 88100, Catanzaro, Italy.
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Harrop S, Polliack A, Tam CS. Chronic lymphoproliferative disorders and secondary cancers in the era of purine analogues and beyond. Leuk Lymphoma 2020; 62:771-778. [PMID: 33222561 DOI: 10.1080/10428194.2020.1849682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The low grade chronic lymphoproliferative disorders include chronic lymphocytic leukemia, Waldenstroms macroglobulinemia, follicular lymphoma and hairy cell leukemia. Traditionally considered incurable, these disorders have been associated with a risk of haematological and solid organ malignancies secondary to both the underlying disease and the associated treatment. The introduction of purine analogues into treatment paradigms has seen increased rates of therapy related myelodysplasia reported and it remains unclear yet on the impact the targeted novel therapies play in the development of secondary cancers. We review the rates of secondary malignancy in the chronic lymphoproliferative disorders with a particular focus on the role of the purine analogues in the development of therapy related MDS.
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Affiliation(s)
- Sean Harrop
- Peter MacCallum Cancer Centre, Melbourne, Australia.,Epworth Healthcare, Melbourne, Australia
| | - Aaron Polliack
- Department of Haematology, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Constantine S Tam
- Peter MacCallum Cancer Centre, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
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Davids MS, Fisher DC, Tyekucheva S, McDonough M, Hanna J, Lee B, Francoeur K, Montegaard J, Odejide O, Armand P, Arnason J, Brown JR. A phase 1b/2 study of duvelisib in combination with FCR (DFCR) for frontline therapy for younger CLL patients. Leukemia 2020; 35:1064-1072. [PMID: 32820271 PMCID: PMC7895867 DOI: 10.1038/s41375-020-01010-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 02/06/2023]
Abstract
Fludarabine, cyclophosphamide, and rituximab (FCR) is highly effective initial therapy for younger patients with chronic lymphocytic leukemia (CLL); however, most eventually relapse. Duvelisib is a delta/gamma PI3K inhibitor approved for relapsed/refractory CLL. We conducted an investigator-initiated, phase 1b/2 study of duvelisib + FCR (DFCR) as initial treatment for CLL patients aged ≤65. A standard 3 + 3 design included two dose levels of duvelisib (25 mg qd and 25 mg bid). Duvelisib was given for 1 week, then with standard FCR added for up to six 28-day cycles, then up to 2 years of duvelisib maintenance. Thirty-two patients were enrolled. The phase 2 dose of duvelisib was identified as 25 mg bid. Hematologic toxicity was common, and all-grade non-hematologic toxicities included transaminitis (28%), febrile neutropenia (22%), pneumonia (19%), and colitis (6%). The best overall response rate by ITT was 88% (56% CR/CRi and 32% PR). The best rate of bone marrow undetectable minimal residual disease (BM-uMRD) by ITT was 66%. The rate of CR with BM-uMRD at end of combination treatment (primary endpoint) was 25%. Three-year PFS and OS are 73 and 93%, respectively. DFCR is active as initial therapy of younger CLL patients. Immune-mediated and infectious toxicities occurred and required active management.
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Affiliation(s)
- Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - David C Fisher
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Svitlana Tyekucheva
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mikaela McDonough
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - John Hanna
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brandon Lee
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Karen Francoeur
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Josie Montegaard
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Oreofe Odejide
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Philippe Armand
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jon Arnason
- Department of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jennifer R Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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