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Rigolin GM, Olimpieri PP, Summa V, Celant S, Scarfò L, Ballardini MP, Urso A, Gambara S, Cavazzini F, Ghia P, Cuneo A, Russo P. Outcomes and prognostic factors in 3306 patients with relapsed/refractory chronic lymphocytic leukemia treated with ibrutinib outside of clinical trials: A nationwide study. Hemasphere 2024; 8:e70017. [PMID: 39380844 PMCID: PMC11459203 DOI: 10.1002/hem3.70017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 06/21/2024] [Accepted: 07/06/2024] [Indexed: 10/10/2024] Open
Abstract
We performed a cohort study that included all patients with relapsed/refractory chronic lymphocytic leukemia (R/R CLL) who received ibrutinib in the Italian National Health Service. With a median follow-up of 42.2 months (IQR 30.8-54.6 months), the study involved 3306 patients with a median age of 72.1 years, of whom 42.6% had received ≥2 previous lines of treatment. The estimated 24-month probabilities of being on treatment and alive were 57.9% (95% confidence interval [CI]: 59.6-56.2) and 76.6% (95% CI: 75.2-78.1), respectively. The median time to treatment discontinuation (TTD) was 31.3 months (95% CI: 29.5-33.5). Out of 3306 patients, 2015 (60.9%) discontinued treatment, with 993 cases attributed to death or disease progression (30.0% of all cases). Among the 1022 patients who discontinued treatment for reasons other than progression or death, 564 (17.1%) patients did so due to toxicity or medical decision, while 458 patients (13.8%) were lost to follow-up. Multivariable analysis revealed that age, Eastern Cooperative Oncology Group Performance Status, the number of previous lines of therapy, refractoriness to the last treatment, and reduced renal function were associated with shorter TTD and overall survival (OS). The coexistence of 17p- and TP53 mutations had an independent unfavorable impact on TTD and OS. Nonstandard doses were associated with shorter TTD and advanced stage with shorter OS. The median OS postprogression and postdiscontinuation for other reasons were estimated at 12.9 (95% CI: 11.3-16.2) and 22.7 months (95% CI: 20.2-28.3), respectively. This large real-world study shows that ibrutinib is an effective treatment for R/R CLL. Baseline patient characteristics and double-hit TP53 aberrations were associated with inferior prognosis, and discontinuation due to CLL progression portended a poor outcome.
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Affiliation(s)
- Gian Matteo Rigolin
- Hematology Unit, Department of Medical SciencesUniversity of FerraraFerraraItaly
| | | | | | | | - Lydia Scarfò
- Università Vita‐Salute San RaffaeleMilanItaly
- IRCCS Ospedale San RaffaeleMilanItaly
| | - Maria Pia Ballardini
- Hematology Unit, Department of Medical SciencesUniversity of FerraraFerraraItaly
| | - Antonio Urso
- Hematology Unit, Department of Medical SciencesUniversity of FerraraFerraraItaly
| | - Silvia Gambara
- Hematology Unit, Department of Medical SciencesUniversity of FerraraFerraraItaly
| | - Francesco Cavazzini
- Hematology Unit, Department of Medical SciencesUniversity of FerraraFerraraItaly
| | - Paolo Ghia
- Università Vita‐Salute San RaffaeleMilanItaly
- IRCCS Ospedale San RaffaeleMilanItaly
| | - Antonio Cuneo
- Hematology Unit, Department of Medical SciencesUniversity of FerraraFerraraItaly
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Hatashima A, Shadman M. BTK inhibitors: moving the needle on the treatment of chronic lymphocytic leukemia. Expert Rev Hematol 2024; 17:687-703. [PMID: 39163531 DOI: 10.1080/17474086.2024.2391097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 08/07/2024] [Indexed: 08/22/2024]
Abstract
INTRODUCTION Bruton's tyrosine kinaseinhibitors (BTKis) changed the trajectory of upfront and relapsed/refractory chronic lymphocytic leukemia (CLL) treatment. However, BTKis are plagued by a spectrum of toxicities. Zanubrutinib was developed to circumvent challenges with prolonged tolerability by increasing BTK selectivity and maximizing efficacy through pharmacokinetic/pharmacodynamic optimization. However, with the availability of ibrutinib, acalabrutinib, and zanubrutinib, limited data exists to guide sequencing of BTKi therapy in the relapsed/refractory setting. AREAS COVERED We review the first head-to-head trial (ALPINE) of zanubrutinib versus ibrutinib for the treatment of relapsed/refractory CLL and compare zanubrutinib's clinical efficacy and toxicities, including in patients with del(17p) and/or TP53 mutations to ibrutinib and acalabrutinib. EXPERT OPINION Zanubrutinibrepresents one of the new standards of care for relapsed/refractory CLL based on superior progression-free survival and response rates over ibrutinib. Whilezanubrutinib is associated with fewer cardiac toxicities, similar rates of neutropenia and hypertension are noted. Ongoing studies are pushing the envelope, utilizing targeted drug combinations and minimal residual disease markers as well as receptor tyrosine kinase-like orphan receptor 1 inhibitors, chimeric antigen receptor T-cells, and novel BTK degraders. However, zanubrutinibrepresents a strong contender in the arsenal of treatment options for relapsed/refractory CLL.
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Affiliation(s)
- Alycia Hatashima
- Fred Hutchinson Cancer Center, University of Washington, Seattle, WA, USA
| | - Mazyar Shadman
- Fred Hutchinson Cancer Center, University of Washington, Seattle, WA, USA
- Division of Hematology and Oncology, University of Washington, Seattle, WA, USA
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Hemminki K, Zitricky F, Försti A, Tapaninen T, Hemminki A, Juliusson G, Niemann CU. Complex Relationships between Diagnostics and Survival in Chronic Lymphocytic Leukemia in Denmark, Finland, Norway, and Sweden. Cancers (Basel) 2024; 16:3229. [PMID: 39335200 PMCID: PMC11429559 DOI: 10.3390/cancers16183229] [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: 09/02/2024] [Revised: 09/16/2024] [Accepted: 09/20/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) is a common hematological malignancy with highly variable clinical presentation. Many patients never require any treatment but for the others, chemotherapy, immunochemotherapy, and newer targeted therapies have changed the treatment landscape. Diagnostic age influences the applied treatment, and we thus wanted to analyze age-specific survival trends through 50 years up to 2020s. METHODS We used 1- and 5-year relative survival from the NORDCAN database, with data from Denmark (DK), Finland (FI), Norway (NO), and Sweden (SE). Because of the variable presentation of CLL, we also considered incidence and mortality trends. For comparison, US SEER data were used. RESULTS The large age-specific survival differences in 1972-76 almost disappeared by 2017-21. While 5-year survival in younger patients exceeded 90%, for those diagnosed at age 80-89 years, survival reached 90% in DK and SE women, 80% in NO and SE men, but only 50% in FI. DK 5-year overall survival for men was 92.4%, and for women, it was 96.3%. These survival figures were higher than age-group-specific US survival data. CONCLUSIONS The DK data are probably global top figures for national survival which could be achieved by boosting survival even among the oldest patients. The qualification to these figures and international comparisons is that survival needs to be considered in terms of incidence, which is high in DK and NO. Low survival of the FI 80-89-year-old patients, even in the first year after diagnosis, may suggest delayed diagnosis, which should call for a closer national scrutiny.
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Affiliation(s)
- Kari Hemminki
- Biomedical Center, Faculty of Medicine, Charles University, 323 00 Pilsen, Czech Republic;
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 580, 69120 Heidelberg, Germany
| | - Frantisek Zitricky
- Biomedical Center, Faculty of Medicine, Charles University, 323 00 Pilsen, Czech Republic;
| | - Asta Försti
- Hopp Children’s Cancer Center (KiTZ), 69120 Heidelberg, Germany;
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), 72076 Heidelberg, Germany
| | - Tuija Tapaninen
- Department of Clinical Pharmacology, University of Helsinki, 00014 Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, 00014 Helsinki, Finland
- Department of Clinical Pharmacology, HUS Diagnostic Center, Helsinki University Hospital, 00014 Helsinki, Finland
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center, 00029 Helsinki, Finland
| | - Akseli Hemminki
- Cancer Gene Therapy Group, Translational Immunology Research Program, University of Helsinki, 00014 Helsinki, Finland;
- Comprehensive Cancer Center, Helsinki University Hospital, 00290 Helsinki, Finland
| | - Gunnar Juliusson
- Department of Hematology, Stem Cell Center, Skåne University Hospital, Lund, Department of Laboratory Medicine, Lund University, SE-221 84 Lund, Sweden;
| | - Carsten Utoft Niemann
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark;
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Svanberg Teglgaard R, Marquart HV, Hartling HJ, Bay JT, da Cunha-Bang C, Brieghel C, Faitová T, Enggaard L, Kater AP, Levin MD, Kersting S, Ostrowski SR, Niemann CU. Improved Innate Immune Function in Patients with Chronic Lymphocytic Leukemia Treated with Targeted Therapy in Clinical Trials. Clin Cancer Res 2024; 30:1959-1971. [PMID: 38393694 DOI: 10.1158/1078-0432.ccr-23-2522] [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: 08/21/2023] [Revised: 12/06/2023] [Accepted: 02/21/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE Patients with chronic lymphocytic leukemia (CLL) have increased risk of severe infections. Although adaptive immune dysfunction is well described, clinical tools for identifying patients at risk are lacking, warranting investigation of additional immune components. In contrast to chemotherapy, targeted agents could spare or even improve innate immune function. Therefore, we investigated innate immune phenotypes and function in patients with CLL before and during targeted treatment. EXPERIMENTAL DESIGN Baseline and consecutive blood samples were collected from patients with CLL treated with acalabrutinib (n = 17) or ibrutinib+venetoclax (n = 18) in clinical trials. Innate immune function was assessed by TruCulture, a whole-blood ligand-stimulation assay quantifying cytokine release in response to standardized stimuli. Innate immune phenotypes were characterized by flow cytometry. As a proxy for infections, we mapped antimicrobial use before and during treatment. RESULTS At baseline, patients with CLL displayed impaired stimulated cytokine responses to the endotoxin lipopolysaccharide (LPS) along with deactivated monocytes, enrichment of myeloid-derived suppressor cells and metamyelocytes, and elevated (unstimulated) proinflammatory cytokines. Two/three cycles of acalabrutinib or ibrutinib normalized LPS-stimulated responses, in parallel with decreased duration of infections. Innate immune profiles and elevated proinflammatory cytokines further normalized during longer-term acalabrutinib or ibrutinib+venetoclax, paralleled by decreased infection frequency. CONCLUSIONS Innate immune impairment and infection susceptibility in patients with CLL were restored in parallel during targeted therapy. Thus, targeted treatment may reduce the risk of infections in CLL, as currently under investigation in the PreVent-ACaLL phase 2 trial of acalabrutinib+venetoclax for high-risk CLL (NCT03868722).
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Affiliation(s)
| | | | | | - Jakob Thaning Bay
- Department of Clinical Immunology, Zealand University Hospital, Køge, Denmark
| | | | | | - Tereza Faitová
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
| | | | - Arnon P Kater
- Department of Hematology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Lymphoma and Myeloma Center Amsterdam, Amsterdam, the Netherlands
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Sabina Kersting
- Department of Hematology, Haga Ziekenhuis, Den Haag, the Netherlands
| | - Sisse Rye Ostrowski
- Department of Clinical Immunology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Carsten U Niemann
- Department of Hematology, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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5
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Parviz M, Agius R, Rotbain EC, Vainer N, Aarup K, Niemann CU. Identifying CLL patients at high risk of atrial fibrillation on treatment using machine learning. Leuk Lymphoma 2024; 65:449-459. [PMID: 38179708 DOI: 10.1080/10428194.2023.2299737] [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: 09/19/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024]
Abstract
An increased risk of developing atrial fibrillation (AF) has been observed in patients with chronic lymphocytic leukemia (CLL) who were treated with ibrutinib and other BTK inhibitors. Previous studies have explored the prevalence of AF in CLL and the risk of developing AF at time of diagnosis. However, the interaction between treatment type with other risk factors on risk of developing atrial fibrillation at the time of treatment initiation has not been investigated. This becomes particularly crucial in CLL, as there is often a substantial time gap between diagnosis and treatment, unlike many other cancers. We propose a treatment-aware approach using predictive modeling to identify the risk factors associated with AF at time of treatment initiation. Moreover, the model provides treatment-dependent risk factors by including the interaction between the treatment types and other risk factors. The results demonstrated that the treatment-aware modeling including interactions outperformed currentrisk scores.
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Affiliation(s)
- Mehdi Parviz
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Rudi Agius
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | - Noomi Vainer
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Kathrine Aarup
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Carsten U Niemann
- Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
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Dartigeas C, Quinquenel A, Ysebaert L, Dilhuydy MS, Anglaret B, Slama B, Le Du K, Tardy S, Tchernonog E, Orfeuvre H, Voillat L, Guidez S, Malfuson JV, Dupuis S, Deslandes M, Feugier P, Leblond V. Final results on effectiveness and safety of Ibrutinib in patients with chronic lymphocytic leukemia from the non-interventional FIRE study. Ann Hematol 2024:10.1007/s00277-024-05666-3. [PMID: 38443660 DOI: 10.1007/s00277-024-05666-3] [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: 12/26/2023] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
We conducted an observational study (FIRE) to understand the effectiveness and safety outcomes of ibrutinib in patients with chronic lymphocytic leukemia (CLL) in France, after a maximum follow-up of five years. Patients were included according to the French marketing authorization in 2016 (i.e. patients with relapsed or refractory CLL or to previously untreated CLL patients with deletion 17p and/or tumor protein p53 mutations unsuitable for chemoimmunotherapy) and could have initiated ibrutinib more than 30 days prior their enrolment in the study (i.e. retrospective patients) or between 30 days before and 14 days after their enrolment (i.e. prospective patients). The results showed that in the effectiveness population (N = 388), the median progression-free survival (PFS) was 53.1 (95% CI: 44.5-60.5) months for retrospective patients and 52.9 (95% CI: 40.3-60.6) months for prospective patients and no difference was shown between the PFS of patients who had at least one dose reduction versus the PFS of patients without dose reduction (p = 0.7971 for retrospective and p = 0.3163 for prospective patients). For both retrospective and prospective patients, the median overall survival was not reached. The most frequent treatment-emergent adverse event of interest was infections (57.6% retrospective; 71.4% prospective). A total of 14.6% of the retrospective patients and 22.4% of the prospective patients had an adverse event leading to death. Our findings on effectiveness were consistent with other studies and the fact that patients with dose reductions had similar PFS than patients without dose reduction is reassuring. No additional safety concerns than those already mentioned in previous studies could be noticed.Trial registration ClinicalTrials.gov, NCT03425591. Registered 1 February 2018 - Retrospectively registered.
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Affiliation(s)
- Caroline Dartigeas
- Hématologie et Thérapie Cellulaire, CHRU Hôpitaux de Tours, 2 Boulevard Tonnellé, 37044, Tours Cedex 9, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Véronique Leblond
- AP-HP Hôpital de La Pitié-Salpêtrière, Paris La Sorbonne, Paris, France
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von Tresckow J, Heyl N, Robrecht S, Giza A, Aldaoud A, Schlag R, Klausmann M, Linde H, Stein W, Schwarzer A, Fischer K, Cramer P, Eichhorst B, Hallek M, Fink AM. Treatment with idelalisib in patients with chronic lymphocytic leukemia - real world data from the registry of the German CLL Study Group. Ann Hematol 2023; 102:3083-3090. [PMID: 37358640 PMCID: PMC10567876 DOI: 10.1007/s00277-023-05314-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/07/2023] [Indexed: 06/27/2023]
Abstract
Idelalisib in combination with rituximab is an efficacious treatment for patients suffering from chronic lymphocytic leukemia (CLL) with known limitations due to toxicities. However, the benefit after prior Bruton tyrosine kinase inhibitor (BTKi) therapy remains unclear. For this analysis, 81 patients included in a non-interventional registry study of the German CLL study group (registered at www.clinicaltrials.gov as # NCT02863692) meeting the predefined criteria of a confirmed diagnosis of CLL and being treated with idelalisib containing regimens outside clinical trials were considered. 11 patients were treatment naïve (13.6%) and 70 patients (86.4%) pretreated. Patients had median of one prior therapy line (range 0-11). Median treatment duration with idelalisib was 5.1 months (range 0-55.0 months). Of 58 patients with documented treatment outcome, 39 responded to idelalisib containing therapy (67.2%). Patients treated with the BTKi ibrutinib as last prior treatment prior to idelalisib responded in 71.4% compared to a response rate of 61.9% in patients without prior ibrutinib. Median event free survival (EFS) was 15.9 months with a 16 versus 14 months EFS in patients with ibrutinib as last prior treatment or not, respectively. Median overall survival was 46.6 months. In conclusion, treatment with idelalisib appears to have a valuable impact in patients being refractory to prior ibrutinib therapy even though there are limitations in our analysis due to the low number of patients included.
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Affiliation(s)
- Julia von Tresckow
- Clinic for Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Nikola Heyl
- Department I for Internal Medicine and Centre of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Sandra Robrecht
- Department I for Internal Medicine and Centre of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Adam Giza
- Department I for Internal Medicine and Centre of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ali Aldaoud
- Praxis für Hämatologie und Onkologie, Leipzig, Germany
| | - Rudolf Schlag
- Hämatologisch-Onkologische Schwerpunktpraxis, Würzburg, Germany
| | | | - Hartmut Linde
- MVZ für Blut und Krebserkrankungen, Potsdam, Germany
| | | | | | - Kirsten Fischer
- Department I for Internal Medicine and Centre of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Paula Cramer
- Department I for Internal Medicine and Centre of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Barbara Eichhorst
- Department I for Internal Medicine and Centre of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael Hallek
- Department I for Internal Medicine and Centre of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anna Maria Fink
- Department I for Internal Medicine and Centre of Integrated Oncology Aachen, Bonn, Cologne, Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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8
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Andersson ML, Johansson H, Österborg A, Månsson-Broberg A, Hansson L, Palma M. Incidence of cardiovascular and bleeding events and reasons for discontinuation in patients with chronic lymphocytic leukemia treated with ibrutinib-A retrospective analysis on consecutive patients from a well-defined region. Eur J Haematol 2023; 111:748-756. [PMID: 37565648 DOI: 10.1111/ejh.14072] [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: 06/05/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE Ibrutinib treatment is associated with cardiovascular side effects, in particular atrial fibrillation (AF) and hypertension, as well as increased risk of bleeding. Here, we aimed at describing the incidence of these events during long-term follow-up in patients with chronic lymphocytic leukemia treated outside clinical trials as well as identifying clinical factors predictive of developing AF. Additionally, other reasons for treatment withdrawal were analyzed. METHODS The study was retrospective, data were collected from medical records. RESULTS A total of 134 patients were identified. Median follow-up was 32 months (range 3-103) and median duration of ibrutinib treatment was 26 months (range 1-103). Of 110 patients with no prior history of AF, 24.5% were diagnosed during treatment. Newly diagnosed or worsening of pre-existing hypertension occurred in 15.7%. Sixty-six % of the patients experienced bleeding events, of which 7.5% grade 3-4. Treatment discontinuation and dose reduction occurred in 68% and 47% of the patients, respectively, mostly due to toxicity. CONCLUSIONS The incidence of AF was high and at a median follow-up of 2.5 years, two-thirds of the patients discontinued treatment mostly due to bleeding and infections. Treatment-related toxicity of any grade should be regarded as a concern of prolonged ibrutinib therapy.
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Affiliation(s)
- Maria L Andersson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Lymphoma Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Hemming Johansson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Anders Österborg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Lymphoma Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Månsson-Broberg
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Lotta Hansson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Lymphoma Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Marzia Palma
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Lymphoma Unit, Karolinska University Hospital, Stockholm, Sweden
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Slot M, Niemann CU, Ehlers LH, Rotbain EC. Cost-effectiveness of targeted treatment vs chemoimmunotherapy in treatment-naive unfit CLL without TP53 aberrations. Blood Adv 2023; 7:4186-4196. [PMID: 37184985 PMCID: PMC10415699 DOI: 10.1182/bloodadvances.2023010108] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/31/2023] [Accepted: 04/24/2023] [Indexed: 05/17/2023] Open
Abstract
Several targeted treatments, such as venetoclax + obinutuzumab (VenO) and ibrutinib, have been developed to treat patients with treatment-naive chronic lymphocytic leukemia (CLL) and have been shown to improve progression-free survival compared with chlorambucil + obinutuzumab (ClbO). However, novel targeted agents are associated with a significant cost investment. The objective of this study was to investigate the cost-effectiveness of VenO compared with ClbO and ibrutinib in treatment-naive CLL without del17p/TP53 mutation in Denmark. We used a decision-analytic modeling approach to simulate hypothetical cohorts of patients with CLL from the initiation of first-line treatment to death, including the full treatment pathway and second-line therapy. VenO, ClbO, or ibrutinib was included as first-line therapy followed by either Ven + rituximab or ibrutinib. Model outcomes were expected quality-adjusted life years (QALYs), life years (LYs), and cost per patient, which were used to calculate incremental cost-effectiveness ratios (ICERs) with a willingness to pay from €23 600 to €35 600 per QALY. Compared with ClbO, VenO was associated with a QALY gain of 1.30 (1.42 LYs) over a lifetime. The incremental cost was €12 360, resulting in an ICER of €9491 per QALY gained, indicating that VenO is cost-effective. Compared with VenO, ibrutinib was associated with a QALY gain of 0.82 (1.74 LYs) but at a substantially increased incremental cost of €247 488 over a lifetime horizon. The ICER was €302 156 per QALY, indicating that ibrutinib in first-line treatment would not be considered cost-effective in Danish health care, compared with VenO. Future analyses in fit patients with CLL are needed to determine the cost-effectiveness of VenO.
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Affiliation(s)
- Matilde Slot
- Nordic Institute of Health Economics, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Carsten Utoft Niemann
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Emelie Curovic Rotbain
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Hematology Research Group, Danish Cancer Society Research Center, Copenhagen, Denmark
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11
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Mattiello V, Barone A, Giannarelli D, Noto A, Cecchi N, Rampi N, Cassin R, Reda G. Predictors of ibrutinib-associated atrial fibrillation: 5-year follow-up of a prospective study. Hematol Oncol 2023; 41:363-370. [PMID: 36762406 DOI: 10.1002/hon.3126] [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: 11/20/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023]
Abstract
Ibrutinib-associated atrial fibrillation (IRAF) emerged among the adverse events of major interests in ibrutinib-treated patients as real-world studies showed a higher incidence compared to clinical trials. We prospectively analyzed predictors of IRAF in 43 single-center consecutive patients affected by chronic lymphocytic leukemia that started therapy with ibrutinib between 2015 and 2017. Key secondary endpoints were to describe the management of IRAF and survival outcomes. During a median follow-up period of 52 months, we registered 45 CV events, with a total of 23 AF events in 13 patients (CI 30.0% (95% CI: 16.5-43.9)). Pre-existent cardiovascular risk factors, in particular hypertension, a previous history of AF and a high Shanafelt risk score emerged as predictors of IRAF. Baseline echocardiographic evaluation of left atrial (LA) dimensions confirmed to predict IRAF occurrence and cut-off values were identified in our cohort: 32 mm for LA diameter and 18 cm2 for LA area. No difference in progression free survival and overall survival emerged in patients experiencing IRAF. Following AF, anticoagulation was started in all eligible patients, and cardioactive therapy was accordingly modified. Echocardiography represents a highly reproducible and widespread tool to be included in the work-up of ibrutinib candidates; the identification of IRAF predictors represents a useful guide to clinical practice.
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Affiliation(s)
| | - Angelica Barone
- Hematology Unit, Fondazione IRCCS Ca' Granda Policlinico, Milan, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Diana Giannarelli
- Facility of Epidemiology and Biostatistics, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Alessandro Noto
- Hematology Unit, Fondazione IRCCS Ca' Granda Policlinico, Milan, Italy
| | - Nicola Cecchi
- Hematology Unit, Fondazione IRCCS Ca' Granda Policlinico, Milan, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Nicolò Rampi
- Hematology Unit, Fondazione IRCCS Ca' Granda Policlinico, Milan, Italy
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Ramona Cassin
- Hematology Unit, Fondazione IRCCS Ca' Granda Policlinico, Milan, Italy
| | - Gianluigi Reda
- Hematology Unit, Fondazione IRCCS Ca' Granda Policlinico, Milan, Italy
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12
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Gargiulo E, Teglgaard RS, Faitová T, Niemann CU. Immune Dysfunction and Infection - Interaction between CLL and Treatment: A Reflection on Current Treatment Paradigms and Unmet Needs. Acta Haematol 2023; 147:84-98. [PMID: 37497921 DOI: 10.1159/000533234] [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: 03/30/2023] [Accepted: 07/24/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) is a hematological malignancy characterized by immune dysfunction, which significantly contributes to increased morbidity and mortality due to infections. SUMMARY Advancement in therapeutic strategies based on combination chemoimmunotherapy and targeted treatment have increased life expectancy for patients affected by CLL. However, mortality and morbidity due to infection showed no improvement over the last decades. Although therapy options are highly efficient in targeting leukemic cells, several studies highlighted the interactions of different treatments with the tumor microenvironment immune components, significantly impacting their clinical efficacy and fostering increased risk of infections. KEY MESSAGES Given the profound immune dysfunction caused by CLL itself, treatment can thus represent a double-edged sword. Thus, it is essential to increase our understanding and awareness on how conventional therapies affect the disease-microenvironment-infection axis to ensure the best personalized strategy for each patient. This requires careful consideration of the advantages and disadvantages of efficient treatments, whether chemoimmunotherapy or targeted combinations, leading to risk of infectious complications. To this regard, our machine learning-based algorithm CLL Treatment-Infection Model, currently implemented into the local electronic health record system for Eastern Denmark, aims at early identification of patients at high risk of serious infections (PreVent-ACaLL; NCT03868722). We here review strategies for management of immune dysfunction and infections in CLL.
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Affiliation(s)
- Ernesto Gargiulo
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Infectious Diseases, PERSIMUNE, Rigshospitalet, Copenhagen, Denmark
| | | | - Tereza Faitová
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Carsten Utoft Niemann
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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13
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Yan Y, Lv R, Wang T, Yu Y, Huang Y, Xiong W, Li Y, Sui W, Wang Q, Huang W, An G, Zou D, Wang J, Qiu L, Yi S. Real-world treatment patterns, discontinuation and clinical outcomes in patients with B-cell lymphoproliferative diseases treated with BTK inhibitors in China. Front Immunol 2023; 14:1184395. [PMID: 37483630 PMCID: PMC10360166 DOI: 10.3389/fimmu.2023.1184395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Bruton tyrosine kinase inhibitor (BTKi) has demonstrated substantial efficacy in treating B-cell lymphoproliferative diseases (BLPD). Nonetheless, the significant discontinuation rates due to toxicity or financial reasons cannot be overlooked. In China, empirical evidence on the usage of BTKi remains scarce. Methods To address this, a retrospective cohort study was conducted focused on 673 Chinese patients with BLPD who underwent at least one month of BTKi therapy. Results Median age at BTKi initiation was 60 years. The median duration on BTKi treatment of the whole cohort was 36.4 months. The median post-BTK survival was not reach. BTKi-based treatment was permanently discontinued in 288 (43.8%) patients during follow-up, mostly attributed to progressive disease. Within the first 6 months of BTKi treatment, 76 patients (26.3%) had early treatment discontinuation. Patients with early discontinuation had extreme worse outcome with a median post-discontinuation survival of only 6.9 months. On multivariate analysis, withdrawal BTKi by toxicity and withdrawal BTKi within 6 months retained to be independent predictors of post-BTK survival, after taking account of the response depth, lines of therapy and baseline cytogenetics including 17p deletion. The decision between BTKi monotherapy and combination therapy, along with the preference for first or second-generation BTKi, exerted no significant impact on survival. Discussions These observations contribute valuable real-world insights into the utilization of BTKi in China. We concluded that BTKi is an effective and well-tolerated treatment for long-term use in Chinese patient population. However, it is imperative to stress that a proportion of patients discontinue BTKi early, leading to suboptimal outcomes. This study underscores the importance of adherence to BTKi therapy for improved clinical outcomes in real-world patients.
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Affiliation(s)
- Yuting Yan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Rui Lv
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Tingyu Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Ying Yu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yanshan Huang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wenjie Xiong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yuxi Li
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Weiwei Sui
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Qi Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wenyang Huang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Gang An
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Dehui Zou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Jianxiang Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Lugui Qiu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Shuhua Yi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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14
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Johnson PC, Woyach JA, Ulrich A, Marcotte V, Nipp RD, Lage DE, Nelson AM, Newcomb RA, Rice J, Lavoie MW, Ritchie CS, Bartlett N, Stephens DM, Ding W, Owen C, Stone R, Ruppert AS, Mandrekar SJ, Byrd JC, El-Jawahri A, Le-Rademacher J, Rosko A. Geriatric assessment measures are predictive of outcomes in chronic lymphocytic leukemia. J Geriatr Oncol 2023; 14:101538. [PMID: 37329769 PMCID: PMC10599966 DOI: 10.1016/j.jgo.2023.101538] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/05/2023] [Accepted: 05/25/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) commonly affects older adults. However, few studies have examined the relationship between baseline geriatric domains and clinical outcomes in this population. Here, we aim to evaluate the use of a comprehensive geriatric assessment in older (>65 years) untreated patients with CLL to predict outcomes. MATERIALS AND METHODS We conducted a planned analysis of 369 patients with CLL age 65 or older treated in a phase 3 randomized trial of bendamustine plus rituximab versus ibrutinib plus rituximab versus ibrutinib alone (A041202). Patients underwent evaluations of geriatric domains including functional status, psychological status, social activity, cognition, social support, and nutritional status. We examined associations among baseline geriatric domains with grade 3+ adverse events using multivariable logistic regression and overall survival (OS) and progression-free survival (PFS) using multivariable Cox regression models. RESULTS In this study, the median age was 71 years (range: 65-87). In the combined multivariable model, the following geriatric domains were significantly associated with PFS: Medical Outcomes Study (MOS) - social activities survey score (hazard ratio [HR] [95% confidence interval (CI)] 0.974(0.961, 0.988), p = 0.0002) and nutritional status (≥5% weight loss in the preceding six months: (HR [95% CI] 2.717[1.696, 4.354], p < 0.001). MOS - social activities score [HR (95% CI) 0.978(0.958, 0.999), p = 0.038] was associated with OS. No geriatric domains were significantly associated with toxicity. There were no statistically significant interactions between geriatric domains and treatment. DISCUSSION Geriatric domains of social activity and nutritional status were associated with OS and/or PFS in older adults with CLL. These findings highlight the importance of assessing geriatric domains to identify high-risk patients with CLL who may benefit from additional support during treatment.
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Affiliation(s)
- P Connor Johnson
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Jennifer A Woyach
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
| | - Angela Ulrich
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Veronique Marcotte
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Ryan D Nipp
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Daniel E Lage
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ashley M Nelson
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard A Newcomb
- Dana-Farber/Partners CancerCare, Harvard Medical School, Boston, MA, USA
| | - Julia Rice
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Nancy Bartlett
- Washington University - Siteman Cancer Center, St. Louis, MO, USA
| | | | | | - Carolyn Owen
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alberta, Canada
| | - Richard Stone
- Dana-Farber/Partners CancerCare, Harvard Medical School, Boston, MA, USA
| | - Amy S Ruppert
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | | | - John C Byrd
- University of Cincinnati, Cincinnati, OH, USA
| | - Areej El-Jawahri
- Dana-Farber/Partners CancerCare, Harvard Medical School, Boston, MA, USA
| | | | - Ashley Rosko
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
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15
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Yang S, Li N, Zhu R, Feng Y, Zhuo J, Gale RP, Huang X. Impacts of early therapy response, interval to therapy interruption, and cumulative therapy interruption duration on outcome of ibrutinib therapy in relapsed/refractory chronic lymphocytic leukemia. Ann Hematol 2023:10.1007/s00277-023-05309-z. [PMID: 37393401 DOI: 10.1007/s00277-023-05309-z] [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: 11/01/2022] [Accepted: 05/31/2023] [Indexed: 07/03/2023]
Abstract
To investigate the impact of early response and treatment interruption on the survival of patients with relapsed/refractory chronic lymphocytic leukemia or small lymphocytic lymphoma (r/r CLL/SLL) treated with ibrutinib. This post hoc analysis used data of patients received ibrutinib treatment from an open-label, multicenter phase 3 study comparing ibrutinib with rituximab in patients with r/r CLL/SLL. The association of complete or partial response at 6 months, interruption within the first 6 months, cumulative interruption durations during the ibrutinib-treated period with progression-free survival (PFS) and overall survival (OS) were evaluated using the adjusted Cox hazard proportional model. The study included 87 patients treated with ibrutinib, of which 74 patients had at least 6 months of ibrutinib treatment and were analyzed. The response at 6 months did not affect PFS (HR = 0.58, 95%CI: 0.22-1.49) or OS (HR = 0.86, 95%CI: 0.22-3.31). The onset of interruption before or after 6 months was not associated with PFS (HR = 0.88, 95%CI: 0.34-2.30) or OS (HR = 0.75, 95%CI: 0.23-2.52). However, a cumulative interruption of more than 35 days was independently associated with worse PFS (HR = 2.4, 95%CI: 0.99-5.74) and OS (HR = 2.6, 95%CI: 0.88-7.44). Continuous interruption for more than 14 days was associated with a numerically lower 3-year PFS rate (> 14 vs. ≤ 14 days: 42% vs. 73%) and 3-year OS rate (> 14 vs. ≤ 14 days: 58% vs. 84%, both P > 0.05). Response status at 6 months or early therapy interruptions did not affect survival in patients with r/r CLL/SLL treated with ibrutinib. However, a cumulative temporary interruption of more than 35 days could potentially impact patient outcomes.
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Affiliation(s)
- Shenmiao Yang
- Peking University People's Hospital, Peking University Institute of Hematology, 11 Xizhimen Nan Street, Beijing, 100044, China
| | - Nan Li
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Rong Zhu
- Xian Janssen Pharmaceutical, Beijing & Shanghai, China
| | - Yu Feng
- Xian Janssen Pharmaceutical, Beijing & Shanghai, China
| | | | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, 11 Xizhimen Nan Street, Beijing, 100044, China.
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16
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Khelifi RS, Huang SJ, Savage KJ, Villa D, Scott DW, Ramadan K, Connors JM, Sehn LH, Toze CL, Gerrie AS. Population-level impact of ibrutinib for chronic lymphocytic leukemia in British Columbia, Canada. Leuk Lymphoma 2023:1-10. [PMID: 37086469 DOI: 10.1080/10428194.2023.2199340] [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: 04/24/2023]
Abstract
Ibrutinib has dramatically changed the treatment landscape for chronic lymphocytic leukemia (CLL) since its availability in British Columbia (BC), Canada in 2014. We analyzed patterns of use and real-world survival outcomes in 370 patients who received ibrutinib for first-line (1 L, n = 35) and relapsed/refractory (R/R, n = 335) CLL between 2014-2018 in BC. Dose reductions and interruptions were frequent in 32% and 27%, respectively. With a median follow-up of 27.6 months, 35% of patients discontinued ibrutinib, primarily for adverse events (AEs) rather than progressive disease. Over the course of treatment, 87% of patients experienced at least one adverse event. The 2-year overall survival (OS) and event-free survival (EFS) were excellent at 83.9% and 76.1%, respectively, with medians not reached. However, patients who discontinued ibrutinib had a median OS of 32.5 months and median EFS of only 3.8 months from time of discontinuation, highlighting the need to minimize toxicity in the real-world.
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Affiliation(s)
- Rania S Khelifi
- Department of Experimental Medicine, University of British Columbia, Vancouver, Canada
| | - Steven J Huang
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Vancouver General Hospital, BC Cancer, University of British Columbia, Vancouver, Canada
| | - Kerry J Savage
- Centre for Lymphoid Cancer, BC Cancer, Division of Medical Oncology, University of British Columbia, Vancouver, Canada
| | - Diego Villa
- Centre for Lymphoid Cancer, BC Cancer, Division of Medical Oncology, University of British Columbia, Vancouver, Canada
| | - David W Scott
- Centre for Lymphoid Cancer, BC Cancer, Division of Medical Oncology, University of British Columbia, Vancouver, Canada
| | - Khaled Ramadan
- St. Paul's Hospital, Division of Hematology, University of British Columbia, Vancouver, Canada
| | - Joseph M Connors
- Centre for Lymphoid Cancer, BC Cancer, Division of Medical Oncology, University of British Columbia, Vancouver, Canada
| | - Laurie H Sehn
- Centre for Lymphoid Cancer, BC Cancer, Division of Medical Oncology, University of British Columbia, Vancouver, Canada
| | - Cynthia L Toze
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Vancouver General Hospital, BC Cancer, University of British Columbia, Vancouver, Canada
| | - Alina S Gerrie
- Department of Experimental Medicine, University of British Columbia, Vancouver, Canada
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Vancouver General Hospital, BC Cancer, University of British Columbia, Vancouver, Canada
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17
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Moldovianu AM, Stoia R, Vasilica M, Ursuleac I, Badelita SN, Tomescu AA, Preda OD, Bardas A, Cirstea M, Coriu D. Real-World Clinical Outcomes and Adverse Events in Patients with Chronic Lymphocytic Leukemia Treated with Ibrutinib: A Single-Center Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020324. [PMID: 36837525 PMCID: PMC9959500 DOI: 10.3390/medicina59020324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/28/2023] [Accepted: 02/07/2023] [Indexed: 02/12/2023]
Abstract
Background and Objectives: The treatment of chronic lymphocytic leukemia (CLL) has acquired new targeted therapies. In clinical trials, ibrutinib improved outcomes safely. Real-world data called for a reappraisal of ibrutinib strategies. We report on a single center's experience with ibrutinib monotherapy, aiming to explore the outcomes, tolerability, and prognosis of CLL patients in routine clinical practice. Materials and Methods: Data were collected from all CLL patients treated with ibrutinib at Fundeni Clinical Institute, Bucharest, Romania, between January 2016 and June 2021. Results: A total of one hundred twenty-three CLL adult patients were treated with ibrutinib. Of the patients, 87% had relapsed/refractory CLL. The median age at ibrutinib initiation was 65 years; 44.7% of patients were staged Rai III/IV. At 32-month median follow-up, the median progression-free survival (PFS) was 50 months, the overall survival (OS) was not reached, and the overall response rate (ORR) was 86.2%. The age or number of previous therapies did not impact outcomes or tolerability. An Eastern Cooperative Oncology Group performance status (ECOG PS) score ≥ 2 and shorter time from initiation of last therapy (TILT) before ibrutinib predicted inferior PFS. Baseline characteristics had no impact on the OS except for TILT in R/R CLL patients. Drug-related adverse events (AEs) of any grade and grade ≥ 3 AEs were reported in 82.1% and 30.9% of the patients, respectively. Infections were the most common AEs (29.3%). Drug discontinuation was permanent in 43.9% of patients, mainly due to disease progression (17.1%) and toxicity (8.9%). Patients with a Cumulative Illness Rating Scale (CIRS) score ≥ 6 had a higher risk for toxicity-related discontinuation. An ECOG PS ≥ 2 predicted an increased rate of permanent discontinuation and grade ≥ 3 AEs. Conclusions: The outcomes of this study align with the results from ibrutinib clinical trials. Our study demonstrated that poor patient fitness, early relapse before ibrutinib, and permanent ibrutinib discontinuation are essential outcome determinants. Patient comorbidity burden and fitness were significant predictors for ibrutinib intolerance.
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Affiliation(s)
- Ana-Maria Moldovianu
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Hematology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
- Correspondence:
| | - Razvan Stoia
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Mariana Vasilica
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Iulia Ursuleac
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Hematology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Sorina Nicoleta Badelita
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Andra Alina Tomescu
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Oana Diana Preda
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Alexandru Bardas
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Mihaela Cirstea
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Hematology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
| | - Daniel Coriu
- Department of Hematology and Bone Marrow Transplant, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Department of Hematology, University of Medicine and Pharmacy “Carol Davila”, 050474 Bucharest, Romania
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18
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Mato A, Tang B, Azmi S, Yang K, Han Y, Zhang X, Roeker L, Wallis N, Stern JC, Hedrick E, Huang J, Sharman JP. A real-world study to assess the association of cardiovascular adverse events (CVAEs) with ibrutinib as first-line (1L) treatment for patients with chronic lymphocytic leukaemia (CLL) in the United States. EJHAEM 2023; 4:135-144. [PMID: 36819172 PMCID: PMC9928661 DOI: 10.1002/jha2.638] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 12/15/2022] [Indexed: 01/24/2023]
Abstract
Ibrutinib, a Bruton's tyrosine kinase inhibitor, is often used as first-line (1L) treatment of chronic lymphocytic leukaemia (CLL); however, it is associated with an increased risk for cardiovascular adverse events (CVAEs). This real-world study adds to existing literature by simultaneously investigating the correlation between pre-existing CV risk factors and the relative cardiotoxicity of ibrutinib vs other therapies in CLL/small lymphocytic lymphoma (SLL). Using a real-world database, the risk of subsequent CVAEs (any CVAE, atrial fibrillation [AF], or hypertension) were compared among patients who received 1L ibrutinib monotherapy or another type of non-ibrutinib therapy, grouped as intensive (IT) or non-intensive therapy (NIT). Each patient's baseline CV risk was estimated using the Framingham risk score. Inverse probability treatment weighting was incorporated into a logistic regression model to reduce baseline imbalance. Results showed ibrutinib was significantly associated with higher risk of CVAEs regardless of baseline CV risk. Compared with IT, odds ratios of any CVAE, hypertension, or AF were 2.61, 3.66, and 3.02, respectively vs 1.88, 2.13, and 2.46, respectively, with NIT. Sensitivity analyses confirmed the findings were robust. These results suggest clinical caution should be taken when selecting ibrutinib for patients with CLL/SLL, especially in those with high baseline CV risk.
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Affiliation(s)
- Anthony Mato
- Division of Hematological OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | | | | | - Keri Yang
- BeiGene, Ltd.EmeryvilleCaliforniaUSA
| | - Yi Han
- BeiGene, Ltd.EmeryvilleCaliforniaUSA
| | | | - Lindsey Roeker
- Division of Hematological OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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19
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Effectiveness and Safety of Ibrutinib for Chronic Lymphocytic Leukemia in Routine Clinical Practice: 3-Year Follow-up of the Belgian Ibrutinib Real-World Data (BiRD) Study. Clin Hematol Int 2022; 4:133-143. [PMID: 36227519 PMCID: PMC9763520 DOI: 10.1007/s44228-022-00020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/16/2022] [Indexed: 11/07/2022] Open
Abstract
The multicenter observational BiRD study investigated the real-world effectiveness and safety of ibrutinib in patients with chronic lymphocytic leukemia (CLL), mantle cell lymphoma (MCL) and Waldenström's macroglobulinemia (WM) in Belgium. This interim analysis reports results for patients with CLL, with a median follow-up of 34 months. Overall, patients had predominantly relapsed/refractory disease (73%) and were elderly (median age 72 years) with high-risk features such as del17p and/or TP53 mutations (59%). Patients were included either prospectively or retrospectively, and the total patient population effectiveness results were adjusted with left truncation. In the effectiveness population (N = 221: prospective, n = 71; retrospective, n = 150), the overall response rate was 90.0%. Median progression-free survival was 38.3 months (prospective, not estimable; retrospective, 51.5 months) and median overall survival was not yet estimable in the total, prospective and retrospective groups. Treatment-emergent adverse events (TEAEs) for the prospective and retrospective groups are reported separately. Any-grade TEAEs of interest in the prospective/retrospective groups included infections (67.1%/60.1%), diarrhea (20.5%/10.5%), hypertension (16.4%/9.8%) and atrial fibrillation (12.3%/7.2%). Major bleeding was reported in 5.5%/3.3% of prospective/retrospective patients, with little difference observed between those receiving versus not receiving antithrombotic treatment. Discontinuations due to toxicity were reported in 10.5% of patients. Results from this interim analysis show treatment with ibrutinib to be effective and tolerable, with no new safety signals observed. Future analyses will report on longer-term follow-up.
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Dartigeas C, Slama B, Doyle M, Tapprich C, Albrecht C, Dupuis S, Wapenaar R, Schmidt-Hieber C, Leblond V. FIRE Study: Real-World Effectiveness and Safety of Ibrutinib in Clinical Practice in Patients with CLL and MCL. Clin Hematol Int 2022; 4:65-74. [PMID: 36103041 PMCID: PMC9492818 DOI: 10.1007/s44228-022-00015-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/15/2022] [Indexed: 12/02/2022] Open
Abstract
The FIRE study investigated the real-world effectiveness and safety of ibrutinib in prospectively observed patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) and mantle cell lymphoma (MCL) in France. Patients were mostly relapsed/refractory with high-risk features. First-line CLL/SLL patients had del17p and/or TP53 mutations. In this interim analysis, the median follow-up time for patients with CLL/SLL and MCL was 17.7 and 15.1 months, respectively. In the effectiveness populations for CLL/SLL (n = 200) and MCL (n = 59), the median progression-free survival was not estimable and 12.4 months, respectively; the 12-month overall survival rates were 88.5% and 65.8%, respectively. Treatment-emergent adverse events of interest for patients with CLL/SLL (n = 202) and MCL (n = 59) included: infections and infestations (53.5% and 32.2%), major bleeding (5.0% and 5.1%), and atrial fibrillation (5.9% and 8.5%); 135 (66.8%) and 20 (33.9%) patients were continuing treatment at the time of data cutoff. Future analyses will report on longer-term follow-up (Trial registration: ClinicalTrials.gov, NCT03425591. Registered 1 February 2018—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03425591).
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Arustamyan M, Kibrik P, Hatipoglu D, Bungo B, Mentias A, Hill BT, Moudgil R. The Safety of Bruton's Tyrosine Kinase Inhibitors in B-cell Malignancies: A Systematic Review. Eur J Haematol 2022; 109:696-710. [PMID: 36030394 DOI: 10.1111/ejh.13854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 12/01/2022]
Abstract
B-cell malignancies, most notably lymphomas, make up most of the non-Hodgkin lymphomas in the United States. There is limited randomized data comparing 1st and 2nd generation Bruton Tyrosine Kinase inhibitors. Our aim was to compare the safety profiles of 1st versus 2nd generation Bruton Tyrosine Kinase inhibitors. A systematic search was performed from database inception to January 13, 2020. Studies with Bruton Tyrosine Kinase inhibitor monotherapy for the treatment of B-cell malignancies in the adult population (> 18 years old) were utilized and the adverse events were extracted. Fifty-five studies that met the inclusion criteria were included in the systematic review with forty-one studies with 1st generation and fourteen studies with 2nd generation. The review included both clinical trials and retrospective studies with average time of follow-up of 2 years for the 1st generation group and 18 months for the 2nd generation group. We found that the incidence of cardiovascular adverse events was significantly higher in the 1st generation group (20.8%) as compared to the 2nd generation group (6.3%). However, there was a higher incidence of hematologic/oncologic and gastrointestinal side effects in the 2nd generation group compared to the 1st (62.3% compared to 39.2% and 36.9% compare to 28.9%). The number of Grade 5 cardiovascular events (death) were same in the 1st generation group compared to the 2nd generation. Further research is needed to develop highly selective Bruton Tyrosine Kinase inhibitors to avoid unwanted adverse events by minimizing off-targets. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Michael Arustamyan
- Section of Clinical Cardiology, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Section of Leukemia/Lymphoma, Department of Hematology and Medical Oncology
| | - Pavel Kibrik
- Section of Clinical Cardiology, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Section of Leukemia/Lymphoma, Department of Hematology and Medical Oncology
| | - Dilara Hatipoglu
- Section of Clinical Cardiology, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Section of Leukemia/Lymphoma, Department of Hematology and Medical Oncology
| | - Brandon Bungo
- Section of Clinical Cardiology, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Section of Leukemia/Lymphoma, Department of Hematology and Medical Oncology.,Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH
| | - Amgad Mentias
- Section of Clinical Cardiology, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Section of Leukemia/Lymphoma, Department of Hematology and Medical Oncology
| | - Brian T Hill
- Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH
| | - Rohit Moudgil
- Section of Clinical Cardiology, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Section of Leukemia/Lymphoma, Department of Hematology and Medical Oncology
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Kater AP, Levin MD, Dubois J, Kersting S, Enggaard L, Veldhuis GJ, Mous R, Mellink CHM, van der Kevie-Kersemaekers AMF, Dobber JA, Poulsen CB, Frederiksen H, Janssens A, Schjødt I, Dompeling EC, Ranti J, Brieghel C, Mattsson M, Bellido M, Tran HTT, Nasserinejad K, Niemann CU. Minimal residual disease-guided stop and start of venetoclax plus ibrutinib for patients with relapsed or refractory chronic lymphocytic leukaemia (HOVON141/VISION): primary analysis of an open-label, randomised, phase 2 trial. Lancet Oncol 2022; 23:818-828. [DOI: 10.1016/s1470-2045(22)00220-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 11/25/2022]
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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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Abrisqueta P, Loscertales J, Terol MJ, Ramírez Payer Á, Ortiz M, Pérez I, Cuellar-García C, Fernández de la Mata M, Rodríguez A, Lario A, Delgado J, Godoy A, Arguiñano Pérez JM, Berruezo MJ, Oliveira A, Hernández-Rivas JÁ, García Malo MD, Medina Á, García Martin P, Osorio S, Baltasar P, Fernández-Zarzoso M, Marco F, Vidal Manceñido MJ, Smucler Simonovich A, López Rubio M, Jarque I, Suarez A, Fernández Álvarez R, Lancharro Anchel A, Ríos E, Losada Castillo MDC, Pérez Persona E, García Muñoz R, Ramos R, Yáñez L, Bello JL, Loriente C, Acha D, Villanueva M. Real-World Characteristics and Outcome of Patients Treated With Single-Agent Ibrutinib for Chronic Lymphocytic Leukemia in Spain (IBRORS-LLC Study). CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2021; 21:e985-e999. [PMID: 34511320 DOI: 10.1016/j.clml.2021.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Ibrutinib demonstrated remarkable efficacy and favorable tolerability in patients with untreated or relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL), including those with high-risk genetic alterations. The IBRORS-CLL study assessed the characteristics, clinical management and outcome of CLL patients receiving ibrutinib in routine clinical practice in Spain. PATIENTS Observational, retrospective, multicenter study in CLL patients who started single-agent ibrutinib as first-line treatment or at first or second relapse between January 2016 and January 2019. RESULTS A total of 269 patients were included (median age: 70.9 years; cardiovascular comorbidity: 55.4%, including hypertension [47.6%] and atrial fibrillation [AF] [7.1%]). Overall, 96.7% and 69% of patients underwent molecular testing for del(17p)/TP53 mutation and IGHV mutation status. High-risk genetic features included unmutated IGHV (79%) and del(17p)/TP53 mutation (first-line: 66.3%; second-line: 23.1%). Overall, 84 (31.2%) patients received ibrutinib as first-line treatment, and it was used as second- and third-line therapy in 121 (45.0%) and 64 (23.8%) patients. The median progression-free survival and overall survival were not reached irrespective of del(17p)/TP53, or unmutated IGHV. Common grade ≥3 adverse events were infections (12.2%) and bleeding (3%). Grade ≥3 AF occurred in 1.5% of patients. CONCLUSION This real-world study shows that single-agent ibrutinib is an effective therapy for CLL, regardless of age and high-risk molecular features, consistent with clinical trials. Additionally, single-agent ibrutinib was well tolerated, with a low rate of cardiovascular events. This study also emphasized a high molecular testing rate of del(17p)/TP53 mutation and IGHV mutation status in clinical practice according to guideline recommendations.
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Affiliation(s)
| | | | | | | | - Macarena Ortiz
- Hospital Regional Universitario de Málaga, Malaga, Spain
| | | | | | | | | | - Ana Lario
- Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Ana Godoy
- Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - Ana Oliveira
- ICO L'Hospitalet, L'Hospitalet de Llobregat, Spain
| | | | | | | | | | - Santiago Osorio
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Fernando Marco
- Hospital Universitario de Basurto, Bilbo, Bizkaia, Spain
| | | | | | | | | | - Alexia Suarez
- Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas, Spain
| | | | | | - Eduardo Ríos
- Hospital Universitario Virgen de Valme, Sevilla, Spain
| | | | | | | | - Rafael Ramos
- Hospital Universitario de Badajoz, Badajoz, Spain
| | - Lucrecia Yáñez
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - José Luis Bello
- Hospital Clínico Universitario de Santiago-CHUS, Santiago de Compostela, A Coruña, Spain
| | | | - Daniel Acha
- Medical Department-Hematology Janssen-Cilag, S.A., Madrid, Spain
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Seung SJ, Hurry M, Hassan S, Elnoursi A, Scheider KAB, Wagner D, Edwin JJ, Aw ATW. Examining Treatment Patterns and Real-World Outcomes in Chronic Lymphocytic Leukemia Using Administrative Data in Ontario. Curr Oncol 2021; 28:4832-4844. [PMID: 34898565 PMCID: PMC8628804 DOI: 10.3390/curroncol28060408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 11/24/2022] Open
Abstract
Information on the real-world experience of Canadians diagnosed with chronic lymphocytic leukemia (CLL) is limited. This study was conducted to report treatment patterns and outcomes of CLL using Ontario administrative data. A retrospective cohort study was conducted in patients diagnosed with CLL between 1 January 2010 and 31 December 2017 identified in the Ontario Cancer Registry (OCR). Data were accessed using the Institute of Clinical Evaluative Sciences (ICES), which collects various population-level health information. In the Ontario Cancer Registry, 2887 CLL patients receiving treatment and diagnosed between 2010–2017 were identified. Fludarabine, cyclophosphamide and rituximab (FCR) chemoimmunotherapy was most frequently used as a first line, but use declined since ibrutinib and obinutuzumab combinations were funded in 2015. In patients treated with frontline FCR, survival at year one was 89% pre-2015 and 96% post-2015; at year four, survival was 73% and 87%, respectively. Survival in patients treated with frontline chlorambucil was 76% pre-2015 and 75% post-2015 in year 1, and 45% and 56% in year 3. Our analysis shows that, as the treatment landscape for CLL has shifted, use of newer and novel agents as a first line or earlier in the relapsed/refractory setting has resulted in improved survival outcomes.
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Affiliation(s)
- Soo Jin Seung
- HOPE Research Centre, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada;
- Correspondence:
| | - Manjusha Hurry
- AstraZeneca Canada, Mississauga, ON L4Y 1M4, Canada; (M.H.); (A.E.); (K.A.B.S.); (D.W.); (J.J.E.)
| | - Shazia Hassan
- HOPE Research Centre, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada;
| | - Ashlie Elnoursi
- AstraZeneca Canada, Mississauga, ON L4Y 1M4, Canada; (M.H.); (A.E.); (K.A.B.S.); (D.W.); (J.J.E.)
| | - Krystin A. B. Scheider
- AstraZeneca Canada, Mississauga, ON L4Y 1M4, Canada; (M.H.); (A.E.); (K.A.B.S.); (D.W.); (J.J.E.)
| | - Dennis Wagner
- AstraZeneca Canada, Mississauga, ON L4Y 1M4, Canada; (M.H.); (A.E.); (K.A.B.S.); (D.W.); (J.J.E.)
| | - Jonathan J. Edwin
- AstraZeneca Canada, Mississauga, ON L4Y 1M4, Canada; (M.H.); (A.E.); (K.A.B.S.); (D.W.); (J.J.E.)
| | - Andrew T. W. Aw
- The Ottawa Hospital General Campus, Ottawa, ON K1H 8L6, Canada;
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Svanberg R, Janum S, Patten PEM, Ramsay AG, Niemann CU. Targeting the tumor microenvironment in chronic lymphocytic leukemia. Haematologica 2021; 106:2312-2324. [PMID: 33882636 PMCID: PMC8409023 DOI: 10.3324/haematol.2020.268037] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 03/31/2021] [Indexed: 11/24/2022] Open
Abstract
The tumor microenvironment (TME) plays an essential role in the development, growth, and survival of the malignant B-cell clone in chronic lymphocytic leukemia (CLL). Within the proliferation niches of lymph nodes, bone marrow, and secondary lymphoid organs, a variety of phenotypically and functionally altered cell types, including T cells, natural killer cells, monocytes/macrophages, endothelial and mesenchymal stroma cells, provide crucial survival signals, along with CLL-cellinduced suppression of antitumor immune responses. The B-cell receptor pathway plays a pivotal role in mediating the interaction between CLL cells and the TME. However, an increasing number of additional components of the multifactorial TME are being discovered. Although the majority of therapeutic strategies employed in CLL hitherto have focused on targeting the leukemic cells, emerging evidence implies that modulation of microenvironmental cells and CLL-TME interactions by novel therapeutic agents significantly affect their clinical efficacy. Thus, improving our understanding of CLL-TME interactions and how they are affected by current therapeutic agents may improve and guide treatment strategies. Identification of novel TME interactions may also pave the road for the development of novel therapeutic strategies targeting the TME. In this review, we summarize current evidence on the effects of therapeutic agents on cells and interactions within the TME. With a growing demand for improved and personalized treatment options in CLL, this review aims at inspiring future exploration of smart drug combination strategies, translational studies, and novel therapeutic targets in clinical trials.
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Affiliation(s)
| | - Sine Janum
- Department of Clinical Haemato-oncology, Bartholomew's Hospital, Barts Health Trust, London
| | - Piers E M Patten
- School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London
| | - Alan G Ramsay
- School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London
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Cho HJ, Baek DW, Kim J, Lee JM, Moon JH, Sohn SK. Keeping a balance in chronic lymphocytic leukemia (CLL) patients taking ibrutinib: ibrutinib-associated adverse events and their management based on drug interactions. Expert Rev Hematol 2021; 14:819-830. [PMID: 34375536 DOI: 10.1080/17474086.2021.1967139] [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: 10/20/2022]
Abstract
INTRODUCTION Ibrutinib is a highly effective drug for patients with chronic lymphocytic leukemia (CLL), and is well tolerated even by older patients and those unfit to receive conventional immuno-chemotherapy. AREAS COVERED The occurrence of adverse events was revealed as a major cause of ibrutinib failure in the real-world. Ibrutinib-induced lymphocytosis carries the risk of an untimely interruption of therapy because it may be misinterpreted as disease progression. In addition, drug interactions can worsen ibrutinib-associated toxicities by increasing the plasma concentration of ibrutinib. In this review, we present a case of major hemorrhage and atrial fibrillation (AF) during ibrutinib use and summarize the adverse events associated with ibrutinib. Furthermore, the practical management of ibrutinib-associated toxicities was covered with reference to a drug interaction mechanism. EXPERT OPINION Clinicians should examine the prescribed drugs prior to ibrutinib initiation and carefully monitor toxicities while taking ibrutinib. A reduced dose of ibrutinib with the concurrent use of CYP3A inhibitors such as antifungal agents could be an attractive strategy to reduce toxicities and may confer financial benefits. Reducing unexpected toxicities is as significant as achieving treatment response in the era of life-long therapy with ibrutinib in patients with CLL.
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Affiliation(s)
- Hee Jeong Cho
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Dong Won Baek
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Juhyung Kim
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Jung Min Lee
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Joon Ho Moon
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Sang Kyun Sohn
- Department of Hematology/Oncology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
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Venetoclax and ibrutinib for patients with relapsed/refractory chronic lymphocytic leukemia. Blood 2021; 137:1117-1120. [PMID: 33027809 DOI: 10.1182/blood.2020008608] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/26/2020] [Indexed: 11/20/2022] Open
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Abstract
ABSTRACT In this article, we carry out an overview on the management options available for chronic lymphocytic leukemia (CLL) patients and discuss possible treatment decisions, taking into account the issue of sustainability and availability. Targeted agents have shown to be superior compared with chemoimmunotherapy (CIT) in terms of progression-free survival in high-risk CLL. In the majority of studies, however, continuous treatment was compared with fixed-duration CIT and no overall survival or progression-free survival-2 (time from randomization to second progression or death) advantage could be documented. Meanwhile, a substantial financial burden on both patients and payers has raised issues about affordability and adherence to treatment. Therefore, value-based pricing of new drugs has been used to set up price negotiation policies in several countries, and fixed-duration therapy has shown to be less costly than continuous treatment. Thus, CIT continues to have a role in the treatment of CLL patients with a favorable genetic profile, that is, with a mutated IGHV gene profile and a wild-type TP53. Targeted treatment represents the preferred choice in patients with an unmutated IGHV gene configuration and/or a TP53 disruption, provided that adherence to treatment is guaranteed and bearing in mind that should costly drugs not be available for frontline treatment, new agents can be very effective as first salvage treatment.
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Bödör C, Kotmayer L, László T, Takács F, Barna G, Kiss R, Sebestyén E, Nagy T, Hegyi LL, Mikala G, Fekete S, Farkas P, Balogh A, Masszi T, Demeter J, Weisinger J, Alizadeh H, Kajtár B, Kohl Z, Szász R, Gergely L, Gurbity Pálfi T, Sulák A, Kollár B, Egyed M, Plander M, Rejtő L, Szerafin L, Ilonczai P, Tamáska P, Pettendi P, Lévai D, Schneider T, Sebestyén A, Csermely P, Matolcsy A, Mátrai Z, Alpár D. Screening and monitoring of the BTK C481S mutation in a real-world cohort of patients with relapsed/refractory chronic lymphocytic leukaemia during ibrutinib therapy. Br J Haematol 2021; 194:355-364. [PMID: 34019713 DOI: 10.1111/bjh.17502] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/01/2021] [Indexed: 11/28/2022]
Abstract
The Bruton's tyrosine kinase (BTK) inhibitor ibrutinib has revolutionised the therapeutic landscape of chronic lymphocytic leukaemia (CLL). Acquired mutations emerging at position C481 in the BTK tyrosine kinase domain are the predominant genetic alterations associated with secondary ibrutinib resistance. To assess the correlation between disease progression, and the emergence and temporal dynamics of the most common resistance mutation BTKC481S , sensitive (10-4 ) time-resolved screening was performed in 83 relapsed/refractory CLL patients during single-agent ibrutinib treatment. With a median follow-up time of 40 months, BTKC481S was detected in 48·2% (40/83) of the patients, with 80·0% (32/40) of them showing disease progression during the examined period. In these 32 cases, representing 72·7% (32/44) of all patients experiencing relapse, emergence of the BTKC481S mutation preceded the symptoms of clinical relapse with a median of nine months. Subsequent Bcl-2 inhibition therapy applied in 28/32 patients harbouring BTKC481S and progressing on ibrutinib conferred clinical and molecular remission across the patients. Our study demonstrates the clinical value of sensitive BTKC481S monitoring with the largest longitudinally analysed real-world patient cohort reported to date and validates the feasibility of an early prediction of relapse in the majority of ibrutinib-treated relapsed/refractory CLL patients experiencing disease progression.
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Affiliation(s)
- Csaba Bödör
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Lili Kotmayer
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Tamás László
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Ferenc Takács
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Gábor Barna
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Richárd Kiss
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Endre Sebestyén
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Tibor Nagy
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Lajos László Hegyi
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Gábor Mikala
- South-Pest Central Hospital-National Institute of Hematology and Infectology, Budapest, Hungary
| | - Sándor Fekete
- South-Pest Central Hospital-National Institute of Hematology and Infectology, Budapest, Hungary
| | - Péter Farkas
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Alexandra Balogh
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Tamás Masszi
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Judit Demeter
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Júlia Weisinger
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Hussain Alizadeh
- 1st Department of Internal Medicine, Clinical Centre, University of Pécs, Pécs, Hungary
| | - Béla Kajtár
- Department of Pathology, University of Pécs Medical School, Pécs, Hungary
| | - Zoltán Kohl
- 1st Department of Internal Medicine, Clinical Centre, University of Pécs, Pécs, Hungary
| | - Róbert Szász
- Division of Hematology, Department of Internal Medicine, University of Debrecen, Debrecen, Hungary
| | - Lajos Gergely
- Division of Hematology, Department of Internal Medicine, University of Debrecen, Debrecen, Hungary
| | - Timea Gurbity Pálfi
- 2nd Department of Internal Medicine and Cardiology Center, University of Szeged, Szeged, Hungary
| | - Adrienn Sulák
- 2nd Department of Internal Medicine and Cardiology Center, University of Szeged, Szeged, Hungary
| | - Balázs Kollár
- Kaposi Mór University Teaching Hospital of County Somogy, Kaposvár, Hungary
| | - Miklós Egyed
- Kaposi Mór University Teaching Hospital of County Somogy, Kaposvár, Hungary
| | - Márk Plander
- Markusovszky University Teaching Hospital, Szombathely, Hungary
| | - László Rejtő
- Hospitals of County Szabolcs-Szatmár-Bereg and University Teaching Hospital, Nyíregyháza, Hungary
| | - László Szerafin
- Hospitals of County Szabolcs-Szatmár-Bereg and University Teaching Hospital, Nyíregyháza, Hungary
| | - Péter Ilonczai
- Hospitals of County Szabolcs-Szatmár-Bereg and University Teaching Hospital, Nyíregyháza, Hungary.,Markhot Ferenc Teaching Hospital of County Heves, Eger, Hungary
| | - Péter Tamáska
- Borsod-Abaúj-Zemplén County Hospital and University Teaching Hospital, Miskolc, Hungary
| | - Piroska Pettendi
- Hetényi Géza Hospital and Clinic of County Jász-Nagykun-Szolnok, Szolnok, Hungary
| | - Dóra Lévai
- National Institute of Oncology, Budapest, Hungary
| | | | - Anna Sebestyén
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
| | - Péter Csermely
- Department of Molecular Biology, Institute of Biochemistry and Molecular Biology, Semmelweis University, Budapest, Hungary
| | - András Matolcsy
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary.,Department of Laboratory Medicine, Karolinska Institute, Solna, Sweden
| | - Zoltán Mátrai
- South-Pest Central Hospital-National Institute of Hematology and Infectology, Budapest, Hungary
| | - Donát Alpár
- HCEMM-SE Molecular Oncohematology Research Group, 1st Department of Pathology and Experimental Cancer Research, Semmelweis University, Budapest, Hungary
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31
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Brieghel C, Aarup K, Torp MH, Andersen MA, Yde CW, Tian X, Wiestner A, Ahn IE, Niemann CU. Clinical Outcomes in Patients with Multi-Hit TP53 Chronic Lymphocytic Leukemia Treated with Ibrutinib. Clin Cancer Res 2021; 27:4531-4538. [PMID: 33963002 DOI: 10.1158/1078-0432.ccr-20-4890] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/23/2021] [Accepted: 05/04/2021] [Indexed: 01/21/2023]
Abstract
PURPOSE TP53 aberration (TP53 mutation and/or 17p deletion) is the most important predictive marker in chronic lymphocytic leukemia (CLL). Although each TP53 aberration is considered an equal prognosticator, the prognostic value of carrying isolated (single-hit) or multiple (multi-hit) TP53 aberrations remains unclear, particularly in the context of targeted agents. PATIENTS AND METHODS We performed deep sequencing of TP53 using baseline samples collected from 51 TP53 aberrant patients treated with ibrutinib in a phase II study (NCT01500733). RESULTS We identified TP53 mutations in 43 patients (84%) and del(17p) in 47 (92%); 9 and 42 patients carried single-hit and multi-hit TP53, respectively. The multi-hit TP53 subgroup was enriched with younger patients who had prior treatments and unmutated immunoglobulin heavy-chain variable region gene status. We observed significantly shorter overall survival, progression-free survival (PFS), and time-to-progression (TTP) in patients with multi-hit TP53 compared with those with single-hit TP53. Clinical outcomes were similar in patient subgroups stratified by 2 or >2 TP53 aberrations. In multivariable analyses, multi-hit TP53 CLL was independently associated with inferior PFS and TTP. In sensitivity analyses, excluding mutations below 1% VAF demonstrated similar outcome. Results were validated in an independent population-based cohort of 112 patients with CLL treated with ibrutinib. CONCLUSIONS In this study, single-hit TP53 defines a distinct subgroup of patients with an excellent long-term response to single-agent ibrutinib, whereas multi-hit TP53 is independently associated with shorter PFS. These results warrant further investigations on prognostication and management of multi-hit TP53 CLL.See related commentary by Bomben et al., p. 4462.
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Affiliation(s)
- Christian Brieghel
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kathrine Aarup
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mathias H Torp
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Michael A Andersen
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christina W Yde
- Center for Genomic Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Xin Tian
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Adrian Wiestner
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Inhye E Ahn
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Carsten U Niemann
- Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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32
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Groenland SL, Ratain MJ, Chen LS, Gandhi V. The Right Dose: From Phase I to Clinical Practice. Am Soc Clin Oncol Educ Book 2021; 41:92-106. [PMID: 34010057 DOI: 10.1200/edbk_319567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To realize the full potential of promising new anticancer drugs, it is of paramount importance to administer them at the right dose. The aim of this educational article is to provide several opportunities to optimize anticancer drug dosing, focusing on oral targeted therapies. First, therapeutic drug monitoring can optimize exposure in individual patients, if the optimal concentration is known. This approach is of particular interest in regard to oral kinase inhibitors with high interindividual pharmacokinetic variability. If exposure is related to response, then therapeutic drug monitoring is potentially feasible, although the clinical utility of this approach has not yet been established. Other approaches to reduce variability include administration of more frequent, smaller doses and administration under optimal prandial conditions. However, for many drugs, the labeled dose has not been demonstrated to be the optimal dose; for such agents, the vast majority of patients may be receiving excessive doses, which results in excessive toxicity. Furthermore, administration of lower off-label doses may reduce both medical and financial toxicity. These strategies should be applied from registration studies to clinical practice, with the goal of better optimizing anticancer treatment.
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Affiliation(s)
- Stefanie L Groenland
- Department of Clinical Pharmacology, Division of Medical Oncology, the Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Mark J Ratain
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Lisa S Chen
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Varsha Gandhi
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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