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Richter J, Davids MS, Anderson-Smits C, Kamieniak M, Ren K, Hull M, Multani JK, Shah D, Siffel C. Burden of Infection in Patients With and Without Secondary Immunodeficiency Disease Following Diagnosis of a Mature B Cell Malignancy. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:553-563. [PMID: 38734499 DOI: 10.1016/j.clml.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND This retrospective cohort study compared patient characteristics and burden of infection in patients with mature B cell malignancies with and without secondary immunodeficiency disease (SID). PATIENTS AND METHODS Data were extracted from the Humedica database (H-DB) and Guardian Research Network (GRN) database from October 1, 2015 to March 10, 2020, including a 6-month pre-index period (PIP) and 12-month follow-up. Patients aged ≥18 years diagnosed with chronic lymphocytic leukemia/small lymphocytic lymphoma, multiple myeloma, or non-Hodgkin's lymphoma in the PIP were stratified into 2 cohorts: SID (hypogammaglobulinemia [using ICD-10-CM codes] or serum IgG levels <5.0 g/L, both with signs and symptoms of SID or at least 1 infection) and no-SID. Patients with SID or primary immunodeficiency diseases in the PIP were excluded. RESULTS Overall, 2221 patients with SID (H-DB/GRN: n = 1959/262), and 19,141 patients without SID (n = 17,598/1543) were included. Baseline characteristics were similar across cohorts. At 12-month follow-up, significantly more patients with SID had experienced ≥1 infection and ≥1 severe bacterial infection than those without SID (both P < .001). H-DB/GRN mean (standard deviation) number of severe bacterial infections was 7.6 (9.9)/2.9 (2.7) for the SID cohort versus 5.2 (6.8)/2.4 (2.2) for the no-SID cohort. CONCLUSION This study confirms that patients with mature B cell malignancies and SID face a significantly higher burden of infections than those without SID.
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Affiliation(s)
- Joshua Richter
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Matthew S Davids
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Kaili Ren
- Takeda Development Center Americas, Inc., Cambridge, MA
| | | | | | - Drishti Shah
- Takeda Development Center Americas, Inc., Cambridge, MA
| | - Csaba Siffel
- Takeda Development Center Americas, Inc., Cambridge, MA; College of Allied Health Sciences, Augusta University, Augusta, GA, USA.
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Vainer N, Rotbain Curovic V, Niemann CU, Slager SL, Rotbain EC. Understanding the interplay between chronic lymphocytic leukemia and type 2 diabetes. Expert Rev Hematol 2024:1-13. [PMID: 39041465 DOI: 10.1080/17474086.2024.2383417] [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: 02/01/2024] [Accepted: 07/18/2024] [Indexed: 07/24/2024]
Abstract
INTRODUCTION Comorbidities play an important role in the management of chronic lymphocytic leukemia (CLL) and may influence survival and treatment outcomes. Considering the aging general population and increasing incidence of type 2 diabetes (T2D), a comprehensive understanding of the interplay between CLL and T2D is essential for optimizing care and outcomes. AREAS COVERED We present current knowledge on co-existing CLL and T2D including prevalence, shared etiology and risk factors and how the conditions and treatment hereof may influence the outcome of one another. A literature search was performed using PubMed with the cutoff date on 1 February 2024. EXPERT OPINION The increased mortality observed in persons with CLL who have co-existing T2D is partially ascribed to infections, prompting physicians managing individuals with both conditions to consider closer monitoring during instances of infection and individualized prophylaxis. People with CLL and T2D should be managed for CLL in accordance with the international working group on CLL criteria, and we recommend that physicians exercise particular care not to delay treatment for these individuals. Multidisciplinary approaches with involvement of several specialties may be required for optimal supportive care of co-occurring T2D and CLL.
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Affiliation(s)
- Noomi Vainer
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Hematology Group, Danish Cancer Institute, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Carsten Utoft Niemann
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Susan L Slager
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Emelie Curovic Rotbain
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Hematology Group, Danish Cancer Institute, Copenhagen, Denmark
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Molica S. Defining treatment success in chronic lymphocytic leukemia: exploring surrogate markers, comorbidities, and patient-centered endpoints. Expert Rev Hematol 2024; 17:279-285. [PMID: 38856076 DOI: 10.1080/17474086.2024.2366534] [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: 03/28/2024] [Accepted: 06/06/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Traditionally, the success of chronic lymphocytic leukemia (CLL) treatment has been primarily assessed based on clinical outcomes, such as disease response, progression-free survival (PFS), and overall survival (OS). However, the evolution of treatment approaches recognizes the importance of a patient-centered perspective that includes factors directly affecting patients' quality of life and overall well-being. AREAS COVERED Studies addressing the impact of targeted agents on improving either OS or other endpoint surrogates were selected using PubMed and MEDLINE platforms. Our search also included studies that considered patient-centric endpoints such as health-related quality of life and patient-reported outcomes (PROs). EXPERT OPINION The changing landscape of CLL treatment underscores the importance of continually exploring various endpoints to thoroughly define treatment success. Beyond conventional metrics such as OS and surrogate endpoints, namely, PFS, time to next treatment (TTNT), and measurable residual disease (MRD) assessment, it becomes crucial to integrate enhanced comorbidity evaluations and patient-centered viewpoints into a CLL success roadmap.Subsequent investigations ought to concentrate on enhancing current surrogate endpoints, discerning their contextual significance, and exploring innovative indicators of treatment efficacy and safety. Given the dynamic nature of CLL and the heterogeneity among patient groups, personalized strategies are essential, taking into account individual traits and patient preferences.
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MESH Headings
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Humans
- Quality of Life
- Treatment Outcome
- Patient Reported Outcome Measures
- Comorbidity
- Patient-Centered Care
- Biomarkers, Tumor
- Biomarkers
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Affiliation(s)
- Stefano Molica
- Department Hematology, Hull University Teaching Hospitals NHS Trust, Hull, UK
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Mauro FR, Frustaci AM, Visentin A, Vitale C, Bartoletti M, Oltolini C, Zappulo E, Mikulska M. Severe infections in patients with chronic lymphocytic leukemia included in trials investigating BTK and BCL2 inhibitors. Crit Rev Oncol Hematol 2024; 201:104408. [PMID: 38880368 DOI: 10.1016/j.critrevonc.2024.104408] [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: 02/28/2024] [Revised: 04/30/2024] [Accepted: 06/04/2024] [Indexed: 06/18/2024] Open
Abstract
Bruton tyrosine kinase inhibitors (BTKi) and the BCL-2 inhibitor venetoclax have significantly improved the prognosis of patients with chronic lymphocytic leukemia (CLL). However, the incidence of severe infections in patients receiving these agents needs to be better understood. Our review aimed to provide an overview of grade ≥3 infections in patients with CLL who received BTKi and venetoclax-based therapy in prospective trials. Infection rates were influenced by the age of patients and the duration of follow-up. For treatment-naive (TN) patients receiving BTKi, infection rates ranged between 11.4 % and 27.4 % and were close to 30 % in relapsed/refractory (R/R) patients. TN and R/R patients receiving fixed-duration venetoclax-based treatments showed variable rates, with maximum values around 20 %. Opportunistic and fatal infections were uncommon. In conclusion, infections remain a concern in patients with CLL receiving targeted agents. A better definition of factors increasing infection vulnerability could help identify those patients who require infection prophylaxis.
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Affiliation(s)
- Francesca R Mauro
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
| | | | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy
| | - Candida Vitale
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Turin, Italy
| | - Michele Bartoletti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele Milan 20090, Italy; Infectious Disease Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Milan 20089, Italy
| | - Chiara Oltolini
- Clinic of Infectious Diseases, Vita-Salute University, San Raffaele Scientific Institute, Milan, Italy
| | - Emanuela Zappulo
- Department of Clinical Medicine and Surgery University of Naples Federico II, Napoli, Italy
| | - Malgorzata Mikulska
- Department of Health Sciences (DISSAL) University of Genoa, Italy; Infectious Diseases Unit IRCCS Ospedale Policlinico San Martino Genoa, Italy
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Alshemmari SH, AlSarraf A, Kaempf A, Danilov AV. Prognostic impact of chronic lymphocytic leukemia comorbidity index in a young population: a real-world evidence study of a national gulf region cohort. BMC Cancer 2024; 24:584. [PMID: 38741031 DOI: 10.1186/s12885-024-12343-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 05/06/2024] [Indexed: 05/16/2024] Open
Abstract
In chronic lymphocytic leukaemia (CLL), comorbidities assessed by the CLL comorbidity index (CLL-CI) have been associated with outcomes in Western cohorts. We conducted a retrospective analysis of an unselected Middle Eastern cohort of newly diagnosed CLL patients seen at the Kuwait Cancer Control Center (n = 300). Compared to Western studies, these Middle Eastern patients were diagnosed at a younger age (median of 59) and had a higher comorbidity burden (69% non-low risk CLL-CI). A higher CLL-CI score was independently associated with significantly shorter event-free survival and greater risk of death. Our analysis demonstrates that CLL-CI is a valuable tool for comorbidity assessment and prognostic influence in (relatively young) Middle Eastern CLL patients.
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Affiliation(s)
- Salem H Alshemmari
- Department of Medicine, Faculty of Medicine, Kuwait University, State of Kuwait, PO BOX: 24923-23110 SAFAT, Jabriya, Kuwait.
- Department of Hematology, Kuwait Cancer Center, Shuwaikh, Kuwait.
| | - Ahmad AlSarraf
- Department of Medicine, Faculty of Medicine, Kuwait University, State of Kuwait, PO BOX: 24923-23110 SAFAT, Jabriya, Kuwait
| | - Andy Kaempf
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Alexey V Danilov
- Department of Hematology and Hematopoietic Stem Cell Transplant, City of Hope National Medical Center, Duarte, CA, USA
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Murru R, Galitzia A, Barabino L, Presicci R, La Nasa G, Caocci G. Prediction of severe infections in chronic lymphocytic leukemia: a simple risk score to stratify patients at diagnosis. Ann Hematol 2024; 103:1655-1664. [PMID: 38236391 PMCID: PMC11009768 DOI: 10.1007/s00277-024-05625-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/11/2024] [Indexed: 01/19/2024]
Abstract
Chronic Lymphocytic Leukemia (CLL) is well-known for increasing susceptibility to infections. Factors such as immune dysregulation, IGHV status, hypogammaglobulinemia, and patient comorbidity and treatment, contribute to higher infection rates and mortality. However, the impact of hypogammaglobulinemia on infection rates is controversial. We aimed to identify clinical and biological parameters linked to the risk of severe infectious events. Additionally, we set up a straightforward risk infection score to stratify CLL patients at diagnosis, thereby enabling the development of suitable infection prevention strategies. We retrospectively evaluated 210 unselected CLL patients diagnosed between 1988 and 2018. This evaluation encompassed demographics, Binet stage, immunoglobulin (Ig) levels, treatment history, comorbidities, and IGHV mutational status at diagnosis. The frequency and severity of infectious events were recorded. Analysis revealed that age, IGHV mutational status, Binet stage, and hypogammaglobulinemia were statistically associated with the Time to First Infection (TTFI) in univariate and multivariate analyses. Using hazard ratios from the multivariate analysis, we finally devised a risk scoring system that integrated age, IGHV mutational status, immunoglobulin levels, and Binet stage to stratify patients at diagnosis based on their specific infection risk. In our cohort, disease progression and infections were the leading cause of death. These findings pointed out the clinical need for a screening process strategic for defining infectious risk at the time of CLL diagnosis, with a significant enhancement in the clinical management of these patients.
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Affiliation(s)
- Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale Oncologico A. Businco, ARNAS G. Brotzu, Cagliari, Italy
| | - Andrea Galitzia
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Luca Barabino
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Roberta Presicci
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giorgio La Nasa
- Hematology and Stem Cell Transplantation Unit, Ospedale Oncologico A. Businco, ARNAS G. Brotzu, Cagliari, Italy
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Giovanni Caocci
- Hematology and Stem Cell Transplantation Unit, Ospedale Oncologico A. Businco, ARNAS G. Brotzu, Cagliari, Italy.
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
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Gordon MJ, Duan Z, Zhao H, Nastoupil L, Iyer S, Ferrajoli A, Danilov AV, Giordano SH. Comparison of Comorbidity Models Within a Population-Based Cohort of Older Adults With Non-Hodgkin Lymphoma. JCO Clin Cancer Inform 2024; 8:e2300223. [PMID: 38684043 DOI: 10.1200/cci.23.00223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/25/2024] [Accepted: 03/08/2024] [Indexed: 05/02/2024] Open
Abstract
PURPOSE Compare the association of individual comorbidities, comorbidity indices, and survival in older adults with non-Hodgkin lymphoma (NHL), including in specific NHL subtypes. METHODS Data source was SEER-Medicare, a population-based registry of adults age 65 years and older with cancer. We included all incident cases of NHL diagnosed during 2008-2017 who met study inclusion criteria. Comorbidities were classified using the three-factor risk estimate scale (TRES), Charlson comorbidity index (CCI), and National Cancer Institute (NCI) comorbidity index categories and weights. Overall survival (OS) and lymphoma-specific survival, with death from other causes treated as a competing risk, were estimated using the Kaplan-Meier method from time of diagnosis. Multivariable Cox models were constructed, and Harrel C-statistics were used to compare comorbidity models. A two-sided P value of <.05 was considered significant. RESULTS A total of 40,486 patients with newly diagnosed NHL were included. Patients with aggressive NHL had higher rates of baseline comorbidity. Despite differences in baseline comorbidity between NHL subtypes, cardiovascular, pulmonary, diabetes, and renal comorbidities were frequent and consistently associated with OS in most NHL subtypes. These categories were used to construct a candidate comorbidity score, the non-Hodgkin lymphoma 5 (NHL-5). Comparing three validated comorbidity scores, TRES, CCI, NCI, and the novel NHL-5 score, we found similar associations with OS and lymphoma-specific survival, which was confirmed in sensitivity analyses by NHL subtypes. CONCLUSION The optimal measure of comorbidity in NHL is unknown. Here, we demonstrate that the three-category TRES and five-category NHL-5 scores perform as well as the 14-16 category CCI and NCI scores in terms of association with OS and lymphoma-specific survival. These simple scores could be more easily used in clinical practice without prognostic loss.
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Affiliation(s)
- Max J Gordon
- Department of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
- National Cancer Institute, Lymphoid Malignancy Branch, Bethesda, MD
| | - Zhigang Duan
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Loretta Nastoupil
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Swaminathan Iyer
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexey V Danilov
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
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Lee CY, Gordon MJ, Markofski MM, LaVoy EC, Peterson SK, Li L, Fares S, Baum M, Pace M, Walsh D, Ferrajoli A, Basen-Engquist K. Optimization of mHealth behavioral interventions for patients with chronic lymphocytic leukemia: the HEALTH4CLL study. J Cancer Surviv 2024:10.1007/s11764-024-01555-w. [PMID: 38472612 DOI: 10.1007/s11764-024-01555-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/15/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE This pilot study of a diet and physical activity intervention (HEALTH4CLL) was conducted to reduce fatigue and improve physical function (PF) in patients with chronic lymphocytic leukemia (CLL). METHODS The HEALTH4CLL study used a randomized factorial design based on the multiphase optimization strategy (MOST). Patients received diet, exercise, and body weight management instructional materials plus a Fitbit and were randomized to undergo one of 16 combinations of 4 evidence-based mHealth intervention strategies over 16 weeks. Patients' fatigue, PF, health-related quality of life, behavior changes, and program satisfaction and retention were assessed. Paired t-tests were used to examine changes in outcomes from baseline to follow-up among patients. Factorial analysis of variance examined effective intervention components and their combinations regarding improvement in fatigue and PF scores. RESULTS Among 31 patients, we observed significant improvements in fatigue (+ 11.8; t = 4.08, p = 0.001) and PF (+ 2.6; t = 2.75, p = 0.01) scores. The combination of resistance and aerobic exercise with daily self-monitoring was associated with improved fatigue scores (β = 3.857, SE = 1.617, p = 0.027). Analysis of the individual components of the MOST design demonstrated greater improvement in the PF score with resistance plus aerobic exercise than with aerobic exercise alone (β = 2.257, SE = 1.071, p = 0.048). CONCLUSIONS Combined aerobic and resistance exercise and daily self-monitoring improved PF and reduced fatigue in patients with CLL. IMPLICATIONS FOR CANCER SURVIVORS This pilot study supported the feasibility of a low-touch mHealth intervention for survivors of CLL and provided preliminary evidence that exercising, particularly resistance exercise, can improve their symptoms and quality of life.
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Affiliation(s)
- Che Young Lee
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1440, Houston, TX, 77030, USA
| | - Max J Gordon
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 428, Houston, TX, 77030, USA
| | - Melissa M Markofski
- Department of Health and Human Performance, University of Houston, 3875 Holman St., Rm 104 Garrison, Houston, TX, 77204, USA
| | - Emily C LaVoy
- Department of Health and Human Performance, University of Houston, 3875 Holman St., Rm 104 Garrison, Houston, TX, 77204, USA
| | - Susan K Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1330, Houston, TX, 77030, USA
| | - Liang Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1411, Houston, TX, 77030, USA
| | - Sara Fares
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1440, Houston, TX, 77030, USA
| | - Miranda Baum
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1440, Houston, TX, 77030, USA
| | - Margaret Pace
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 428, Houston, TX, 77030, USA
| | - Danielle Walsh
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 428, Houston, TX, 77030, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 428, Houston, TX, 77030, USA.
| | - Karen Basen-Engquist
- Department of Health Disparities Research, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 1440, Houston, TX, 77030, USA.
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Bennett R, Seymour JF. Update on the management of relapsed/refractory chronic lymphocytic leukemia. Blood Cancer J 2024; 14:33. [PMID: 38378673 PMCID: PMC10879527 DOI: 10.1038/s41408-024-01001-1] [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: 12/19/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024] Open
Abstract
Chronic lymphocytic leukemia (CLL) predominantly affects older adults, characterized by a relapsing and remitting pattern with sequential treatments available for many patients. Identification of progressive/relapsed CLL should prompt close monitoring and early discussion about the next therapies when treatment indications are present. The intervening period represents an opportunity to optimize patient health, including establishing adequate vaccination and surveillance for second primary malignancies, and treating non-CLL-related comorbidities which may impact well-being and CLL therapy. We now see patients with relapsed/refractory (RR) CLL in the clinic who have been previously treated with chemoimmunotherapy (CIT) and/or one or more novel therapies. Continuous covalent inhibitors of Bruton's tyrosine kinase (cBTKi) and fixed-duration venetoclax (Ven)-anti-CD20 monoclonal antibody (mAb) are preferred over CIT given the survival advantages associated with these therapies, although have never been evaluated head-to-head. While both classes are effective for RR CLL, potential side effects and the logistics of administration differ. Few randomized data demonstrate the sequential use of cBTKi and fixed-duration Ven-anti-CD20 mAb; however, they may be used in either sequence. Newer non-covalent BTKi, active against BTK C481 resistance mutations emerging with continuous cBTKi exposure, and novel approaches such as BTK degraders, bispecific antibodies, and chimeric antigen receptor T-cell therapies demonstrate impressive efficacy. In this review of RR CLL we explore relevant investigations, consideration of broader CLL- and non-CLL-related health needs, and evidence for efficacy and safety of B-cell receptor inhibitors and Ven, including available data to support drug sequencing or switching. We describe novel approaches to RR CLL, including rechallenging with fixed-duration therapies, allogeneic stem cell transplant indications in the novel therapy era, and highlight early data supporting the use of T-cell directing therapies and novel drug targets.
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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
| | - 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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10
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Martino EA, Mauro FR, Reda G, Laurenti L, Visentin A, Frustaci A, Vigna E, Pepe S, Catania G, Loseto G, Murru R, Chiarenza A, Sportoletti P, Del Principe MI, Laureana R, Coscia M, Galimberti S, Ferretti E, Zucchetto A, Bomben R, Polesel J, Tedeschi A, Rossi D, Trentin L, Neri A, Morabito F, Gattei V, Gentile M. Ibrutinib as first line therapy in chronic lymphocytic leukemia patients over 80 years old: A retrospective real-life multicenter Italian cohort. Hematol Oncol 2024; 42:e3249. [PMID: 38287529 DOI: 10.1002/hon.3249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/28/2023] [Accepted: 12/31/2023] [Indexed: 01/31/2024]
Abstract
Although chronic lymphocytic leukemia (CLL) predominantly affects the elderly, limited data exists about the outcomes of over 80-year-old patients, usually underrepresented in clinical trials. We conducted a multicenter study enrolling 79 consecutive CLL patients ≥80 years at the time of frontline therapy, all treated with ibrutinib. Nearly 48% of cases exhibited unmutated IGHV genes, 32% 17p deletion, and 39.2% TP53 mutations; 63.3% displayed a cumulative illness rating scale (CIRS) > 6. The overall response rate on ibrutinib, computed in 74/79 patients (5 patients excluded for early withdrawal), was 89.9%. After a median follow-up of 28.9 months, the median progression-free survival (PFS) and overall survival (OS) were 42.5 and 51.8 months, respectively. CIRS>6 and temporary discontinuation of ibrutinib lasting for 7-30 days were the only parameters associated with a significantly shorter PFS and were both relevant in predicting a shorter PFS compared to patients with CIRS≤6 and therapy discontinuation ≤7 days. The most common grade≥3 adverse events were infections (25.5%), neutropenia (10.1%), and anemia (2.5%). Eighteen patients (22.8%) experienced a cardiovascular event, including grade-2 atrial fibrillation (n = 9; 11%), grade-2 hypertension (n = 5; 6%), heart failure (n = 3; 3%), and acute coronary syndrome (n = 1; 1%). Mild bleeding events were observed in 27 patients (34.2%). Ibrutinib was permanently discontinued in 26 patients due to progressive disease (n = 11, including 5 Richter's syndromes), secondary malignancies (n = 6), infections (n = 3), cardiac failure (n = 3), severe bleeding (n = 2), and sudden death (n = 1). In conclusion, our analyses confirmed the overall effectiveness and favorable safety profile of the ibrutinib-single agent therapeutic approach in CLL patients ≥80 years.
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Affiliation(s)
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | - Gianluigi Reda
- Hematology Unit, Fondazione Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Laurenti
- Dipartimento Scienze Radiologiche ed Ematologiche, Divisione di Ematologia Fondazione Policlinico universitario A Gemelli, Rome, Italy
| | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Annamaria Frustaci
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Sara Pepe
- Hematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
| | | | | | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale A. Businco, ARNAS G. Brotzu, Cagliari, Italy
| | - Annalisa Chiarenza
- Divisione di Ematologia, A.O.U. Policlinico, PO G.Rodolico, Catania, Italy
| | - Paolo Sportoletti
- Centro di Ricerca Emato-Oncologica (CREO), Dipartimento di Medicina e Chirurgia, Università di Perugia, Perugia, Italy
| | - Maria Ilaria Del Principe
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università degli Studi di Roma "Tor Vergata," Rome, Rome, Italy
| | - Roberta Laureana
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università degli Studi di Roma "Tor Vergata," Rome, Rome, Italy
| | - Marta Coscia
- University Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino and Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | | | - Eleonora Ferretti
- Clinical Trials Center Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Antonella Zucchetto
- Clinical and Experimental Onco-Hematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Riccardo Bomben
- Clinical and Experimental Onco-Hematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Jerry Polesel
- Unit of Cancer Epidemiology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Alessandra Tedeschi
- Department of Haematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Davide Rossi
- Oncology Institute of Southern Switzerland and Institute of Oncology Research, Bellinzona, Switzerland
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Antonino Neri
- Scientific Directorate, Azienda USL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | | | - Valter Gattei
- Clinical and Experimental Onco-Hematology Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Massimo Gentile
- Hematology Unit, AO Cosenza, Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, Rende, Italy
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11
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Cohen D, Osadchy A, Cohen-Hagai K, Jarchowsky Dolberg O, Israeli-Shani L, Lishner M, Breslavsky A, Shitrit D, Wand O. Bronchiectasis in Subjects With Chronic Lymphocytic Leukemia. Arch Bronconeumol 2023; 59:839-841. [PMID: 37827951 DOI: 10.1016/j.arbres.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Dovev Cohen
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexandra Osadchy
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Radiology Department, Meir Medical Center, Kfar Saba, Israel
| | - Keren Cohen-Hagai
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Nephrology and Hypertension, Meir Medical Center, Kfar Saba, Israel
| | - Osnat Jarchowsky Dolberg
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Internal Medicine Department A, Meir Medical Center, Kfar Saba, Israel; Hematology Institute, Meir Medical Center, Kfar Saba, Israel
| | - Lilach Israeli-Shani
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Lishner
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Internal Medicine Department A, Meir Medical Center, Kfar Saba, Israel
| | - Anna Breslavsky
- Division of Pulmonary Medicine, Barzilai University Medical Center, Ashkelon, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - David Shitrit
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Wand
- Division of Pulmonary Medicine, Barzilai University Medical Center, Ashkelon, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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12
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Duchesneau ED, McNeill AM, Schary W, Pate V, Lund JL. Prognosis of older adults with chronic lymphocytic leukemia: A Surveillance, Epidemiology, and End Results-Medicare cohort study. J Geriatr Oncol 2023; 14:101602. [PMID: 37696241 DOI: 10.1016/j.jgo.2023.101602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/06/2023] [Accepted: 08/04/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION While prognosis for patients with chronic lymphocytic leukemia (CLL) has improved over time in younger adults, only modest improvements have occurred in older adults. We conducted a descriptive study of prognosis in older adults with CLL. MATERIALS AND METHODS We used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database from 2003 to 2016. We identified older adults (≥66 years) diagnosed with primary CLL between 2004 and 2015 (Overall Cohort). A subset who initiated CLL-directed therapy during the year following diagnosis was also identified (Treated Cohort). Both cohorts were matched to Medicare beneficiaries without cancer based on age, sex, and region. For each year from 2004 to 2013, three-year survival for patients with CLL and non-cancer comparators was described using Kaplan-Meier analysis. Inverse probability weighted Cox regression models were used to compare survival in the CLL and non-cancer comparator cohorts, accounting for demographic information and comorbidity and frailty indices. Among older adults with CLL, ten-year cause-specific cumulative mortality was estimated using Aalen-Johansen estimators that accounted for competing risks. Predictors of cause-specific mortality, including comorbidity and frailty burden, were assessed using sub-distribution hazards models. RESULTS In the Overall Cohort, three-year survival increased non-monotonically from 71.4% in 2004 to 73.4% in 2013, with a peak of 74.4% in 2011, and was lower than survival in non-cancer comparators (78.3% in 2004 to 83.2% in 2013). In the Treated Cohort, three-year survival was 56.3% in 2004 and 56.5% in 2013, with a peak of 64.2% in 2011. Cox models suggested that survival in the Treated Cohort was approaching survival in non-cancer comparators after 2011 (hazard ratio = 1.04, 95% confidence interval, 0.93-1.17). Ten-year cumulative mortality was 68.6% in the Overall Cohort and 81.7% in the Treated Cohort, with most deaths attributed to non-CLL causes. In the sub-distribution hazards models, age, year of diagnosis, frailty, and comorbidities were all associated with prognosis. DISCUSSION Prognosis in older adults has been stable over time and most patients with CLL die from non-CLL causes. CLL-directed treatment decision-making in older adults should consider age-related factors, such as comorbidity and frailty.
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Affiliation(s)
- Emilie D Duchesneau
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, 2101 McGavran-Greenberg Hall CB #7435, Chapel Hill, NC 27599-7435, United States of America.
| | - Ann Marie McNeill
- AbbVie Inc., 1400 Sheridan Rd, North Chicago, IL, 60064, United States of America
| | - William Schary
- AbbVie Inc., 1400 Sheridan Rd, North Chicago, IL, 60064, United States of America
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, 2101 McGavran-Greenberg Hall CB #7435, Chapel Hill, NC 27599-7435, United States of America
| | - Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, 2101 McGavran-Greenberg Hall CB #7435, Chapel Hill, NC 27599-7435, United States of America
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13
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González-Gascón-y-Marín I, Ballesteros-Andrés M, Martínez-Flores S, Rodríguez-Vicente AE, Pérez-Carretero C, Quijada-Álamo M, Rodríguez-Sánchez A, Hernández-Rivas JÁ. The Five "Ws" of Frailty Assessment and Chronic Lymphocytic Leukemia: Who, What, Where, Why, and When. Cancers (Basel) 2023; 15:4391. [PMID: 37686667 PMCID: PMC10486487 DOI: 10.3390/cancers15174391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Chronic lymphocytic leukemia (CLL) is a disease of the elderly, but chronological age does not accurately discriminate frailty status at the inter-individual level. Frailty describes a person's overall resilience. Since CLL is a stressful situation, it is relevant to assess the patient´s degree of frailty, especially before starting antineoplastic treatment. We are in the era of targeted therapies, which have helped to control the disease more effectively and avoid the toxicity of chemo (immuno) therapy. However, these drugs are not free of side effects and other aspects arise that should not be neglected, such as interactions, previous comorbidities, or adherence to treatment, since most of these medications are taken continuously. The challenge we face is to balance the risk of toxicity and efficacy in a personalized way and without forgetting that the most frequent cause of death in CLL is related to the disease. For this purpose, comprehensive geriatric assessment (GA) provides us with the opportunity to evaluate multiple domains that may affect tolerance to treatment and that could be improved with appropriate interventions. In this review, we will analyze the state of the art of GA in CLL through the five Ws.
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Affiliation(s)
| | | | - Sara Martínez-Flores
- Department of Geriatric Medicine, University Hospital Infanta Leonor, 28031 Madrid, Spain
| | - Ana-E Rodríguez-Vicente
- IBSAL, IBMCC, CSIC, Cancer Research Center, University of Salamanca, 37007 Salamanca, Spain
- Department of Hematology, University Hospital of Salamanca, 37007 Salamanca, Spain
| | - Claudia Pérez-Carretero
- IBSAL, IBMCC, CSIC, Cancer Research Center, University of Salamanca, 37007 Salamanca, Spain
- Department of Hematology, University Hospital of Salamanca, 37007 Salamanca, Spain
| | - Miguel Quijada-Álamo
- IBSAL, IBMCC, CSIC, Cancer Research Center, University of Salamanca, 37007 Salamanca, Spain
- Department of Hematology, University Hospital of Salamanca, 37007 Salamanca, Spain
| | - Alberto Rodríguez-Sánchez
- IBSAL, IBMCC, CSIC, Cancer Research Center, University of Salamanca, 37007 Salamanca, Spain
- Department of Hematology, University Hospital of Salamanca, 37007 Salamanca, Spain
| | - José-Ángel Hernández-Rivas
- Department of Hematology, University Hospital Infanta Leonor, 28031 Madrid, Spain
- Department of Medicine, Complutense University, 28040 Madrid, Spain
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14
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Urso A, Cavazzini F, Ballardini MP, Gambara S, Consolo S, Rigolin GM, Cuneo A. First-Line Treatment of Older Patients with CLL: A New Approach in the Chemo-Free Era. Cancers (Basel) 2023; 15:3859. [PMID: 37568676 PMCID: PMC10417156 DOI: 10.3390/cancers15153859] [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: 06/26/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Bruton tyrosine kinase inhibitors (BTKi) and the BCL2 inhibitor venetoclax, with or without the anti-CD20 monoclonal antibody Obinutuzumab, represent the preferred options for the first-line therapy of CLL because they are more effective and may improve quality of life. However, patient inclusion criteria are heterogeneous across trials designed for older patients, and the identification of CLL-specific parameters identifying unfit patients at risk of developing drug-specific adverse events is required to guide treatment choice. Due to inclusion/exclusion criteria in trials, higher discontinuation rates with BTKi were reported in real-world studies, and registry analyses provided useful information on factors predicting earlier discontinuation in a real-world setting. Though targeted agents were shown to be cost-effective treatments in high-income countries, the out-of-pocket expenses may limit accessibility to these drugs, and the overall expenditure for new drugs in CLL is projected to increase substantially, posing an issue for sustainability. This being said, the choice of a finite-duration treatment based on venetoclax-containing regimens or treatment until progression with BTKi is today possible in high-income countries, and the therapy choice drivers are represented by coexisting medical conditions rather than age, patient expectations, logistics, and sustainability.
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Affiliation(s)
| | | | | | | | | | | | - Antonio Cuneo
- Hematology Unit, University of Ferrara, 44121 Ferrara, Italy (F.C.); (M.P.B.); (S.C.)
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15
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Gordon MJ, Jones JE, George B, Peterson C, Burger JA, Jain N, Keating M, Wierda WG, Durand JB, Ferrajoli A. Long-term outcomes in patients with chronic lymphocytic leukemia treated with ibrutinib: Focus on hypertension and cardiovascular toxicity. Cancer 2023; 129:2192-2200. [PMID: 37016930 PMCID: PMC10882584 DOI: 10.1002/cncr.34787] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/13/2023] [Accepted: 02/28/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Continuous ibrutinib administration is needed to maintain efficacy in patients with chronic lymphocytic leukemia (CLL) and, as such, long-term toxicity is a concern. The authors report the 5-year follow-up of patients with CLL who received treatment with ibrutinib with a focus on hypertension and cardiovascular toxicities. METHODS Patient characteristics were assessed, including blood pressure, cardiovascular disease, disease progression, and death. Univariate logistic regression analysis assessed the relation of patient characteristics and the development of new or worsened hypertension. The incidence of hypertensive outcomes was evaluated using competing risk. Survival was estimated using the Kaplan-Meier method. RESULTS Three hundred patients with CLL who were treated with ibrutinib on clinical trials were included. The median patient age at study enrollment was 65 years (range, 29-83 years). Seventy percent of patients were men, and 88% were Caucasian. Sixty-nine percent of patients had hypertension at baseline, and 47% were on antihypertensive medication. Eighty-eight percent had relapsed or refractory CLL. New-onset and worsening hypertension were common, occurring in 68.5% and 38% of patients, respectively. Systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg was observed in 16.9% of patients. Hypertension was reversible after ibrutinib discontinuation. Older age, male sex, tobacco use, and chronic kidney disease were associated with ibrutinib-related hypertension. Baseline hypertension was not associated with major adverse cardiovascular events in ibrutinib-treated patients nor with event-free or overall survival. CONCLUSIONS Hypertension is a common toxicity in patients with CLL who receive ibrutinib but is manageable in most patients. Other than chronic kidney disease, baseline cardiovascular disease did not affect ibrutinib-related hypertension nor was hypertension associated with major adverse cardiovascular events or survival. PLAIN LANGUAGE SUMMARY Ibrutinib is an effective treatment for patients with chronic lymphocytic leukemia. Ibrutinib is a well tolerated therapy, however hypertension can develop or worsen in patients receiving ibrutinib and other cardiovascular events are significant challenges to the use of this drug. This may be particularly true in patients with heart disease. Short-term side effects may worsen heart disease, but the long-term impact is unknown. The long-term results of ibrutinib on heart disease and hypertension are described.
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Affiliation(s)
- Max J Gordon
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jade E Jones
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Binsah George
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Division of Cancer Medicine, Houston, Texas, USA
| | - Christine Peterson
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Division of Cancer Medicine, Houston, Texas, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Division of Cancer Medicine, Houston, Texas, USA
| | - Michael Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Division of Cancer Medicine, Houston, Texas, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Division of Cancer Medicine, Houston, Texas, USA
| | - Jean-Bernard Durand
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Division of Cancer Medicine, Houston, Texas, USA
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16
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Yang J, Yang L, Tordon B, Bucher O, Nugent Z, Landego I, Bourrier N, Uminski K, Brown K, Squires M, Marshall AJ, Katyal S, Mahmud S, Decker K, Geirnaert M, Dawe DE, Gibson SB, Johnston JB, Banerji V. Clinical Outcomes in a Large Canadian Centralized CLL Clinic Based on Treatment and Molecular Factors over a Decade. Curr Oncol 2023; 30:6411-6431. [PMID: 37504332 PMCID: PMC10378068 DOI: 10.3390/curroncol30070472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/23/2023] [Accepted: 06/28/2023] [Indexed: 07/29/2023] Open
Abstract
FISH cytogenetics, TP53 sequencing, and IGHV mutational status are increasingly used as prognostic and predictive markers in chronic lymphocytic leukemia (CLL), particularly as components of the CLL International Prognostic Index (CLL-IPI) and in directing therapy with novel agents. However, testing outside of clinical trials is not routinely available in Canada. As a centralized CLL clinic at CancerCare Manitoba, we are the first Canadian province to evaluate clinical outcomes and survivorship over a long period of time, incorporating the impact of molecular testing and the CLL-IPI score. We performed a retrospective analysis on 1315 patients diagnosed between 1960 and 2018, followed over a 12-year period, where 411 patients had molecular testing and 233 patients had a known CLL-IPI score at the time of treatment. Overall, 40.3% (n = 530) of patients received treatment, and 47.5% (n = 252) of patients received multiple lines of therapy. High-risk FISH and CLL-IPI (4-10) were associated with higher mortality (HR 2.03, p = 0.001; HR 2.64, p = 0.002), consistent with other studies. Over time, there was an increase in the use of targeted agents in treated patients. The use of Bruton's tyrosine kinase inhibitors improved survival in patients with unmutated IGHV and/or TP53 aberrations (HR 2.20, p = 0.001). The major cause of death in patients who received treatment was treatment/disease-related (32%, n = 42) and secondary malignancies (57%, n = 53) in those who were treatment-naïve. Our data demonstrate the importance of molecular testing in determining survivorship in CLL and underpinning the likely immune differences in outcomes for those treated for CLL.
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Affiliation(s)
- Jiayu Yang
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Lin Yang
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Bryan Tordon
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Oliver Bucher
- Department of Epidemiology, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Zoann Nugent
- Department of Biochemistry and Medical Genetics Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Ivan Landego
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Nicole Bourrier
- Paul Albrechtsen Research Institute CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Kelsey Uminski
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Kevin Brown
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Mandy Squires
- Paul Albrechtsen Research Institute CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Aaron J Marshall
- Department of Immunology, Max Rady College of Medicine, University of Manitoba, Rady Faculty of Health Sciences, Winnipeg, MB R3E 0T5, Canada
| | - Sachin Katyal
- Paul Albrechtsen Research Institute CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
- Department of Pharmacology and Therapeutics, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
| | - Salah Mahmud
- Department of Community Health Sciences, Max Rady College of Medicine Community Health Sciences, Winnipeg, MB R3E 0W2, Canada
| | - Kathleen Decker
- Department of Epidemiology, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
- Department of Community Health Sciences, Max Rady College of Medicine Community Health Sciences, Winnipeg, MB R3E 0W2, Canada
| | - Marc Geirnaert
- Department of Pharmacy, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - David E Dawe
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
- Paul Albrechtsen Research Institute CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Spencer B Gibson
- Department of Biochemistry and Medical Genetics Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
- Paul Albrechtsen Research Institute CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - James B Johnston
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
- Paul Albrechtsen Research Institute CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
| | - Versha Banerji
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
- Department of Biochemistry and Medical Genetics Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 3P4, Canada
- Paul Albrechtsen Research Institute CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
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17
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Molica S. Redefining efficacy and safety endpoints for chronic lymphocytic leukemia in the era of targeted therapy. Expert Rev Hematol 2023; 16:803-806. [PMID: 37830359 DOI: 10.1080/17474086.2023.2271170] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/11/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Stefano Molica
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull University NHS Trust, Hull, UK
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18
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Gordon MJ, Duan Z, Zhao H, Nastoupil L, Ferrajoli A, Danilov AV, Giordano SH. A novel comorbidity score for older adults with non-Hodgkin lymphoma: the 3-factor risk estimate scale. Blood Adv 2023; 7:2632-2642. [PMID: 36753602 PMCID: PMC10282013 DOI: 10.1182/bloodadvances.2022009507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 02/10/2023] Open
Abstract
For patients with non-Hodgkin lymphoma (NHL), formal comorbidity assessment is recommended but is rarely conducted in routine practice. A simple, validated measure of comorbidities that standardizes their assessment could improve adherence to guidelines. We previously constructed the 3-factor risk estimate scale (TRES) among patients with chronic lymphocytic leukemia (CLL). Here, we investigated TRES in multiple NHL subtypes. In the surveillance, epidemiology, and end results-Medicare database, patients with NHL diagnosed from 2008 to 2017 were included. Upper gastrointestinal, endocrine, and vascular comorbidities were identified using ICD-9/ICD-10 codes to assign TRES scores. Patient characteristic distributions were compared using χ2 or t test. Association of mortality and TRES score was assessed using Kaplan-Meier and multivariable Cox regression model for competing risk. A total of 40 486 patients were included in the study. Median age was 77 years (interquartile range [IQR], 71-83 years). The most frequent NHL subtypes were CLL (28.2%), diffuse large B-cell (27.6%), and follicular lymphoma (12.6%). Median follow-up was 33 months (IQR, 13-60 months). TRES was low, intermediate, and high in 40.8%, 37.0%, and 22.2% of patients, corresponding to median overall survival (OS) of 8.2, 5.3, and 2.9 years (P < .001), respectively. TRES was associated with OS in all NHL subtypes. In multivariable models, TRES was associated with inferior OS and NHL-specific survival. TRES is clinically translatable and associated with OS and lymphoma-specific survival in older adults with NHL.
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Affiliation(s)
- Max J. Gordon
- Department of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zhigang Duan
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Loretta Nastoupil
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexey V. Danilov
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Sharon H. Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
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19
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Crane JC, Gordon MJ, Basen-Engquist K, Ferrajoli A, Markofski MM, Lee CY, Fares S, Simpson RJ, LaVoy EC. Relationships between T-lymphocytes and physical function in adults with chronic lymphocytic leukemia: Results from the HEALTH4CLL pilot study. Eur J Haematol 2023; 110:732-742. [PMID: 36946440 PMCID: PMC10929688 DOI: 10.1111/ejh.13958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/15/2023] [Accepted: 03/20/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Examine physical function and T-cell phenotype in patients with chronic lymphocytic leukemia (CLL) before and after a physical activity (PA) intervention. METHODS Physical function measures and blood samples were collected from CLL patients (Rai stage 0-4, 50% receiving targeted therapy, N = 24) enrolled in a 16-week intervention of at-home aerobic and/or resistance exercise. Flow cytometry characterized T-cells in cryopreserved peripheral blood cells. Wilcoxon signed-rank test compared physical function and T-cell phenotype at baseline and 16-weeks; Kendall's Tau assessed associations between variables. RESULTS Godin leisure-time PA score increased from baseline to 16-weeks (mean difference: 14.61, p < .01) and fatigue decreased (mean difference: 6.71, p < .001). At baseline, lower fatigue correlated with a lower proportion of CD8+ T-cells (τ = 0.32, p = .03) and cardiorespiratory fitness (CRF) inversely correlated with the percentage of PD-1+CD8+ T-cells (τ -0.31, p = .03). At 16-weeks, CRF inversely correlated with the proportion of PD-1+CD4+ T-cells (τ -0.34, p = .02). Reduced fatigue at 16-weeks correlated with an increased CD4:CD8 ratio (τ = 0.36, p = .02) and lower percentage of HLA-DR+PD-1+CD4+ T-cells (τ = -0.37, p = .01). CONCLUSIONS This intervention increased leisure-time PA and decreased fatigue in CLL patients. These changes correlated with an increased CD4:CD8 T-cell ratio and reduced proportion of T-cells subsets previously associated with poor outcomes in CLL patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02194387.
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Affiliation(s)
- Justin C. Crane
- Department of Health and Human Performance, University of Houston; Houston, TX, USA
| | - Max J. Gordon
- The University of Texas MD Anderson Cancer Center; Houston, TX, USA
| | - Karen Basen-Engquist
- The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Department of Behavioral Science, Division of Cancer Prevention and Population Services, The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Center for Energy Balance in Cancer Prevention and Survivorship, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Department of Health Promotion and Behavioral Sciences, The University of Texas School of Public Health; Houston, TX, USA
- Department of Kinesiology, Rice University; Houston, TX, USA
| | - Alessandra Ferrajoli
- The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center; Houston, TX, USA
| | - Melissa M. Markofski
- Department of Health and Human Performance, University of Houston; Houston, TX, USA
| | - Che Young Lee
- The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Department of Behavioral Science, Division of Cancer Prevention and Population Services, The University of Texas MD Anderson Cancer Center; Houston, TX, USA
| | - Sara Fares
- The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Department of Behavioral Science, Division of Cancer Prevention and Population Services, The University of Texas MD Anderson Cancer Center; Houston, TX, USA
| | - Richard J Simpson
- School of Nutritional Sciences and Wellness, The University of Arizona; Tucson, AZ, USA
- Department of Pediatrics, The University of Arizona; Tucson, AZ, USA
- Department of Immunobiology, The University of Arizona; Tucson, AZ, USA
- The University of Arizona Cancer Center; Tucson, AZ, USA
| | - Emily C. LaVoy
- Department of Health and Human Performance, University of Houston; Houston, TX, USA
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20
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Šimkovič M, Turcsányi P, Špaček M, Mihályová J, Ryznerová P, Maco M, Vodárek P, Écsiová D, Poul H, Móciková H, Zuchnická J, Panovská A, Lekaa M, Oršulová M, Prchlíková A, Stejskal L, Mašlejová S, Brychtová Y, Bezděková L, Papajík T, Lysák D, Trněný M, Smolej L, Doubek M. COVID-19 in patients with chronic lymphocytic leukemia: a multicenter analysis by the Czech CLL study group. Ann Hematol 2023; 102:811-817. [PMID: 36847805 PMCID: PMC9969021 DOI: 10.1007/s00277-023-05147-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 12/15/2022] [Indexed: 03/01/2023]
Abstract
Patients with chronic lymphocytic leukemia (CLL) have a high risk of poor outcomes related to coronavirus disease 2019 (COVID-19). This multicenter cohort study evaluated the impact of COVID-19 infection on the population of CLL patients in the Czech Republic. Between March 2020 and May 2021, 341 patients (237 males) with CLL and COVID-19 disease were identified. The median age was 69 years (range 38-91). Out of the 214 (63%) patients with the history of therapy for CLL, 97 (45%) were receiving CLL-directed treatment at diagnosis of COVID-19: 29% Bruton tyrosine kinase inhibitor (BTKi), 16% chemoimmunotherapy (CIT), 11% Bcl-2 inhibitor, and 4% phosphoinositide 3-kinase inhibitor. Regarding the severity of COVID-19, 60% pts required admission to the hospital, 21% pts were admitted to the intensive care unit (ICU), and 12% received invasive mechanical ventilation. The overall case fatality rate was 28%. Major comorbidities, age over 72, male gender, CLL treatment in history, CLL-directed treatment at COVID-19 diagnosis were associated with increased risk of death. Of note, concurrent therapy with BTKi compared to CIT was not associated with better outcome of COVID-19.
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Affiliation(s)
- Martin Šimkovič
- 4th Department of Internal Medicine - Hematology, Faculty of Medicine in Hradec Králové, University Hospital and Charles University in Prague, Prague, Czech Republic.
| | - Peter Turcsányi
- Department of Haematology-Oncology, University Hospital, Olomouc, Czech Republic
| | - Martin Špaček
- First Department of Medicine - Haematology, University General Hospital, Prague, Czech Republic
| | - Jana Mihályová
- Department of Hematooncology, University Hospital, Ostrava, Czech Republic
| | - Pavlína Ryznerová
- Department of Haematology-Oncology, University Hospital, Olomouc, Czech Republic
| | - Mária Maco
- Department of Internal Medicine - Haematology, University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Pavel Vodárek
- 4th Department of Internal Medicine - Hematology, Faculty of Medicine in Hradec Králové, University Hospital and Charles University in Prague, Prague, Czech Republic
| | - Dominika Écsiová
- 4th Department of Internal Medicine - Hematology, Faculty of Medicine in Hradec Králové, University Hospital and Charles University in Prague, Prague, Czech Republic
| | - Hynek Poul
- Department of Hematology and Transfusion Medicine, Hospital Pelhrimov, Pelhrimov, Czech Republic
| | - Heidi Móciková
- Department of Internal Medicine - Haematology, University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Jana Zuchnická
- Department of Hematooncology, University Hospital, Ostrava, Czech Republic
| | - Anna Panovská
- Department of Internal Medicine - Haematology and Oncology, University Hospital, Brno, Czech Republic
| | - Mohammad Lekaa
- Department of Hematology and Oncology, Medical School and Teaching Hospital in Plzen, Charles University in Prague, Plzen, Czech Republic
| | - Martina Oršulová
- Department of Internal Medicine - Haematology and Oncology, University Hospital, Brno, Czech Republic
| | - Adéla Prchlíková
- Department of Internal Medicine - Haematology and Oncology, University Hospital, Brno, Czech Republic
| | - Lukáš Stejskal
- Haematology/Tranfusiology Department, Silesian Hospital Opava, Opava, Czech Republic
| | - Stanislava Mašlejová
- Department of Internal Medicine - Haematology and Oncology, University Hospital, Brno, Czech Republic
| | - Yvona Brychtová
- Department of Internal Medicine - Haematology and Oncology, University Hospital, Brno, Czech Republic
| | - Lucie Bezděková
- Department of Internal Medicine - Haematology and Oncology, University Hospital, Brno, Czech Republic
| | - Tomáš Papajík
- Department of Haematology-Oncology, University Hospital, Olomouc, Czech Republic
| | - Daniel Lysák
- Department of Hematology and Oncology, Medical School and Teaching Hospital in Plzen, Charles University in Prague, Plzen, Czech Republic
| | - Marek Trněný
- First Department of Medicine - Haematology, University General Hospital, Prague, Czech Republic
| | - Lukáš Smolej
- 4th Department of Internal Medicine - Hematology, Faculty of Medicine in Hradec Králové, University Hospital and Charles University in Prague, Prague, Czech Republic
| | - Michael Doubek
- Department of Internal Medicine - Haematology and Oncology, University Hospital, Brno, Czech Republic
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21
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Rhodes JM, Barrientos JC, Rai KR. How Have Targeted Agents Changed the Treatment Landscape for Elderly Patients with CLL? Curr Oncol Rep 2022; 24:1705-1713. [PMID: 36334220 DOI: 10.1007/s11912-022-01322-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/08/2022]
Abstract
PURPOSE OF REVIEW Chronic lymphocytic leukemia (CLL) is a common hematologic malignancy in elderly patients. At the time of diagnosis, most patients have comorbid medical conditions. Although patients have other competing medical issues, the majority of patients will die from CLL or CLL-related complications. This review will discuss treatment in elderly patients with CLL. RECENT FINDINGS Recent work has focused on understanding the role comorbid medical conditions play in the management of CLL in elderly patients, including the use of geriatric assessment, Charlson comorbidity index, cumulative illness rating scale, and most recently, the CLL-comorbidity index. The treatment landscape for CLL has shifted from chemoimmunotherapy to the use of targeted agents. Several clinical trials in elderly patients have demonstrated improvement in progression-free survival (PFS) with ibrutinib + / - obinutuzumab, acalabrutinib + / - obinutuzumab, zanubrutinib, venetoclax-obinutuzumab, idelalisib, and duvelisib. The adverse event profile and potential for drug-drug interactions in the treatment of CLL in elderly patients have not been described, and further studies are needed to determine optimal treatment. Treatment of elderly patients with CLL should be made on a case-by-case basis based on a patient's fitness, comorbid medical conditions, and concomitant medications. The use of targeted agents has improved outcomes in this patient population, but further studies are needed to determine the best practice.
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Affiliation(s)
- Joanna M Rhodes
- Division of Hematology-Oncology, Department of Medicine at Zucker School of Medicine at Hofstra/Northwell, CLL Research and Treatment Center, 410 Lakeville Road, Suite 212, Lake Success, NY, 11042, USA.
| | - Jacqueline C Barrientos
- Division of Hematology-Oncology, Department of Medicine at Zucker School of Medicine at Hofstra/Northwell, CLL Research and Treatment Center, 410 Lakeville Road, Suite 212, Lake Success, NY, 11042, USA
- Mount Sinai Medical Center Comprehensive Cancer Center, Miami, FL, USA
| | - Kanti R Rai
- Division of Hematology-Oncology, Department of Medicine at Zucker School of Medicine at Hofstra/Northwell, CLL Research and Treatment Center, 410 Lakeville Road, Suite 212, Lake Success, NY, 11042, USA
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22
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Farris KB, Cadwallader T, Farley J, Gatwood K, Mackler E, Gatwood J. Implementation of a model integrating primary and oncology pharmacists' care for patients taking oral anticancer agents (OAA). EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 7:100163. [PMID: 35957656 PMCID: PMC9358049 DOI: 10.1016/j.rcsop.2022.100163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 06/21/2022] [Accepted: 07/26/2022] [Indexed: 11/28/2022] Open
Abstract
Improvements in chronic myeloid leukemia (CML), chronic lymphocytic leukemia (CLL), and multiple myeloma (MM) treatment options have increased the 5-year survival rates for patients with these hematologic malignancies. In addition to cancer management, these patients may need help to manage multiple chronic conditions (MCC). The overall objective of this study is to examine the impact and implementation of a model that coordinates care between oncology and primary care pharmacists for people taking an oral anti-cancer agent (OAAs) and medications for comorbid chronic conditions. This is a multi-center, prospective, single-arm pilot study that will recruit up to 40 patients from Michigan Medicine and Vanderbilt University Medical Center (VUMC). Eligible participants will be 18 years of age or older, prescribed an OAA, have a diagnosis of either CML, CLL or MM, and be diagnosed with and taking medication for at least two specified chronic conditions. The Pharmacists Coordinated Care Oncology Model (PCOM) is a two-month intervention that builds upon current pharmacist clinical responsibilities. Generally, participants will complete a patient-reported outcome measure at 2 and 6 weeks post-OAA initiation that is sent to their oncology pharmacist, and they will also receive a comprehensive medication review at week 4 from a primary care pharmacist for their chronic medications. The pharmacists will communicate about the results via electronic medical record (EMR) and intervene if necessary. The primary endpoints are (1) dose-adjusted OAA proportion of days covered (PDC), and (2) PDC for chronic condition medications. PDCs will be determined via prescription records. The association of OAA and chronic medication PDCs will be quantified via correlation and chi-squared tests. The association between symptom experience and OAA adherence will be examined via correlation analyses. For implementation, characteristics of patient participants, feasibility, acceptability, adoption, fidelity, and trialability will be described. Data will be collected via EMR and pharmacist and patient interviews. Median/IQR for acceptability, adoption and fidelity will be reported, and patient interviews will be analyzed using a grounded theory approach and pharmacist interviews will be analyzed using thematic analyses.
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23
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Causes of Death in Low Grade B-Cell Lymphomas in the Rituximab Era: A Prospective Cohort Study. Blood Adv 2022; 6:5210-5221. [PMID: 35849723 PMCID: PMC9631639 DOI: 10.1182/bloodadvances.2022007990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022] Open
Abstract
Mortality for patients with marginal zone and indolent B-cell lymphoma is largely unrelated to lymphoma in the first decade from diagnosis. Early progression or retreatment within 24 months of diagnosis is strongly associated with increased risk of lymphoma-related mortality.
Low-grade B-cell lymphomas other than follicular and small lymphocytic lymphoma (LGBCL) account for 10% of all B-cell non-Hodgkin lymphomas. Despite improvements in survival outcomes for these patients, little is known about cause of death (COD) in the rituximab era. For a better understanding, we studied 822 newly diagnosed patients with marginal zone, lymphoplasmacytic, and unclassifiable low-grade B-cell lymphoma prospectively enrolled in the University of Iowa/Mayo Clinic Specialized Program of Research Excellence Molecular Epidemiology Resource from 2002 to 2015. COD was assigned based on medical record review using a standard protocol. At a median follow-up of 107 months, 219 (27%) patients had died. The incidence of lymphoma-related deaths when pooling across subtypes was lower than non–lymphoma-related deaths (10-year incidence, 8.0%; 95% confidence interval [CI]: 6.2-10.4 vs 13.6%; 95% CI: 11.2-16.6). The incidence of lymphoma-related deaths varied by subtype, ranging from 3.7% at 10 years in extranodal marginal zone lymphoma to 19.3% in lymphoplasmacytic lymphoma/Waldenström macroglobulinemia. Patients with early progression or retreatment events, defined using event-free survival at 24 months from diagnosis, had significantly higher likelihood of lymphoma-related death compared with patients without early events (10-year estimate: 19.1% vs 5.1%, respectively; P < .001), whereas the rates for non–lymphoma-related death were comparable in patients with or without early events (10-year estimates: 11.0% vs 15.3%, respectively). In conclusion, the most common COD in LGBCLs in the first decade after diagnosis was for causes other than lymphoma. Progression or retreatment within the first 2 years of diagnosis was a strong predictor for risk of lymphoma-related death.
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24
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Differential regulation of CTLA4 expression through BTK-dependent and independent mechanisms in CLL. Blood Adv 2022; 6:5440-5448. [PMID: 35759759 PMCID: PMC9631695 DOI: 10.1182/bloodadvances.2021005571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/15/2022] [Indexed: 11/20/2022] Open
Abstract
Ibrutinib suppresses CLL cell CTLA4 expression in vitro and in vivo. CTLA4 expression on CLL is regulated by non-BTKs that differ from T-cell CTLA4 regulation.
Cytotoxic T lymphocyte antigen 4 (CTLA4) is a major immune checkpoint and target for cancer immunotherapy. Although originally discovered and primarily studied on T cells, its role on other cell types has also been recognized in recent years. Here we describe an unexpected interaction between ibrutinib (a targeted inhibitor of Bruton tyrosine kinase [BTK]) and CTLA4 expression on malignant chronic lymphocytic leukemia (CLL) cells. Although BTK itself does play a role in CTLA4 expression in CLL, we demonstrate that ibrutinib’s main suppressive effect on CTLA4 protein expression and trafficking occurs through non-BTK targets influenced by this drug. This suppression is not seen in T cells, indicating a different mechanism of CTLA4 regulation in CLL vs T cells. Appreciating this distinct mechanism and the beneficial non-BTK effects of ibrutinib may contribute to understanding the immune benefits of ibrutinib treatment and lead to therapeutic approaches to improve immune function in patients with CLL by suppressing CTLA4 expression.
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25
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Nguyen A, Martin-Silva N, de Boysson H, Deshayes S, Gac AC, Reboursière E, Damaj G, Aouba A. Low total gamma globulin level discovery at diffuse large B-cell lymphoma diagnosis predicts high risk of infection-related death: data from a monocentric retrospective study. Swiss Med Wkly 2022; 152:w30143. [PMID: 35704942 DOI: 10.4414/smw.2022.w30143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Diffuse large B-cell lymphoma can complicate the course of B-cell primary immunodeficiencies or induce lowering of total gamma globulin levels, whose clinical status as an effective secondary immunodeficiency remains unspecified. This study aimed to assess the frequency, and clinical and prognostic relevance of the low total gamma-globulin levels discovered at diagnosis of diffuse large B-cell lymphoma. RESULTS In a 2-year monocentric retrospective study, 96 patients diagnosed with diffuse large B-cell lymphoma who had a serum electrophoresis were included. Patients were divided into those with lower (L-TGL and higher (H-TGL) total gamma-globulin levels (total gamma-globulin levels ≤5.5 g/l and >5.5 g/l) and compared for outcomes, including fatal infectious events. Twelve (12.5%; 8 males; age median 68 years, range 55-82 years) exhibited L-TGL. There was no difference between the both groups regarding demographics, Ann Arbor lymphoma stage, inflammatory parameters or chemotherapy regimen. However, overall death rates (10/12, 83.3% versus 22/96, 26.2%; p = 0.03) and infection-related death rates (10/12, 83% versus 6/96, 6.2%; p <0.001) were significantly higher in the L-TGL group. CONCLUSION We demonstrate for the first time the strong negative impact of L-TGL on overall and infection-related mortality in diffuse large B-cell lymphoma. Prospective studies should distinguish immunodeficiencies secondary to the lymphoma from pre-existing humoral primary immunodeficiencies, using biomolecular testing and post-treatment total gamma-globulin level monitoring, to determine the best management strategy for infectious risk during diffuse large B-cell lymphoma treatment in the context of L-TGL.
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Affiliation(s)
- Alexandre Nguyen
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Nicolas Martin-Silva
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Hubert de Boysson
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Anne-Claire Gac
- Department of Clinical Haematology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Emilie Reboursière
- Department of Clinical Haematology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Gandhi Damaj
- Department of Clinical Haematology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine and Clinical Immunology, Normandie Univ, UNICAEN, CHU de Caen Normandie, Caen, France
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26
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Frustaci AM, Deodato M, Zamprogna G, Cairoli R, Montillo M, Tedeschi A. SOHO State of the Art Updates and Next Questions: What is Fitness in the Era of Targeted Agents? CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:356-361. [PMID: 34969641 DOI: 10.1016/j.clml.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/09/2021] [Accepted: 11/14/2021] [Indexed: 06/14/2023]
Abstract
The importance of coexisting conditions in chronic lymphocytic leukemia (CLL) outcome has been increasingly recognized over the past years. The role of comorbidities to predict patients' vulnerability toward immunochemotherapy has been well establish, especially since some of the tools commonly used to evaluate patients' fitness were employed to determine treatment eligibility in randomized trials. Nevertheless, is it still unclear how much fitness weights on treatment outcome with targeted agents and which assessment should be preferred. There are key differences in the toxicity profile between novel agents that are getting much more evident in retrospective, real-life experiences, rather than clinical trials. Therefore, an individual patient's comorbid medical conditions may be a deciding factor in therapy selection. Here, we analyze main evidence in literature on the predicting value of comorbidity assessment on outcome and management of CLL patients receiving novel agents.
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Affiliation(s)
- Anna Maria Frustaci
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy.
| | - Marina Deodato
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Giulia Zamprogna
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Roberto Cairoli
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Marco Montillo
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
| | - Alessandra Tedeschi
- Department of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Niguarda Cancer Center, Milano, Italy
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Usenko G, Gashynova K. Radiological Findings on Chest Computed Tomography in Patients With the Primary Diagnosed Chronic Lymphoproliferative Diseases. Cureus 2022; 14:e22935. [PMID: 35399482 PMCID: PMC8986505 DOI: 10.7759/cureus.22935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction The presence of concomitant respiratory pathology complicates the process of treatment and recovery of patients with chronic lymphoproliferative diseases (CLDs). Therefore, the diagnosis of lung injury is an important step in the management of such patients. Objectives The aim of this study was to determine the prevalence, nature, extent, and location of changes diagnosed by high-resolution chest computed tomography (CT) in patients with CLDs at the initial examination. Methods Medical records of inpatients who were hospitalized in 2018-2019 to the City Hematology Center of the Public Non-Profit Enterprise “City Clinical Hospital #4” of Dnipro City Council with a confirmed clinical diagnosis of CLDs were included in the retrospective study. The results of initial high-resolution chest CT were studied and analyzed. Results Out of 1,004 hospitalized patients with confirmed CLDs, 119 patients were primarily diagnosed. Among them, 81 patients underwent chest CT examination (68.1%) before the beginning of specific therapy. The average age was 65 (56;68) years, 46 (56.8%) were men. 23 (28.4%) patients were diagnosed with chronic lymphocytic leukemia, 28 (34.6%) patients with multiple myeloma, 24 (29.6%) patients with lymphoma, and six patients (7.4%) had other CLDs. It was found that both central and peripheral lymphadenopathy had about a third of the studied cohort of patients (33.3 and 29.6%, respectively), and these symptoms dominated in patients with chronic lymphocytic leukemia (43.5 and 50%, respectively), lymphoma (50 and 52.2%, respectively), and other CLDs (45.8 and 16.7%, respectively), in contrast to patients with multiple myeloma (7.1 and 0%, respectively). Lesions of the lung parenchyma were found in 45.7% of the studied cohort and were met more often in patients with multiple myeloma (67.9%). However, when comparing the prevalence of their categories, no statistically significant differences were found. Predictable bone-destructive changes were statistically significantly more common in patients with multiple myeloma than in other groups of patients with CLDs (P=0.0003). Conclusions Signs of pulmonary diseases during initial chest CT were found almost in half of the patients with CLDs. It potentially may affect the frequency of treatment complications in such patients. Lymphadenopathy was the most common finding on chest CT, especially in patients with chronic lymphocytic leukemia and lymphoma. And enlarged intrathoracic lymph nodes possibly could lead to pulmonary functions disorders. Among the types of lung parenchyma lesions, pneumofibrosis and foci of consolidation in the lower lung lobes were the most often diagnosed. Chest CT is informative at the stage of the initial examination of patients with CLDs not only for clinical diagnosis but also for the diagnosis of respiratory comorbidities and prediction of the disease outcome and treatment complications.
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28
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BTK Inhibitors Impair Humoral and Cellular Responses to Recombinant Zoster Vaccine in CLL. Blood Adv 2022; 6:1732-1740. [PMID: 35157769 PMCID: PMC8941484 DOI: 10.1182/bloodadvances.2021006574] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/06/2022] [Indexed: 11/20/2022] Open
Abstract
Vaccinations effectively prevent infections; however, patients with chronic lymphocytic leukemia (CLL) have reduced antibody responses following vaccinations. Combined humoral and cellular immune responses to novel adjuvanted vaccines are not well characterized in CLL. In an open-label, single-arm clinical trial, we measured the humoral and cellular immunogenicity of the recombinant zoster vaccine (RZV) in CLL patients who were treatment naïve (TN) or receiving Bruton tyrosine kinase inhibitor (BTKi) therapy. The primary endpoint was antibody response to RZV (≥4-fold increase in anti glycoprotein E [gE]). Cellular response of gE-specific CD4+ T cells was assessed by flow cytometry for upregulation of ≥ 2 effector molecules. The antibody response rate was significantly higher in the TN cohort (76.8% [95% confidence interval 65.7-87.8]) compared to patients receiving a BTKi (40.0% [26.4-53.6]; P = .0002). The cellular response rate was also significantly higher in the TN cohort (70.0% [57.3-82.7]) compared to the BTKi group (41.3% [27.1-55.5]; P = .0072). A concordant positive humoral and cellular immune response was observed in 69.1% [56.9-81.3] of subjects with a humoral response, whereas 39.0% [24.1-54.0] of subjects without a humoral response attained a cellular immune response (P = .0033). Antibody titers and T cell responses were not correlated with age, absolute B and T cell counts, or serum immunoglobulin levels (all P > 0.05). RZV induced both humoral and cellular immune responses in treated and untreated CLL patients, albeit with lower response rates in patients on BTKi therapy compared to TN patients. Registered at www.clinicaltrials.gov as #NCT03702231.
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Akhtar OS, Groman A, Singh A, Ghione P, Lund I, Hernandez-Ilizaliturri FJ, Torka P. Frequency and timing of other primary cancers in patients with chronic lymphocytic leukemia (CLL): a 17-year longitudinal study. Leuk Lymphoma 2022; 63:1127-1136. [DOI: 10.1080/10428194.2021.2012662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Othman Salim Akhtar
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Adrienne Groman
- Department of Biostatistics and Statistical Genomics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | | | - Paola Ghione
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Ian Lund
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | | | - Pallawi Torka
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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30
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Gauthier M. La leucémie lymphoïde chronique. Rev Med Interne 2022; 43:356-364. [DOI: 10.1016/j.revmed.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/29/2021] [Accepted: 01/29/2022] [Indexed: 12/01/2022]
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31
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The CLL comorbidity index in a population-based cohort: a tool for clinical care and research. Blood Adv 2022; 6:2701-2706. [PMID: 35008098 PMCID: PMC9043948 DOI: 10.1182/bloodadvances.2021005716] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 12/16/2021] [Indexed: 11/20/2022] Open
Abstract
The CLL comorbidity index demonstrates prognostic significance in a large patient cohort, justifying its use in clinical care and research. The CLL comorbidity index associates with time to first treatment, event-free survival, and overall survival in treatment-naive patients with CLL.
The chronic lymphocytic leukemia comorbidity index (CLL-CI) is an efficient, CLL-specific tool derived from the Cumulative Illness Rating Scale. The CLL-CI is based on the assessment of the organ systems found to be most strongly associated with event-free survival (EFS) in CLL: vascular, upper gastrointestinal, and endocrine, at the time of initiation of CLL therapy. The CLL-CI categorizes patients into low, intermediate, and high risk groups. In the present study, we have employed the CLL-CI in a population-based cohort comprising 4975 patients with CLL. We demonstrate that CLL-CI retains prognostic significance in this large cohort and is associated with overall survival (OS) and EFS from time of first therapy. Furthermore, CLL-CI associates with OS, EFS, and time to first treatment from diagnosis independently of the CLL International Prognostic Index. These findings support the use of the CLL-CI both in research and in clinical practice.
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Rotbain EC, Rostgaard K, Andersen MA, Da Cunha-Bang C, Niemann CU, Frederiksen H, Hjalgrim H. Healthcare Utilization and Comorbidity in Chronic Lymphocytic Leukemia. Clin Epidemiol 2021; 13:1155-1165. [PMID: 35002328 PMCID: PMC8722577 DOI: 10.2147/clep.s337495] [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: 09/13/2021] [Accepted: 11/04/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Age-related comorbidity is highly prevalent in chronic lymphocytic leukemia (CLL). The purpose of this study was to provide information on current patterns of healthcare utilization in CLL. PATIENTS AND METHODS We used data from Danish nation-wide registers to study healthcare utilization the year before and the year after CLL diagnosis and in relation to first-line treatment. Patients diagnosed with CLL between 1997 and 2018 were included and stratified on number of comorbidities, presence of specific comorbidities, and fitness status, respectively. Healthcare utilization was studied in terms of hospital admissions, in-hospital bed days, out-patient visits, emergency room visits, and prescription drugs. Odds ratios with 95% confidence intervals were calculated using multivariable logistic regression analyses adjusting for age, sex, and calendar year. RESULTS The study comprised 9170 patients with CLL with a median age of 71 years, of whom 35% had ≥1 comorbidity. Healthcare utilization increased markedly upon CLL diagnosis both in patients with and without comorbidities. During the year after CLL diagnosis, 39% were hospitalized, 16% visited an emergency room, 88% visited an out-patient clinic, and 93% received prescription drugs. Both individual comorbidities and the total number of comorbidities were associated with increased healthcare utilization of all types, except for contacts to hematological departments. CONCLUSION Our results suggest that CLL diagnosis may unveil incipient diseases and aggravate comorbidities and thereby have considerably wider health implications than those directly related to CLL. These findings may be used by clinicians and decisions makers to guide planning of multidisciplinary care for cancer patients.
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Affiliation(s)
- Emelie C Rotbain
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Hematology, Rigshospitalet, Denmark
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Danish Cancer Society Research Center, Hematology Research Group, Copenhagen, Denmark
| | - Klaus Rostgaard
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Danish Cancer Society Research Center, Hematology Research Group, Copenhagen, Denmark
| | - Michael A Andersen
- Department of Hematology, Rigshospitalet, Denmark
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | | | | | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Academy of Geriatric Cancer Research (AGECARE), Odense University Hospital, Odense, Denmark
| | - Henrik Hjalgrim
- Department of Hematology, Rigshospitalet, Denmark
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Danish Cancer Society Research Center, Hematology Research Group, Copenhagen, Denmark
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Tedeschi A, Frustaci AM, Mauro FR, Chiarenza A, Coscia M, Ciolli S, Reda G, Laurenti L, Varettoni M, Murru R, Baratè C, Sportoletti P, Greco A, Borella C, Rossi V, Deodato M, Biagi A, Zamprogna G, Pelle AC, Lapietra G, Vitale C, Morelli F, Cassin R, Fresa A, Cavalloni C, Postorino M, Ielo C, Cairoli R, Di Raimondo F, Montillo M, Del Poeta G. Do age, fitness, and concomitant medications influence management and outcomes of patients with CLL treated with ibrutinib? Blood Adv 2021; 5:5490-5500. [PMID: 34525181 PMCID: PMC8714729 DOI: 10.1182/bloodadvances.2021004824] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/27/2021] [Indexed: 11/22/2022] Open
Abstract
Functional reserve of organs and systems is known to be relevant in predicting immunochemotherapy tolerance. Age and comorbidities, assessed by the cumulative illness rating scale (CIRS), have been used to address chemotherapy intensity. In the ibrutinib era, it is still unclear whether age, CIRS, and Eastern Cooperative Oncology Group performance status (ECOG-PS) retain their predictive role on treatment vulnerability. In this series of 712 patients with chronic lymphocytic leukemia (CLL) treated with ibrutinib outside clinical trials, baseline ECOG-PS and neutropenia resulted as the most accurate predictors of treatment feasibility and outcomes. Age did not independently influence survival and ibrutinib tolerance, indicating that not age per se, but age-related conditions, may affect drug management. We confirmed the role of CIRS > 6 as a predictor of a poorer progression- and event-free survival (PFS, EFS). The presence of a severe comorbidity was significantly associated with permanent dose reductions (PDRs), not translating into worse outcomes. As expected, del(17p) and/or TP53mut and previous therapies affected PFS, EFS, and overall survival. No study so far has analyzed the influence of concomitant medications and CYP3A inhibitors with ibrutinib. In our series, these factors had no impact, although CYP3A4 inhibitors use correlated with Cox regression analysis, with an increased risk of PDR. Despite the limitation of its retrospective nature, this large study confirmed the role of ECOG-PS as the most accurate predictor of ibrutinib feasibility and outcomes, and importantly, neutropenia emerged as a relevant tool influencing patients' vulnerability. Although CIRS > 6 retained a significant impact on PFS and EFS, its value should be confirmed by prospective studies.
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Affiliation(s)
- Alessandra Tedeschi
- Department of Hematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Anna Maria Frustaci
- Department of Hematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Annalisa Chiarenza
- Division of Hematology, AOU “Policlinico-Vittorio Emanuele,” University of Catania, Catania, Italy
| | - Marta Coscia
- Division of Hematology, AOU Città della Salute e della Scienza di Torino, Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Stefania Ciolli
- Department of Hematology, Università degli Studi di Firenze, Firenze, Italy
| | - Gianluigi Reda
- Department of Hematology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Luca Laurenti
- Hematology Institute, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Roma, Italy
| | - Marzia Varettoni
- Division of Hematology Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale A. Businco, ARNAS “G. Brotzu,” Cagliari, Italy
| | - Claudia Baratè
- Department of Clinical and Experimental Medicine, Section of Hematology, University of Pisa, Pisa, Italy
| | - Paolo Sportoletti
- Division of Hematology and Clinical Immunology, Department of Medicine, University of Perugia, Perugia, Italy
| | - Antonino Greco
- Department of Hematology, Azienda Ospedaliera Giovanni Panìco, Tricase, Italy
| | - Chiara Borella
- Department of Hematology, Ospedale San Gerardo, Monza, Italy
| | - Valentina Rossi
- Hematology & Transfusion Medicine L. Sacco University Hospital and School of Medicine, Milano, Italy; and
| | - Marina Deodato
- Department of Hematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Annalisa Biagi
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Giulia Zamprogna
- Department of Hematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Angelo Curto Pelle
- Division of Hematology, AOU “Policlinico-Vittorio Emanuele,” University of Catania, Catania, Italy
| | - Gianfranco Lapietra
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Candida Vitale
- Division of Hematology, AOU Città della Salute e della Scienza di Torino, Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Francesca Morelli
- Department of Hematology, Università degli Studi di Firenze, Firenze, Italy
| | - Ramona Cassin
- Department of Hematology, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Alberto Fresa
- Hematology Institute, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Roma, Italy
| | - Chiara Cavalloni
- Division of Hematology Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Massimiliano Postorino
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Claudia Ielo
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Policlinico Umberto I, Rome, Italy
| | - Roberto Cairoli
- Department of Hematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Francesco Di Raimondo
- Division of Hematology, AOU “Policlinico-Vittorio Emanuele,” University of Catania, Catania, Italy
| | - Marco Montillo
- Department of Hematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Giovanni Del Poeta
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
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Cabrera ME, Marinov N, Roa M, Castillo JJ, Matutes E. Epidemiology of chronic lymphocytic leukemia in Chilean and Amerindian population in Chile. Leuk Lymphoma 2021; 63:1137-1143. [PMID: 34886754 DOI: 10.1080/10428194.2021.2012663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The study aim was to analyze incidence and presentation features of chronic lymphocytic leukemia (CLL) in Chile, in Amerindian population and in non-Native. Between 2012 and 2019, 912 patients were diagnosed, and 13 (1.4%) were Amerindian. The estimated incidence in Chilean population was 1.17/100,000 person per year, while in Amerindian, 0.09/100,000 person per year. Median age was 73 years. At diagnosis, 48, 27, and 25%, had low (0), intermediate (I/II) and high-risk (III/IV) disease on Rai classification. Diagnostic immunophenotypic Matutes score was ≥4 in 90%. Median follow-up was 37 months (range 2-87). 5-year OS was 56%, with median overall survival (OS) not reached. It was worse in men, ≥65 years, high-risk and those with increased prolymphocytes (CLL/PL). This study shows low incidence and worse OS in Chilean CLL patients, compared to those from European countries, despite similar clinical features. It also demonstrates that CLL is very uncommon in Amerindian population.
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Affiliation(s)
- María Elena Cabrera
- Medicine Service, Hematology Section, Hospital del Salvador, Universidad de Chile, Santiago de Chile, Chile
| | - Neda Marinov
- Hematologia, Hospital Del Salvador, Santiago, Chile
| | - Macarena Roa
- Hematologia, Hospital Del Salvador, Santiago, Chile
| | | | - Estella Matutes
- Haematopathology, Hospital Clinic Barcelona, Barcelona, Spain
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Goede V, Neuendorff NR, Schulz RJ, Hormigo AI, Martinez-Peromingo FJ, Cordoba R. Frailty assessment in the care of older people with haematological malignancies. THE LANCET HEALTHY LONGEVITY 2021; 2:e736-e745. [DOI: 10.1016/s2666-7568(21)00184-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/01/2021] [Accepted: 07/21/2021] [Indexed: 02/03/2023]
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Steingrímsson V, Lund SH, Dickman PW, Weibull CE, Björkholm M, Landgren O, Kristinsson SY. Survival, causes of death, and the prognostic role of comorbidities in chronic lymphocytic leukemia in the pre-ibrutinib era: A population-based study. Eur J Haematol 2021; 108:145-153. [PMID: 34714556 DOI: 10.1111/ejh.13720] [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: 07/06/2021] [Revised: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate temporal trends in survival and causes of death in patients with chronic lymphocytic leukemia (CLL) in a nationwide study. METHODS The cohort consisted of 13,009 Swedish CLL patients diagnosed 1982-2013. Relative survival (RS) and excess mortality rate ratios (EMRR) with 95% confidence intervals (95% CIs) were estimated using flexible parametric survival models. Cause-specific hazard ratios (HRs) were estimated for the linear effect of 10-year increase in year of diagnosis. RESULTS The excess mortality decreased comparing 2003-2013 to 1982-1992 (EMRR = 0.53, 95% CI 0.48-0.58). The 5-year RS increased between 1982 and 2012 for patients >51 years at diagnosis and improved for patients ≤51 years after 2002. The rate of CLL-specific deaths decreased over time (HR = 0.78, 95% CI 0.75-0.81). Compared to patients with no comorbidity, patients with 1 and 2+ Charlson Comorbidity Index points had HR = 1.35 (95% CI 1.25-1.45) and HR = 1.47 (95% CI 1.37-1.57) for CLL-related mortality, respectively. CONCLUSION Survival in CLL patients improved in the era of chemoimmunotherapy, and this was largely explained by reduced CLL-related mortality. The increased rate of CLL-related mortality in patients with comorbidities emphasizes the importance of the newer and better tolerated targeted therapy.
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Affiliation(s)
| | - Sigrún H Lund
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Paul W Dickman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Solna, Sweden
| | - Caroline E Weibull
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Solna, Sweden
| | - Magnus Björkholm
- Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Ola Landgren
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Sigurður Y Kristinsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Medicine, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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Cardoso Borges F, Ramos A, Lourenço A, Gomes da Silva M, Miranda A. Detailing the epidemiological and clinical characteristics of chronic lymphocytic leukaemia in Portugal-Results from a population-based cancer registry cohort study. PLoS One 2021; 16:e0258423. [PMID: 34624053 PMCID: PMC8500441 DOI: 10.1371/journal.pone.0258423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/28/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Chronic lymphocytic leukaemia (CLL) is the most common leukaemia among adults in western countries. Considering the increasing incidence and prevalence of this condition, it is highly relevant to better characterise these patients in Portugal, where data is still scarce. METHODS To determine incidence, clinical presentation, survival and second malignancies, a population-based historical cohort study was conducted. Cases of interest were identified through the South Region Cancer Registry database and additional data sources. Patients aged ≥18 years, with a confirmed diagnosis of CLL or small lymphocytic lymphoma between January 1st, 2013 and December 31st, 2014 were included. Patients were followed-up until death or cut-off date (December 31st, 2019). RESULTS A total of 496 patients were included and median follow-up time was 5.46 years. Crude incidence rates were 5.03 and 5.22 per 100,000 inhabitants for 2013 and 2014, respectively, and age-adjusted incidence rates were 3.18:100,000 European population for 2013 and 3.35:100,000 European population for 2014. Median age at diagnosis was 71 years and the male/female ratio was 1.40. The majority of patients had leukemic presentation of the disease (86.09%), was diagnosed in Binet stage A (75.58%) and did not present B symptoms (84.01%), anaemia (haemoglobin ≤10g/dL; 90.63%) nor thrombocytopenia (platelet count ≤100 000/μL; 91.73%). Five-year overall survival (OS) rate was 70.53% (95%CI 66.31-74.34) and age, lactate dehydrogenase, Binet stage and a ≥5 Charlson comorbidity index score were independently associated with OS. Standardised-incidence ratios for any second malignancy and cutaneous squamous cell carcinoma were 1.59 (95%CI 1.19-2.08) and 10.15 (95%CI 6.28-15.51), respectively. CONCLUSION Incidence, clinical presentation and survival of CLL Portuguese patients are similar to those reported for other western countries. The increased risk of second malignancies raises concerns and needs adequate clinical watchfulness.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/epidemiology
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Male
- Female
- Aged
- Portugal/epidemiology
- Registries
- Middle Aged
- Incidence
- Aged, 80 and over
- Cohort Studies
- Adult
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Affiliation(s)
- Fábio Cardoso Borges
- National Cancer Registry, Instituto Português de Oncologia de Lisboa Francisco Gentil, EPE, Lisboa, Portugal
| | - Adriana Ramos
- National Cancer Registry, Instituto Português de Oncologia de Lisboa Francisco Gentil, EPE, Lisboa, Portugal
| | - António Lourenço
- National Cancer Registry, Instituto Português de Oncologia de Lisboa Francisco Gentil, EPE, Lisboa, Portugal
- NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Maria Gomes da Silva
- Haematology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil, EPE, Lisboa, Portugal
| | - Ana Miranda
- National Cancer Registry, Instituto Português de Oncologia de Lisboa Francisco Gentil, EPE, Lisboa, Portugal
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Mapping comorbidity in chronic lymphocytic leukemia: impact of individual comorbidities on treatment, mortality, and causes of death. Leukemia 2021; 35:2570-2580. [PMID: 33603143 DOI: 10.1038/s41375-021-01156-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 12/23/2020] [Accepted: 01/25/2021] [Indexed: 01/31/2023]
Abstract
Comorbid conditions are highly prevalent in chronic lymphocytic leukemia (CLL), nevertheless, detailed information on the association of specific comorbidities with CLL prognosis is missing. Using Danish, nation-wide registers, we followed consecutive patients from CLL-diagnosis in 1997-2018, until death or end of follow-up. Sub-grouping of comorbidities was defined using a modified Charlson comorbidity index. Patients were matched on sex, date of birth (±1 month), and region of residency with up to ten comparators from the general population. In total, 9170 patients with CLL were included in the study, with a median of 5.0 years of follow-up. All comorbid conditions studied were individually associated with increased mortality, and many also with increased cause-specific mortality, related or unrelated to CLL. Comorbidity correlated with increased mortality from infections and cardiovascular disease. CLL patients, particularly older, had a significant loss of lifetime compared with the general population. This study highlights a large subgroup of comorbid CLL patients with an unmet treatment-need and missing efficacy and safety data on treatment, who are under-prioritized in clinical trials. Also, studies assessing interventions that may provide better tolerability of treatment in older or comorbid patients, with cancer in general, and CLL in particular, are warranted.
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Gordon MJ, Kaempf A, Sitlinger A, Shouse G, Mei M, Brander DM, Salous T, Hill BT, Alqahtani H, Choi M, Churnetski MC, Cohen JB, Stephens DM, Siddiqi T, Rivera X, Persky D, Wisniewski P, Patel K, Shadman M, Park B, Danilov AV. The Chronic Lymphocytic Leukemia Comorbidity Index (CLL-CI): A Three-Factor Comorbidity Model. Clin Cancer Res 2021; 27:4814-4824. [PMID: 34168050 PMCID: PMC8416936 DOI: 10.1158/1078-0432.ccr-20-3993] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 03/03/2021] [Accepted: 06/16/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Comorbid medical conditions define a subset of patients with chronic lymphocytic leukemia (CLL) with poor outcomes. However, which comorbidities are most predictive remains understudied. EXPERIMENTAL DESIGN We conducted a retrospective analysis from 10 academic centers to ascertain the relative importance of comorbidities assessed by the cumulative illness rating scale (CIRS). The influence of specific comorbidities on event-free survival (EFS) was assessed in this derivation dataset using random survival forests to construct a CLL-specific comorbidity index (CLL-CI). Cox models were then fit to this dataset and to a single-center, independent validation dataset. RESULTS The derivation and validation sets comprised 570 patients (59% receiving Bruton tyrosine kinase inhibitor, BTKi) and 167 patients (50% receiving BTKi), respectively. Of the 14 CIRS organ systems, three had a strong and stable influence on EFS: any vascular, moderate/severe endocrine, moderate/severe upper gastrointestinal comorbidity. These were combined to create the CLL-CI score, which was categorized into 3 risk groups. In the derivation dataset, the median EFS values were 58, 33, and 20 months in the low, intermediate, and high-risk groups, correspondingly. Two-year overall survival (OS) rates were 96%, 91%, and 82%. In the validation dataset, median EFS values were 81, 40, and 23 months (two-year OS rates 97%/92%/88%), correspondingly. Adjusting for prognostic factors, CLL-CI was significantly associated with EFS in patients treated with either chemo-immunotherapy or with BTKi in each of our 2 datasets. CONCLUSIONS The CLL-CI is a simplified, CLL-specific comorbidity index that can be easily applied in clinical practice and correlates with survival in CLL.
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Affiliation(s)
- Max J Gordon
- Oregon Health and Science University, Portland, Oregon
| | | | | | - Geoffrey Shouse
- City of Hope Comprehensive Cancer Center, Duarte, California
| | - Matthew Mei
- City of Hope Comprehensive Cancer Center, Duarte, California
| | | | | | | | | | - Michael Choi
- Moores Cancer Center at UC San Diego, San Diego, California
| | | | | | | | - Tanya Siddiqi
- City of Hope Comprehensive Cancer Center, Duarte, California
| | | | | | | | | | - Mazyar Shadman
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Byung Park
- Knight Cancer Institute, Portland, Oregon.
| | - Alexey V Danilov
- Knight Cancer Institute, Portland, Oregon.
- City of Hope Comprehensive Cancer Center, Duarte, California
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Wang Y, Achenbach SJ, Rabe KG, Shanafelt TD, Call TG, Ding W, Kenderian SS, Muchtar E, Leis JF, Koehler AB, Schwager SM, Cerhan JR, Slager SL, Kay NE, Parikh SA. Cause of death in patients with newly diagnosed chronic lymphocytic leukemia (CLL) stratified by the CLL-International Prognostic Index. Blood Cancer J 2021; 11:140. [PMID: 34354039 PMCID: PMC8342603 DOI: 10.1038/s41408-021-00532-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 12/26/2022] Open
Affiliation(s)
- Yucai Wang
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Sara J Achenbach
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Kari G Rabe
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Tait D Shanafelt
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Wei Ding
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Jose F Leis
- Division of Hematology Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - James R Cerhan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Susan L Slager
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Neil E Kay
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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Parry H, McIlroy G, Bruton R, Ali M, Stephens C, Damery S, Otter A, McSkeane T, Rolfe H, Faustini S, Wall N, Hillmen P, Pratt G, Paneesha S, Zuo J, Richter A, Moss P. Antibody responses after first and second Covid-19 vaccination in patients with chronic lymphocytic leukaemia. Blood Cancer J 2021; 11:136. [PMID: 34330895 PMCID: PMC8323747 DOI: 10.1038/s41408-021-00528-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/05/2021] [Accepted: 07/09/2021] [Indexed: 12/15/2022] Open
Abstract
B-cell chronic lymphocytic leukaemia (CLL) is associated with immunosuppression and patients are at increased clinical risk following SARS-CoV-2 infection. Covid-19 vaccines offer the potential for protection against severe infection but relatively little is known regarding the profile of the antibody response following first or second vaccination. We studied spike-specific antibody responses following first and/or second Covid-19 vaccination in 299 patients with CLL compared with healthy donors. 286 patients underwent extended interval (10-12 week) vaccination. 154 patients received the BNT162b2 mRNA vaccine and 145 patients received ChAdOx1. Blood samples were taken either by venepuncture or as dried blood spots on filter paper. Spike-specific antibody responses were detectable in 34% of patients with CLL after one vaccine (n = 267) compared to 94% in healthy donors with antibody titres 104-fold lower in the patient group. Antibody responses increased to 75% after second vaccine (n = 55), compared to 100% in healthy donors, although titres remained lower. Multivariate analysis showed that current treatment with BTK inhibitors or IgA deficiency were independently associated with failure to generate an antibody response after the second vaccine. This work supports the need for optimisation of vaccination strategy in patients with CLL including the potential utility of booster vaccines.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Viral/blood
- Antibodies, Viral/immunology
- Antibody Formation/drug effects
- BNT162 Vaccine
- COVID-19/blood
- COVID-19/immunology
- COVID-19/prevention & control
- COVID-19 Vaccines/administration & dosage
- COVID-19 Vaccines/immunology
- Female
- Humans
- Immunization, Secondary
- Leukemia, Lymphocytic, Chronic, B-Cell/blood
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Male
- Middle Aged
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Affiliation(s)
- H Parry
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - G McIlroy
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - R Bruton
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - M Ali
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - C Stephens
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - S Damery
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - A Otter
- National infection Service, Public Health England, Porton Down, Salisbury, SP4 OJG, UK
| | - T McSkeane
- Cancer Research UK Clinical Trials Unit, University of Birmingham, B15 2TT, Birmingham, UK
| | - H Rolfe
- Cancer Research UK Clinical Trials Unit, University of Birmingham, B15 2TT, Birmingham, UK
| | - S Faustini
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - N Wall
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - P Hillmen
- St. James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, LS9 7TF, UK
| | - G Pratt
- Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, B15 2TH, UK
| | - S Paneesha
- Birmingham Heartlands Hospital, University Hospitals Birmingham, Bordesley Green East, B9 5SS, Birmingham, UK
| | - J Zuo
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - A Richter
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - P Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK.
- Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, B15 2TH, UK.
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42
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Impact of Immune Parameters and Immune Dysfunctions on the Prognosis of Patients with Chronic Lymphocytic Leukemia. Cancers (Basel) 2021; 13:cancers13153856. [PMID: 34359757 PMCID: PMC8345723 DOI: 10.3390/cancers13153856] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 12/13/2022] Open
Abstract
Simple Summary In chronic lymphocytic leukemia (CLL), immune alterations—affecting both the innate and adaptive immunity—are very common. As a clinical consequence, patients with CLL frequently present with autoimmune phenomena, increased risk of infections and second malignancies. The aim of this review article is to present available data on CLL-associated alterations of immune parameters that correlate with known prognostic markers and with clinical outcome. Also, data on the impact of immune-related clinical manifestations on the prognosis of patients with CLL will be discussed. Abstract Chronic lymphocytic leukemia (CLL) is characterized by a wide spectrum of immune alterations, affecting both the innate and adaptive immunity. These immune dysfunctions strongly impact the immune surveillance, facilitate tumor progression and eventually affect the disease course. Quantitative and functional alterations involving conventional T cells, γδ T cells, regulatory T cells, NK and NKT cells, and myeloid cells, together with hypogammaglobulinemia, aberrations in the complement pathways and altered cytokine signature have been reported in patients with CLL. Some of these immune parameters have been shown to associate with other CLL-related characteristics with a known prognostic relevance or to correlate with disease prognosis. Also, in CLL, the complex immune response dysfunctions eventually translate in clinical manifestations, including autoimmune phenomena, increased risk of infections and second malignancies. These clinical issues are overall the most common complications that affect the course and management of CLL, and they also may impact overall disease prognosis.
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43
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Rapid improvement in symptoms and physical function following ibrutinib initiation in chronic lymphocytic leukemia and the associated changes in plasma cytokines. Leuk Res 2021; 109:106628. [PMID: 34134067 DOI: 10.1016/j.leukres.2021.106628] [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: 01/11/2021] [Revised: 05/03/2021] [Accepted: 05/23/2021] [Indexed: 11/23/2022]
Abstract
A prospective pilot study was carried out on 34 CLL patients treated with ibrutinib, evaluating the effects on symptoms and physical function with changes in plasma exosomes (EXs), β2-microglobulin (β2M) and 26 plasma cytokines. The revised Edmonton Symptom Assessment Scale (ESAS-R) demonstrated moderate fatigue, shortness of breath and a sense of unwellness before treatment, which significantly improved within 2 weeks of starting ibrutinib. These changes were associated with a rapid improvement in sit-to-stand and 4 m walking speeds. The plasma levels of CCL11, IL-7, -8 and -10 dropped initially while the levels of TNF-α/-β, CCL3, CCL4, CCL17, and IL-16 continued to decline for 12 months. Despite the initial lymphocytosis, plasma β2M levels fell but no consistent change in plasma EXs occurred. Thus, ibrutinib can produce a rapid and sustained improvement in symptoms and physical function in CLL, associated with a decline in multiple plasma cytokines.
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Comorbidities at Diagnosis, Survival, and Cause of Death in Patients with Chronic Lymphocytic Leukemia: A Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020701. [PMID: 33467494 PMCID: PMC7830671 DOI: 10.3390/ijerph18020701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/07/2021] [Accepted: 01/13/2021] [Indexed: 02/06/2023]
Abstract
This study aimed to examine the prevalence of comorbidities in patients diagnosed with chronic lymphocytic leukemia (CLL), and to assess its influence on survival and cause-specific mortality at a population-based level. Incident CLL cases diagnosed in the Girona province (Spain) during 2008–2016 were extracted from the Girona Cancer Registry. Rai stage and presence of comorbidities at diagnosis, further categorized using the Charlson comorbidity index (CCI), were obtained from clinical records. Observed (OS) and relative survival (RS) were estimated and Cox’s proportional hazard models were used to explore the impact of comorbidity on mortality. Among the 400 cases included in the study, 380 (99.5%) presented at least one comorbidity at CLL diagnosis, with diabetes without end organ damage (21%) being the most common disease. 5-year OS and RS were 68.8 (95% CI: 64.4–73.6) and 99.5 (95% CI 3.13–106.0), respectively, which decreased markedly with increasing CCI, particularly in patients with CCI ≥ 3. Multivariate analysis identified no statistically significant association between the CCI and overall CLL-related or CLL-unrelated mortality. In conclusion, a high CCI score negatively influenced the OS and RS of CLL patients, yet its effect on mortality was statistically non-significant when also considering age and the Rai stage.
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45
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Locher M, Jukic E, Bohn JP, Untergasser G, Steurer M, Cramer CA, Schwendinger S, Vogi V, Verdorfer I, Witsch-Baumgartner M, Nachbaur D, Gunsilius E, Wolf D, Zschocke J, Steiner N. Clonal dynamics in a composite chronic lymphocytic leukemia and hairy cell leukemia-variant. Genes Chromosomes Cancer 2020; 60:287-292. [PMID: 33277788 PMCID: PMC7984250 DOI: 10.1002/gcc.22925] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/29/2020] [Accepted: 11/30/2020] [Indexed: 12/28/2022] Open
Abstract
Composite lymphoma is the rare simultaneous manifestation of two distinct lymphomas. Chronic lymphocytic leukemia (CLL) has a propensity for occurring in composite lymphomas, a phenomenon that remains to be elucidated. We applied cytogenetics, droplet digital polymerase chain reaction, and massively parallel sequencing to analyze longitudinally a patient with CLL, who 3 years later showed transformation to a hairy cell leukemia-variant (HCL-V). Outgrowth of the IGHV4-34-positive HCL-V clone at the expense of the initially dominant CLL clone with trisomy 12 and MED12 mutation started before CLL-guided treatment and was accompanied by a TP53 mutation, which was already detectable at diagnosis of CLL. Furthermore, deep sequencing of IGH showed a composite lymphoma with presence of both disease components at all analyzed timepoints (down to a minor clone: major clone ratio of ~1:1000). Overall, our analyses showed a disease course that resembled clonal dynamics reported for malignancies with intratumoral heterogeneity and illustrate the utility of deep sequencing of IGH to detect distinct clonal populations at diagnosis, monitor clonal response to therapy, and possibly improve clinical outcomes.
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Affiliation(s)
- Maurus Locher
- Institute of Human Genetics, Medical University of Innsbruck, Innsbruck, Austria
| | - Emina Jukic
- Institute of Human Genetics, Medical University of Innsbruck, Innsbruck, Austria
| | - Jan-Paul Bohn
- Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Gerold Untergasser
- Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Steurer
- Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Simon Schwendinger
- Institute of Human Genetics, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Vogi
- Institute of Human Genetics, Medical University of Innsbruck, Innsbruck, Austria
| | - Irmgard Verdorfer
- Institute of Human Genetics, Medical University of Innsbruck, Innsbruck, Austria
| | | | - David Nachbaur
- Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Eberhard Gunsilius
- Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
| | - Dominik Wolf
- Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria.,Medical Clinic III, Oncology, Hematology, Immuno-Oncology and Rheumatology, University Hospital Bonn, Bonn, Germany
| | - Johannes Zschocke
- Institute of Human Genetics, Medical University of Innsbruck, Innsbruck, Austria
| | - Normann Steiner
- Department of Internal Medicine V, Medical University of Innsbruck, Innsbruck, Austria
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46
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Shaikh MS, Ahmed A, Sohail S, Fahim A, Nohario SH, Pervez S. Flow Cytometric Analysis of ZAP-70 Protein Expression for B-Cell Chronic Lymphocytic Leukemia Prognostication: Usefulness and Limitations. Cureus 2020; 12:e11691. [PMID: 33391925 PMCID: PMC7769768 DOI: 10.7759/cureus.11691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: The heterogenous clinical course in B-cell chronic lymphocytic leukemia (B-CLL) can be linked to several genetic and phenotypic characteristics of malignant B-cells. Prognostic analysis in B-CLL is routinely carried out to assist patient management; particularly to predict the time to initiate treatment. Increased ZAP-70 expression is a surrogate marker for unmutated immunoglobulin genes and inferior clinical outcomes which can be quantified to predict future outcomes in B-CLL patients. The study determined the ZAP-70 expression pattern using Z-index in Pakistani patients with B-CLL. Methods: A retrospective analysis of B-CLL cases diagnosed and confirmed on flow cytometry at Aga Khan University Hospital for the last six years which had also undergone ZAP-70 analysis were included. In all these cases, ZAP-70 expression was quantified by measuring mean fluorescence intensities (MFIs) of normal B-cells, T-cells, and CLL-cells (CD19 and CD5 double-positive population). ZAP-70 expression was divided into high, low, and negative categories based on Z-index calculation. Mann-Whitney U test was utilized to determine the significance of ZAP-70 variations in different age groups and genders. P-value <0.05 was considered significant. Results: A total of 120 patients of B-CLL had ZAP-70 analysis during the study period. The median age was 62 with an interquartile range of 35-87 and male to female ratio of 2:1. ZAP-70 expression was high in 18 (15%), low in 52 (43.3%) and negative in 50 (41.7%) cases. No significant difference in ZAP-70 expression with respect to the age or gender of the study population was identified using appropriate statistical calculations. Conclusions: This study showed only 15% of B-CLL cases showing high ZAP-70 expression, a surrogate biomarker for possible aggressive behavior which may necessitate therapeutic intervention and close surveillance.
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Affiliation(s)
| | - Arsalan Ahmed
- Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, PAK
| | - Summaiya Sohail
- Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, PAK
| | - Amin Fahim
- Pathology, Isra University, Hyderabad, PAK
| | | | - Shahid Pervez
- Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi, PAK
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Cherng HJJ, Jain N, Thakral B, Muzzafar T, Miranda RN, Tan D, Rashid A, Kalhor N, Hahn AW, Byers LA, Parseghian CM, Ferrajoli A, Pemmaraju N. Metastatic lung adenocarcinoma mimicking Richter transformation in a patient with chronic lymphocytic leukemia. Leuk Res 2020; 98:106445. [PMID: 32937250 PMCID: PMC9153129 DOI: 10.1016/j.leukres.2020.106445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Hua-Jay J Cherng
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Beenu Thakral
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Tariq Muzzafar
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Roberto N Miranda
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Dongfeng Tan
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Asif Rashid
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Neda Kalhor
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Andrew W Hahn
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Lauren A Byers
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Christine M Parseghian
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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48
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Singh N, Mott SL, Sutamtewagul G, McCarthy A, Slager SL, Cerhan JR, Ballas Z, Link BK. Prevalence and the impact of hypogammaglobulinemia in newly diagnosed chronic lymphocytic lymphoma patients. EJHAEM 2020; 1:537-544. [PMID: 35845010 PMCID: PMC9176078 DOI: 10.1002/jha2.95] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/08/2022]
Abstract
Objective To examine the prevalence of hypogammaglobulinemia in chronic lymphocytic lymphoma (CLL) patients and to test the hypothesis that patients with hypogammaglobulinemia have a distinct clinical profile and outcome. Methods Immunoglobulin levels (IgA, IgG, IgM, IgE) were measured in newly diagnosed, treatment naïve banked samples of 150 patients with CLL followed prospectively for outcomes. Cox regression models were used to assess the effects of clinical variables on overall survival (OS). Results The median age of the selected CLL cohort was 64 years with a male predominance; 96.2% of the patients were white. Fifty-nine deaths occurred during a median follow up of 6.8 years. Hypogammaglobulinemia in CLL was common in our cohort with 88 (58.7%, 95% CI: 50.4-66.6%) patients having a measurable isotype deficiency. The most common Ig deficiency was IgM (44.0%). IgA deficiency or low IgE was associated with higher Rai stages as well as with higher white blood cell counts at presentation. Any immunoglobulin deficiency was not associated with overall survival. Conclusion A significant proportion of treatment-naïve CLL patients had underlying Ig deficiencies - both in isolation and in isotype combinations. Although a deficiency of IgA or IgE was associated with more severe disease at presentation, the impact of this association was mild.
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Affiliation(s)
- Namrata Singh
- Division of RheumatologyUniversity of WashingtonSeattleWashingtonUSA
- Holden Comprehensive Cancer Center (HCCC)University of IowaIowa CityIowaUSA
| | - Sarah L. Mott
- Holden Comprehensive Cancer Center (HCCC)University of IowaIowa CityIowaUSA
| | - Grerk Sutamtewagul
- Holden Comprehensive Cancer Center (HCCC)University of IowaIowa CityIowaUSA
- Division of Allergy and ImmunologyUniversity of IowaIowa CityIowaUSA
| | - Ashley McCarthy
- Holden Comprehensive Cancer Center (HCCC)University of IowaIowa CityIowaUSA
| | - Susan L. Slager
- Mayo ClinicDivision of Biomedical Statistics and InformaticsRochesterMinnesotaUSA
| | | | - Zuhair Ballas
- Holden Comprehensive Cancer Center (HCCC)University of IowaIowa CityIowaUSA
- Division of Allergy and ImmunologyUniversity of IowaIowa CityIowaUSA
| | - Brian K. Link
- Holden Comprehensive Cancer Center (HCCC)University of IowaIowa CityIowaUSA
- Division of Hematology and OncologyUniversity of IowaIowa CityIowaUSA
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Yang S, Varghese AM, Sood N, Chiattone C, Akinola NO, Huang X, Gale RP. Ethnic and geographic diversity of chronic lymphocytic leukaemia. Leukemia 2020; 35:433-439. [PMID: 33077870 DOI: 10.1038/s41375-020-01057-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/02/2020] [Accepted: 10/05/2020] [Indexed: 12/16/2022]
Abstract
East Asians, Asian Indians and Amerindians have a five to ten-fold lower age-adjusted incidence rate (AAIR) of chronic lymphocytic leukaemia (CLL) compared with persons of predominately European descent. The data we review suggest a genetic rather than environmental basis for this discordance. All these populations arose from a common African Black ancestor but different clades have different admixture with archaic hominins including Neanderthals, Denisovans and Homo erectus, which may explain different CLL incidences. There are also some differences in clinical laboratory and molecular co-variates of CLL between these populations. Because the true age-adjusted incidence rate in African Blacks is unknown it is not possible to determine whether modern Europeans acquired susceptibility to CLL or the other populations lost susceptibility and/or developed resistance to developing CLL. We also found other B-cell lymphomas and T- and NK-cell cancers had different incidences in the populations we studied. These data provide clues to determining the cause(s) of CLL.
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Affiliation(s)
- Shenmiao Yang
- Peking University Peoples Hospital; Peking University Institute of Hematology, Beijing, China
| | - Abraham M Varghese
- Little Flower Hospital and Research Centre, Kerala, India.,St James University Hospital, Leeds, UK
| | - Nitin Sood
- Clinical Haematology and Stem Cell Transplant, Medanta-Medicity, Gurgaon, India
| | - Carlos Chiattone
- Department of Hematology and Oncology, Santa Casa Medical School, Sao Paulo, Brazil
| | - Norah O Akinola
- Department of Haematology and Immunology, Obafemi Awolowo University and Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
| | - Xiaojun Huang
- Peking University Peoples Hospital; Peking University Institute of Hematology, Beijing, China
| | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK.
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50
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Tedeschi A. What is Fitness in the Era of Targeted Agents? CLINICAL LYMPHOMA MYELOMA AND LEUKEMIA 2020; 20 Suppl 1:S84-S86. [DOI: 10.1016/s2152-2650(20)30472-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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