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Li X, Suh HS, Lachaine J, Schuh AC, Pratz K, Betts KA, Song J, Dua A, Bui CN. Comparative Efficacy of Venetoclax-Based Combination Therapies and Other Therapies in Treatment-Naive Patients With Acute Myeloid Leukemia Ineligible for Intensive Chemotherapy: A Network Meta-Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1689-1696. [PMID: 37741447 DOI: 10.1016/j.jval.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 07/11/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVES This network meta-analysis (NMA) assessed the efficacy of venetoclax (VEN) + azacitidine (AZA) and VEN + low-dose cytarabine (LDAC) compared with AZA, LDAC, and decitabine monotherapies and best supportive care (BSC) in adults with untreated acute myeloid leukemia ineligible for intensive chemotherapy. METHODS A systematic literature review and feasibility assessment was conducted to select phase III randomized controlled trials for inclusion in the NMA. Complete remission + complete remission with incomplete blood count recovery and overall survival (OS) were compared using a Bayesian fixed-effects NMA. Treatments were ranked using surface under the cumulative ranking curves (SUCRAs) with higher values indicating a higher likelihood of being effective. RESULTS A total of 1140 patients across 5 trials were included. VEN + LDAC (SUCRA 91.4%) and VEN + AZA (87.5%) were the highest ranked treatments for complete remission + complete remission with incomplete blood count recovery. VEN + LDAC was associated significantly higher response rates versus AZA (odds ratio 5.64), LDAC (6.39), and BSC (23.28). VEN + AZA was also associated significantly higher response rates than AZA (5.06), LDAC (5.74), and BSC (20.68). In terms of OS, VEN + AZA (SUCRA: 95.2%) and VEN + LDAC (75.9%) were the highest ranked treatments. VEN + AZA was associated with significant improvements in OS compared with AZA (hazard ratio 0.66), LDAC (0.57), and BSC (0.37), and VEN + LDAC was associated with significant improvements in OS compared with LDAC (0.70) and BSC (0.46). CONCLUSIONS VEN + AZA and VEN + LDAC demonstrated improved efficacy compared with alternative therapies among treatment-naive patients with acute myeloid leukemia ineligible for intensive chemotherapy.
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Affiliation(s)
- Xue Li
- China National Health Development Research Center, Beijing, China; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | | | - Andre C Schuh
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Keith Pratz
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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2
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Ladaique P, Etienne JM, Pedini P, Chiaroni J, Vey N, Picard C, Chabrieres C. Therapeutic efficacy of platelet transfusion treated with amotosalen/UVA pathogen inactivation technology (INTERCEPT TM Blood System) in acute myeloid leukemia patients undergoing chemotherapy with curative intent: a single center experience. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2023; 21:400-408. [PMID: 36795348 PMCID: PMC10497385 DOI: 10.2450/2023.0143-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 11/25/2022] [Indexed: 02/17/2023]
Abstract
BACKGROUND The INTERCEPTTM Blood System (Intercept Blood System, Cerus Europe BV, Amersfoort, the Netherlands) has been used to reduce or inactivate pathogen load in platelet concentrates in France for three years. MATERIALS AND METHODS After comparing the transfusion efficiency between pathogen-reduced platelets (PR_PLT) and untreated platelet products (U_PLT), our single-center observational study assessed the effectiveness of PR_PLT for the prevention of bleeding and for therapeutic treatment of WHO grade 2 bleeding in 176 patients undergoing chemotherapy with curative intent for acute myeloid leukemia (AML). The main endpoints were the 24-hour (h) corrected count increment (24h_CCI) after each transfusion, and time to next transfusion. RESULTS Whereas the transfused doses tended to be higher in the PR_PLT group compared to U_PLT, there was a significant difference in intertransfusion interval (ITI) and 24h_CCI. In prophylactic transfusions, PR_PLT transfusions of >0.65×1011/10 kg, regardless of the age of the product (day 2 to day 5), resulted in a 24h_CCI similar to that of the untreated platelet product; this meant the patient could be transfused at least every 48h. In contrast, most PR_PLT transfusions of <0.55×1011/10 kg did not achieve a transfusion interval of 48h. In the context of WHO grade 2 bleeding, PR_PLT transfusions >0.65×1011/10 kg and storage of less than 4 days seems more effective in stopping bleeding. DISCUSSION These results, which must be confirmed by prospective studies, indicate the need for vigilance regarding the quantity and quality of PR_PLT products used to treat patients at risk of bleeding crisis. Future prospective studies are needed to confirm these findings.
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Affiliation(s)
- Patrick Ladaique
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
| | | | - Pascal Pedini
- EFS PACA-Corse, Marseille, France
- Aix Marseille Université, CNRS, EFS, ADES, Marseille, France
| | - Jacques Chiaroni
- EFS PACA-Corse, Marseille, France
- Aix Marseille Université, CNRS, EFS, ADES, Marseille, France
| | - Norbert Vey
- Hematology Department, Institut Paoli-Calmettes, Marseille, France
- Centre de Recherche en Cancérologie de Marseille (CRCM), Inserm, CNRS, Aix-Marseille Université, Marseille, France
| | - Christophe Picard
- EFS PACA-Corse, Marseille, France
- Aix Marseille Université, CNRS, EFS, ADES, Marseille, France
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Daniels NC, Bodd MH, Locke SC, LeBlanc TW. In their own words: a qualitative study of coping mechanisms employed by patients with acute myeloid leukemia. Support Care Cancer 2023; 31:443. [PMID: 37405579 DOI: 10.1007/s00520-023-07917-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/28/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE Positive coping mediates improved outcomes from integrated palliative care in acute myeloid leukemia (AML). We qualitatively explored patients' coping mechanisms to better understand this relationship. METHODS We enrolled patients with high-risk AML admitted to Duke Hospital's inpatient hematologic malignancy service for intensive chemotherapy. This study is a secondary analysis of previously collected longitudinal qualitative data, with interviews conducted between February 2014 and August 2015. Interviews were coded in NVivo to identify examples of approach-oriented and avoidant coping. RESULTS Patients demonstrated approach-oriented coping in many forms including acceptance, positive reframing, active coping, religious coping, and social coping. Acceptance included accepting their prognosis, the uncertainty of AML, and lifestyle changes due to the disease. Patients exhibited positive reframing by speculating about how their situation could be worse, deriving meaning from their experience, and expressing newfound appreciation for activities previously taken for granted. Social coping involved patients receiving support from their community or care team; however, some expressed guilt for being a "burden" on family. Avoidant coping included denial, behavioral disengagement, and self-blame. Some denied their prognosis, but denial was more commonly demonstrated via patients cognitively distancing themselves from their disease. Much of the behavioral disengagement described by patients was attributed to their symptoms (i.e., lethargy) which prevented patients from maintaining relationships or participating in activities previously enjoyed. CONCLUSION These results demonstrate the diverse and nuanced applications of coping mechanisms amid a recent AML diagnosis. Future research should examine coping in the context of novel low-intensity AML therapies.
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Affiliation(s)
| | - Monica H Bodd
- Duke University School of Medicine, Durham, NC, 27710, USA
| | | | - Thomas W LeBlanc
- Duke University School of Medicine, Durham, NC, 27710, USA.
- Duke Cancer Institute, Durham, NC, USA.
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Gama SM, Varela VA, Ribeiro NM, Bizzarro B, Hernandes C, Aloia TPA, Amano MT, Pereira WO. AKT inhibition interferes with the expression of immune checkpoint proteins and increases NK-induced killing of HL60-AML cells. EINSTEIN-SAO PAULO 2023; 21:eAO0171. [PMID: 37341216 DOI: 10.31744/einstein_journal/2023ao0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 10/03/2022] [Indexed: 06/22/2023] Open
Abstract
OBJECTIVE To determine the role of the AKT pathway in the regulating of natural Killer-induced apoptosis of acute myeloid leukemia cells and to characterize the associated molecular mechanisms. METHODS BALB/c nude mice were injected with HL60 cells to induce a xenogenic model of subcutaneous leukemic tumors. Mice were treated with perifosine, and their spleens were analyzed using biometry, histopathology, and immunohistochemistry. Gene expression analysis in leukemia cells was performed by real-time PCR. Protein analysis of leukemia and natural Killer cells was performed by flow cytometry. AKT inhibition in HL60 cells, followed by co-culture with natural Killer cells was performed to assess cytotoxicity. Apoptosis rate was quantified using flow cytometry. RESULTS Perifosine treatment caused a reduction in leukemic infiltration in the spleens of BALB/c nude mice. In vitro , AKT inhibition reduced HL60 resistance to natural Killer-induced apoptosis. AKT inhibition suppressed the immune checkpoint proteins PD-L1, galectin-9, and CD122 in HL60 cells, but did not change the expression of their co-receptors PD1, Tim3, and CD96 on the natural Killer cell surface. In addition, the death receptors DR4, TNFR1, and FAS were overexpressed by AKT inhibition, thus increasing the susceptibility of HL60 cells to the extrinsic pathway of apoptosis. CONCLUSION The AKT pathway is involved in resistance to natural Killer-induced apoptosis in HL60 cells by regulating the expression of immune suppressor receptors. These findings highlight the importance of AKT in contributing to immune evasion mechanisms in acute myeloid leukemia and suggests the potential of AKT inhibition as an adjunct to immunotherapy.
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Affiliation(s)
- Sofia Mônaco Gama
- Faculdade Israelita de Ciências da Saúde Albert Einstein , Hospital Israelita Albert Einstein , São Paulo , SP , Brazil
| | - Vanessa Araújo Varela
- Faculdade Israelita de Ciências da Saúde Albert Einstein , Hospital Israelita Albert Einstein , São Paulo , SP , Brazil
| | - Natalia Mazini Ribeiro
- Faculdade Israelita de Ciências da Saúde Albert Einstein , Hospital Israelita Albert Einstein , São Paulo , SP , Brazil
| | - Bruna Bizzarro
- Faculdade Israelita de Ciências da Saúde Albert Einstein , Hospital Israelita Albert Einstein , São Paulo , SP , Brazil
| | - Camila Hernandes
- Faculdade Israelita de Ciências da Saúde Albert Einstein , Hospital Israelita Albert Einstein , São Paulo , SP , Brazil
| | - Thiago Pinheiro Arrais Aloia
- Faculdade Israelita de Ciências da Saúde Albert Einstein , Hospital Israelita Albert Einstein , São Paulo , SP , Brazil
| | - Mariane Tami Amano
- Department of Clinical and Experimental Oncology , Escola Paulista de Medicina , Universidade Federal de São Paulo , São Paulo , SP , Brazil
| | - Welbert Oliveira Pereira
- Faculdade Israelita de Ciências da Saúde Albert Einstein , Hospital Israelita Albert Einstein , São Paulo , SP , Brazil
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Hershenfeld SA, Atenafu EG, Chan S, Gupta V, Maze D, Schuh A, Sibai H, Yee K, Schimmer AD. Impact of Geographical Distance from Quaternary Treatment Center on Clinical Trial Participation, Intensive Induction Chemotherapy, and Outcomes in Patients with Newly Diagnosed Acute Myeloid Leukemia. Acta Haematol 2023; 146:366-372. [PMID: 37315549 DOI: 10.1159/000531484] [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: 03/15/2023] [Accepted: 06/02/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Care for patients with acute myeloid leukemia (AML) is centralized in the Ontario single-payer public healthcare system, with intensive induction chemotherapy and clinical trials only offered at specialized cancer centers with large catchment areas. METHODS We therefore conducted a retrospective single-center review of all AML patients assessed at a large specialized cancer center in Ontario, Canada. RESULTS Between 2012 and 2017, 1,310 patients were assessed by our center for upfront AML therapy. The median distance was 33.1 km, with 29% of patients living more than 50 km away from the center. There was no significant difference in probability of intensive induction chemotherapy or clinical trial by distance from center, both in univariate and multivariable analysis adjusting for age, sex, cytogenetics and molecular testing, and performance status. There was no significant difference in overall survival by distance from center on univariate and multivariable analysis. CONCLUSION In conclusion, geographic distance from treatment center does not appear to impact choice of upfront therapy, participation in clinical trials, or clinical outcomes in this study of newly diagnosed patients with AML treated in a single-payer environment.
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Affiliation(s)
| | - Eshetu G Atenafu
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Steven Chan
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Vikas Gupta
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Dawn Maze
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Andre Schuh
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Hassan Sibai
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Karen Yee
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
| | - Arron D Schimmer
- Princess Margaret Cancer Center, University Health Network, ON, Toronto, Canada
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Takahashi S. Combination Therapies with Kinase Inhibitors for Acute Myeloid Leukemia Treatment. Hematol Rep 2023; 15:331-346. [PMID: 37367084 DOI: 10.3390/hematolrep15020035] [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: 12/05/2022] [Revised: 03/10/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
Targeting kinase activity is considered to be an attractive therapeutic strategy to overcome acute myeloid leukemia (AML) since aberrant activation of the kinase pathway plays a pivotal role in leukemogenesis through abnormal cell proliferation and differentiation block. Although clinical trials for kinase modulators as single agents remain scarce, combination therapies are an area of therapeutic interest. In this review, the author summarizes attractive kinase pathways for therapeutic targets and the combination strategies for these pathways. Specifically, the review focuses on combination therapies targeting the FLT3 pathways, as well as PI3K/AKT/mTOR, CDK and CHK1 pathways. From a literature review, combination therapies with the kinase inhibitors appear more promising than monotherapies with individual agents. Therefore, the development of efficient combination therapies with kinase inhibitors may result in effective therapeutic strategies for AML.
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Affiliation(s)
- Shinichiro Takahashi
- Division of Laboratory Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai 983-8536, Japan
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7
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Delmas A, Batchelder L, Arora I, Bayet S, Bruhn D, Eberhardt A, Philpott S, Rodriguez-Leboeuf AM. Exploring preferences of different modes of administration of hypomethylating agent treatments among patients with acute myeloid leukemia. Front Oncol 2023; 13:1160966. [PMID: 37223688 PMCID: PMC10202170 DOI: 10.3389/fonc.2023.1160966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/11/2023] [Indexed: 05/25/2023] Open
Abstract
Introduction About half of patients with Acute Myeloid Leukemia (AML) are not eligible for Standard Induction Chemotherapy (SIC). Hypomethylating Agents (HMAs) intravenously (IV) or subcutaneously (SC) in a clinical setting are typically offered as an alternative. However, injectable HMAs may be burdensome for patients given the frequent hospital visits and side effects. This study explored patient treatment preferences for different modes of administration (MOA) and the relative importance of treatment-related characteristics that influence treatment decisions. Methods Semi-structured 1:1 interviews were conducted with 21 adult patients with AML in Germany, the United Kingdom, and Spain, who are not eligible for SIC, had experience with HMAs or were scheduled to be treated with HMAs. After discussing their experience of living with AML and its treatments, patients were presented with hypothetical treatment scenarios to explore their preferences, and a ranking exercise to assess the relative importance of treatment characteristics that influence their treatment-decisions for AML. Results Most patients reported an overall preference for oral administration over parenteral routes (71%), mostly due to convenience. Those preferring IV or SC routes (24%) reasoned with faster speed of action and onsite monitoring. When presented with a hypothetical situation of a patient having to choose between two AML treatments that were identical except for their MOA, the majority preferred the oral route (76%). Regarding treatment characteristics that influence treatment decisions, patients most frequently reported efficacy (86%) and side effects (62%) as important, followed by mode of administration (29%), daily life impacts (24%) and location of treatment (hospital versus home) (14%). However, only efficacy and side effects were rated as number one deciding factors (67% and 19%, respectively). Patients most frequently rated dosing regimen (33%) as least important. Conclusion The insights gained from this study may help support patients with AML who are receiving HMA treatment instead of SIC. A potential oral HMA with similar efficacy and tolerability profiles to injectable HMAs could influence treatment decisions. Furthermore, an oral HMA treatment might decrease the burden of parenteral therapies and improve patients' overall quality of life. However, the extent of influence MOA has on treatment decisions requires further investigation.
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Affiliation(s)
- Audrey Delmas
- Otsuka Pharmaceutical Europe Ltd., Wexham, United Kingdom
| | | | | | | | - David Bruhn
- Otsuka Pharmaceutical Development & Commercialization Inc., Rockville, MD, United States
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8
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Babakhanlou R, Ravandi-Kashani F. Non-intensive acute myeloid leukemia therapies for older patients. Expert Rev Hematol 2023; 16:171-180. [PMID: 36864772 DOI: 10.1080/17474086.2023.2184342] [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: 03/04/2023]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) is an aggressive disease predominantly affecting the elderly population. The elderly population represents a challenging group to treat and the prognosis is generally poor with significantly worse treatment outcomes compared to the younger population. While the goal of treatment for younger fit patients is cure and includes intensive chemotherapy and stem cell transplantation, these strategies are not always feasible for elderly unfit patients due to increased frailty, co-morbidities, and, subsequently, an increased risk of treatment-related toxicity and mortality. AREAS COVERED This review will discuss both patient- and disease-related factors, outline prognostication models and summarize current treatment options, including intensive and less intensive treatment strategies and novel agents. EXPERT OPINION Although recent years have seen major advances in the development of low-intensity therapies, there is still a lack of consensus on the optimal treatment for this patient group. Because of the heterogeneity of the disease, personalizing the treatment strategy is important and curative-oriented approaches should be selected wisely, rather than following a rigid hierarchical algorithm.
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Affiliation(s)
- Rodrick Babakhanlou
- Department of Leukemia, the University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi-Kashani
- Department of Leukemia, the University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
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9
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Castaneda-Avila MA, Suárez Ramos T, Torres-Cintrón CR, Cotto-Santana LA, Tortolero-Luna G, Ortiz-Ortiz KJ. Induction Therapy and Survival for Acute Myeloid Leukemia in Hispanic Adults from Puerto Rico. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e922-e930. [PMID: 35853812 DOI: 10.1016/j.clml.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is the most common type of leukemia in adults. There are no previous studies evaluating AML treatment patterns in Puerto Rico. We describe the first-line therapy patterns and survival of patients diagnosed with AML in Puerto Rico using the Puerto Rico Central Cancer Registry Health Insurance Linkage Database (2011-2015). METHODS We describe patient characteristics according to intensive, non-intensive, and non-treatment status. We used Cox proportional hazard models to evaluate the factors associated with the risk of death stratified by intensive and non-intensive therapy. For this study, 385 patients with AML were included. RESULTS The mean age was 67 years old and 50.1% were female. Nearly half of AML patients (46.8%) received intensive treatment, 23.6% received non-intensive treatment, and 26.2% did not receive treatment. The overall 3-year survival rate was 17.9%. Among those who received intensive therapy, the risk of death among females was lower than males (hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.44-0.93). Patients 60 years or older who received intensive treatment had a higher risk of death than younger patients (HR: 1.67, 95% CI: 1.09-2.55). Patients with poor/adverse risk receiving intensive (HR: 3.43, 95% CI: 1.76-6.69) or non-intensive (HR: 4.32, 95% CI: 1.66-11.28) treatment had a higher risk of death than patients with a favorable risk category. CONCLUSION Our findings are the first step to monitor the quality of care of patients with AML in Puerto Rico, particularly related to the administration of appropriate induction therapies, which is one of the most important predictors of AML survival.
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Affiliation(s)
- Maira A Castaneda-Avila
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA
| | - Tonatiuh Suárez Ramos
- Puerto Rico Central Cancer Registry, University of Puerto Rico, Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Carlos R Torres-Cintrón
- Puerto Rico Central Cancer Registry, University of Puerto Rico, Comprehensive Cancer Center, San Juan, Puerto Rico
| | | | - Guillermo Tortolero-Luna
- Puerto Rico Central Cancer Registry, University of Puerto Rico, Comprehensive Cancer Center, San Juan, Puerto Rico; Division of Cancer Control and Population Sciences, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Karen J Ortiz-Ortiz
- Puerto Rico Central Cancer Registry, University of Puerto Rico, Comprehensive Cancer Center, San Juan, Puerto Rico; Division of Cancer Control and Population Sciences, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico; Department of Health Services Administration, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico.
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10
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Nelson AM, Amonoo HL, Kavanaugh AR, Webb JA, Jackson VA, Rice J, Lavoie MW, Fathi AT, Brunner AM, Greer JA, Temel JS, El-Jawahri A, LeBlanc TW. Palliative care and coping in patients with acute myeloid leukemia: Mediation analysis of data from a randomized clinical trial. Cancer 2021; 127:4702-4710. [PMID: 34460937 DOI: 10.1002/cncr.33886] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND It has been shown previously that integrated palliative care for patients with acute myeloid leukemia (AML) during intensive chemotherapy leads to improvements in quality of life (QOL) and mood. Coping has been shown to mediate palliative care interventions in advanced cancer; the mechanisms by which improvements occur among patients with AML remain unexplained. METHODS The authors conducted a secondary analysis of data from a multisite randomized trial of integrated palliative and oncology care (IPC; n = 86) versus usual care (n = 74) for hospitalized patients with AML undergoing intensive chemotherapy. IPC patients met with palliative care at least twice weekly during their initial and subsequent hospitalizations. Patients completed the Functional Assessment of Cancer Therapy-Leukemia, the Hospital Anxiety and Depression Scale, and the Brief Coping Orientation to Problems Experienced Inventory to assess QOL, mood, and coping at the baseline and at weeks 2, 4, 12, and 24. Linear regression models were used to assess the effect of IPC on coping. Causal mediation regression models were used to examine whether changes in coping mediated intervention effects on patient-reported outcomes at week 2. RESULTS One hundred sixty eligible patients (68.1%) were enrolled. Those randomized to IPC reported improvements in approach-oriented coping (P < .01) and reductions in avoidant coping (P < .05). These changes in coping mediated the intervention effects on QOL (95% CI, 2.14-13.63), depression (95% CI, -2.05 to -0.27), and anxiety symptoms (95% CI, -1.25 to -0.04). Changes in approach-oriented and avoidant coping accounted for 78% of the total palliative care intervention effect on QOL, for 66% of the effect on depression, and for 35% of the effect on anxiety symptoms. CONCLUSIONS Palliative care integrated during intensive chemotherapy for patients with AML facilitates coping strategy use. Improvement in coping skills accounts for a substantial proportion of the effect from a palliative care intervention on patient-reported outcomes.
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Affiliation(s)
- Ashley M Nelson
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Hermioni L Amonoo
- Harvard Medical School, Boston, Massachusetts.,Brigham and Women's Hospital, Boston, Massachusetts
| | - Alison R Kavanaugh
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jason A Webb
- Duke University School of Medicine, Durham, North Carolina.,Oregon Health and Sciences University, Portland, Oregon
| | - Vicki A Jackson
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Julia Rice
- Massachusetts General Hospital, Boston, Massachusetts
| | | | - Amir T Fathi
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Andrew M Brunner
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Foran JM. Can venetoclax-based therapy replace 7+3 induction in fit older adults with AML? Best Pract Res Clin Haematol 2021; 34:101335. [PMID: 34865692 DOI: 10.1016/j.beha.2021.101335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Older patients with acute myeloid leukemia (AML) face a dismal prognosis. Although venetoclax-based therapy has led to improved outcomes among unfit older patients with AML, it is not curative and its efficacy and long-term outcomes among fit older patients is unclear. This review provides insights into factors that influence treatment choices among older patients with AML and what we would need to know for venetoclax-based therapy to replace standard intensive 7 + 3 induction therapy.
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Affiliation(s)
- James M Foran
- Mayo Clinic Cancer Center, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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12
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Evolving Therapeutic Approaches for Older Patients with Acute Myeloid Leukemia in 2021. Cancers (Basel) 2021; 13:cancers13205075. [PMID: 34680226 PMCID: PMC8534216 DOI: 10.3390/cancers13205075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The better understanding of disease biology, the availability of new effective drugs and the increased awareness of patients’ heterogeneity in terms of fitness and personal expectations has made the current treatment paradigm of AML in the elderly very challenging. Here, we discuss the evolving criteria used to define eligibility for induction chemotherapy and transplantation, the introduction of new agents in the treatment of patients with very different clinical conditions, the implications of precision medicine and the importance of quality of life and supportive care, proposing a simplified algorithm that we follow in 2021. Abstract Acute myeloid leukemia (AML) in older patients is characterized by unfavorable prognosis due to adverse disease features and a high rate of treatment-related complications. Classical therapeutic options range from intensive chemotherapy in fit patients, potentially followed by allogeneic hematopoietic cell transplantation (allo-HCT), to hypomethylating agents or palliative care alone for unfit/frail ones. In the era of precision medicine, the treatment paradigm of AML is rapidly changing. On the one hand, a plethora of new targeted drugs with good tolerability profiles are becoming available, offering the possibility to achieve a prolonged remission to many patients not otherwise eligible for more intensive therapies. On the other hand, better tools to assess patients’ fitness and improvements in the selection and management of those undergoing allo-HCT will hopefully reduce treatment-related mortality and complications. Importantly, a detailed genetic characterization of AML has become of paramount importance to choose the best therapeutic option in both intensively treated and unfit patients. Finally, improving supportive care and quality of life is of major importance in this age group, especially for the minority of patients that are still candidates for palliative care because of very poor clinical conditions or unwillingness to receive active treatments. In the present review, we discuss the evolving approaches in the treatment of older AML patients, which is becoming increasingly challenging following the advent of new effective drugs for a very heterogeneous and complex population.
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Kabra M, Margotto L, Manuguid F. Real-world treatment patterns and healthcare resource use in patients with acute myeloid leukemia in Western Europe. Future Oncol 2021; 17:2769-2784. [PMID: 33881356 DOI: 10.2217/fon-2021-0179] [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: 11/21/2022] Open
Abstract
Aim: Assess treatment patterns and healthcare resource utilization (HRU) in patients with treatment-naive (TN) or relapsed/refractory (R/R) acute myeloid leukemia (AML) in Europe. Patients & methods: Cross-sectional, retrospective, web-based survey of AML-treating healthcare professionals (HCPs) in 12 European countries. Results: 320 HCPs provided information on 1280 TN or R/R patients. Patients ineligible versus eligible for intensive induction therapy required more general practitioner visits (4.1 vs 2.4), more uses of healthcare-related transport (6.9 vs 4.5), but less hospitalization (11.4 vs 27.5 days). Differences were observed in HRU and treatment patterns across countries. Conclusions: This analysis of 'real-world' patients with TN or R/R AML in Europe demonstrates substantial healthcare use, including higher use of resources in patients ineligible for intensive induction therapy.
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Kolesnikova MA, Sen'kova AV, Pospelova TI, Zenkova MA. Drug responsiveness of leukemic cells detected in vitro at diagnosis correlates with therapy response and survival in patients with acute myeloid leukemia. Cancer Rep (Hoboken) 2021; 4:e1362. [PMID: 33675187 PMCID: PMC8388166 DOI: 10.1002/cnr2.1362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/29/2021] [Accepted: 02/17/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) is the most common acute leukemia in adults, and chemotherapy remains the most commonly used treatment approach for this group of hematological disorders. Drug resistance is one of the predictors of unfavorable prognosis for leukemia patients. AIM The purpose of this study was to perform a retrospective analysis of the survival rate in AML patients according to age, tumor status, and chemotherapy regimen received and to analyze the therapy response of AML patients depending on the treatment received, initial responsiveness of tumor cells to chemotherapeutic drugs measured in vitro at diagnosis and expression of immunological markers. METHODS The survival of AML patients (n = 127) was analyzed using the Kaplan-Meier method. Drug sensitivity of tumor cells of AML patients (n = 37) and the expression of immunological markers were evaluated by the WST test and flow cytometry, respectively. Correlation analysis was performed using Spearman's rank order correlation coefficient. RESULTS We found the treatment regimen to be the defining factor in the patient survival rate. In addition, the initial responsiveness of tumor cells to chemotherapeutic drugs measured in vitro at diagnosis correlated with the therapy response of AML: patients with high tumor cell sensitivity to particular cytotoxic drugs demonstrated a good response to treatment including these drugs, and patients with initial resistance of tumor cells to a particular chemotherapeutic agents and received it according to the clinical protocols demonstrated a poor response to antitumor therapy. Correlations of drug resistance in leukemic cells with the expression of immature and aberrant immunophenotype markers as established unfavorable prognostic factors confirm our assumption. CONCLUSION The evaluation of the responsiveness of tumor cells to chemotherapy in vitro at diagnosis can be a useful tool for predicting the response of leukemia patients to planned chemotherapy.
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Affiliation(s)
- Maria A Kolesnikova
- Institute of Chemical Biology and Fundamental Medicine SB RAS, Novosibirsk, Russia.,Novosibirsk Hematology Center, Novosibirsk, Russia
| | | | | | - Marina A Zenkova
- Institute of Chemical Biology and Fundamental Medicine SB RAS, Novosibirsk, Russia
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El-Jawahri A, LeBlanc TW, Kavanaugh A, Webb JA, Jackson VA, Campbell TC, O'Connor N, Luger SM, Gafford E, Gustin J, Bhatnagar B, Walker AR, Fathi AT, Brunner AM, Hobbs GS, Nicholson S, Davis D, Addis H, Vaughn D, Horick N, Greer JA, Temel JS. Effectiveness of Integrated Palliative and Oncology Care for Patients With Acute Myeloid Leukemia: A Randomized Clinical Trial. JAMA Oncol 2021; 7:238-245. [PMID: 33331857 PMCID: PMC7747042 DOI: 10.1001/jamaoncol.2020.6343] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Patients with acute myeloid leukemia (AML) receiving intensive chemotherapy experience substantial decline in their quality of life (QOL) and mood during their hospitalization for induction chemotherapy and often receive aggressive care at the end of life (EOL). However, the role of specialty palliative care for improving the QOL and care for this population is currently unknown. OBJECTIVE To assess the effect of integrated palliative and oncology care (IPC) on patient-reported and EOL outcomes in patients with AML. DESIGN, SETTING, AND PARTICIPANTS We conducted a multisite randomized clinical trial of IPC (n = 86) vs usual care (UC) (n = 74) for patients with AML undergoing intensive chemotherapy. Data were collected from January 2017 through July 2019 at 4 tertiary care academic hospitals in the United States. INTERVENTIONS Patients assigned to IPC were seen by palliative care clinicians at least twice per week during their initial and subsequent hospitalizations. MAIN OUTCOMES AND MEASURES Patients completed the 44-item Functional Assessment of Cancer Therapy-Leukemia scale (score range, 0-176) to assess QOL; the 14-item Hospital Anxiety and Depression Scale (HADS), with subscales assessing symptoms of anxiety and depression (score range, 0-21); and the PTSD Checklist-Civilian version to assess posttraumatic stress disorder (PTSD) symptoms (score range, 17-85) at baseline and weeks 2, 4, 12, and 24. The primary end point was QOL at week 2. We used analysis of covariance adjusting and mixed linear effect models to evaluate patient-reported outcomes. We used Fisher exact test to compare patient-reported discussion of EOL care preferences and receipt of chemotherapy in the last 30 days of life. RESULTS Of 235 eligible patients, 160 (68.1%) were enrolled; of the 160 participants, the median (range) age was 64.4 (19.7-80.1) years, and 64 (40.0%) were women. Compared with those receiving UC, IPC participants reported better QOL (adjusted mean score, 107.59 vs 116.45; P = .04), and lower depression (adjusted mean score, 7.20 vs 5.68; P = .02), anxiety (adjusted mean score, 5.94 vs 4.53; P = .02), and PTSD symptoms (adjusted mean score, 31.69 vs 27.79; P = .01) at week 2. Intervention effects were sustained to week 24 for QOL (β, 2.35; 95% CI, 0.02-4.68; P = .048), depression (β, -0.42; 95% CI, -0.82 to -0.02; P = .04), anxiety (β, -0.38; 95% CI, -0.75 to -0.01; P = .04), and PTSD symptoms (β, -1.43; 95% CI, -2.34 to -0.54; P = .002). Among patients who died, those receiving IPC were more likely than those receiving UC to report discussing EOL care preferences (21 of 28 [75.0%] vs 12 of 30 [40.0%]; P = .01) and less likely to receive chemotherapy near EOL (15 of 43 [34.9%] vs 27 of 41 [65.9%]; P = .01). CONCLUSIONS AND RELEVANCE In this randomized clinical trial of patients with AML, IPC led to substantial improvements in QOL, psychological distress, and EOL care. Palliative care should be considered a new standard of care for patients with AML. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02975869.
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Affiliation(s)
- Areej El-Jawahri
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | - Alison Kavanaugh
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Jason A Webb
- Duke University School of Medicine, Durham, North Carolina
| | - Vicki A Jackson
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | | | - Amir T Fathi
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Andrew M Brunner
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Gabriela S Hobbs
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Showly Nicholson
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Debra Davis
- Duke University School of Medicine, Durham, North Carolina
| | | | | | - Nora Horick
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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Takahashi S. Current Understandings of Myeloid Differentiation Inducers in Leukemia Therapy. Acta Haematol 2020; 144:380-388. [PMID: 33221808 DOI: 10.1159/000510980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022]
Abstract
Differentiation therapy using all-trans retinoic acid for acute promyelocytic leukemia (APL) is well established. Several attempts have been made to treat non-APL, AML patients by employing differentiation inducers, such as hypomethylating agents (HMAs), and low-dose cytarabine (Ara-C) (LDAC), with encouraging results. Other than HMAs and LDAC, various inducers of myeloid cell differentiation have been identified. This review describes and categorizes these inducers, which include glycosylation modifiers, epigenetic modifiers, vitamin derivatives, cytokines, and chemotherapeutic agents. Some of these inducers are currently being used in clinical trials. I highlight the potential applications of glycosylation modifiers and epigenetic modifiers, which are attracting increasing attention in their use as differentiation therapy against AML. Among the agents described in this review, epigenomic modifiers seem particularly promising, and particular attention should also be paid to glycosylation modifiers. These drugs may signal a new era for AML differentiation therapy.
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Affiliation(s)
- Shinichiro Takahashi
- Division of Laboratory Medicine, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai, Japan,
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