1
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Copland M, Ariti C, Thomas IF, Upton L, Sydenham M, Mehta P, Islam S, Kjeldsen L, Burnett AK, Hills RK, Russell N, Dennis M. A randomised evaluation of low-dose cytosine arabinoside plus lenalidomide versus single-agent low-dose cytosine arabinoside in older patients with acute myeloid leukaemia: Results from the LI-1 trial. Br J Haematol 2024; 204:871-876. [PMID: 38016651 DOI: 10.1111/bjh.19220] [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: 09/01/2023] [Revised: 10/26/2023] [Accepted: 11/10/2023] [Indexed: 11/30/2023]
Abstract
Improving outcomes for older patients with acute myeloid leukaemia remains an unmet need. As part of the LI-1 trial, we evaluated lenalidomide (LEN) in combination with low-dose cytosine arabinoside (LDAC) in patients aged >60 years unfit for intensive therapy and compared this to LDAC alone. Two hundred and two patients, randomised 1:1, were evaluable. Overall response rate (CR + CRi) was higher for LDAC + LEN versus LDAC (26% and 13.7% respectively p = 0.031). However, there was no difference in overall survival between the arms (14% and 11.5% at 2 years for LDAC + LEN and LDAC respectively). The addition of LEN was associated with increased toxicity and supportive care requirements.
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Affiliation(s)
- Mhairi Copland
- Paul O'Gorman Leukaemia Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Cono Ariti
- Centre for Trials Research, Cardiff University, Cardiff, UK
- Oxon Epidemiology, Madrid, Spain
| | - Ian F Thomas
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Laura Upton
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mia Sydenham
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Priyanka Mehta
- University Hospitals of Bristol and Weston NHS Trust, Bristol, UK
| | - Shahid Islam
- Department of Haematology, Waikato Hospital, Hamilton, New Zealand
| | - Lars Kjeldsen
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Alan K Burnett
- Paul O'Gorman Leukaemia Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Robert K Hills
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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2
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Santinelli E, Pascale MR, Xie Z, Badar T, Stahl MF, Bewersdorf JP, Gurnari C, Zeidan AM. Targeting apoptosis dysregulation in myeloid malignancies - The promise of a therapeutic revolution. Blood Rev 2023; 62:101130. [PMID: 37679263 DOI: 10.1016/j.blre.2023.101130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/09/2023]
Abstract
In recent years, the therapeutic landscape of myeloid malignancies has been completely revolutionized by the introduction of several new drugs, targeting molecular alterations or pathways crucial for leukemia cells survival. Particularly, many agents targeting apoptosis have been investigated in both pre-clinical and clinical studies. For instance, venetoclax, a pro-apoptotic agent active on BCL-2 signaling, has been successfully used in the treatment of acute myeloid leukemia (AML). The impressive results achieved in this context have made the apoptotic pathway an attractive target also in other myeloid neoplasms, translating the experience of AML. Therefore, several drugs are now under investigation either as single or in combination strategies, due to their synergistic efficacy and capacity to overcome resistance. In this paper, we will review the mechanisms of apoptosis and the specific drugs currently used and under investigation for the treatment of myeloid neoplasia, identifying critical research necessities for the upcoming years.
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Affiliation(s)
- Enrico Santinelli
- Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
| | - Maria Rosaria Pascale
- Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Zhuoer Xie
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Talha Badar
- Division of Hematology and Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Maximilian F Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Jan P Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carmelo Gurnari
- Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, CT, USA.
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3
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Blackwell SE, Schönbrodt FD, Woud ML, Wannemüller A, Bektas B, Braun Rodrigues M, Hirdes J, Stumpp M, Margraf J. Demonstration of a 'leapfrog' randomized controlled trial as a method to accelerate the development and optimization of psychological interventions. Psychol Med 2023; 53:6113-6123. [PMID: 36330836 PMCID: PMC10520605 DOI: 10.1017/s0033291722003294] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The scale of the global mental health burden indicates the inadequacy not only of current treatment options, but also the pace of the standard treatment development process. The 'leapfrog' trial design is a newly-developed simple Bayesian adaptive trial design with potential to accelerate treatment development. A first leapfrog trial was conducted to provide a demonstration and test feasibility, applying the method to a low-intensity internet-delivered intervention targeting anhedonia. METHODS At the start of this online, single-blind leapfrog trial, participants self-reporting depression were randomized to an initial control arm comprising four weeks of weekly questionnaires, or one of two versions of a four-week cognitive training intervention, imagery cognitive bias modification (imagery CBM). Intervention arms were compared to control on an ongoing basis via sequential Bayesian analyses, based on a primary outcome of anhedonia at post-intervention. Results were used to eliminate and replace arms, or to promote them to become the control condition based on pre-specified Bayes factor and sample size thresholds. Two further intervention arms (variants of imagery CBM) were added into the trial as it progressed. RESULTS N = 188 participants were randomized across the five trial arms. The leapfrog methodology was successfully implemented to identify a 'winning' version of the imagery CBM, i.e. the version most successful in reducing anhedonia, following sequential elimination of the other arms. CONCLUSIONS The study demonstrates feasibility of the leapfrog design and provides a foundation for its adoption as a method to accelerate treatment development in mental health. Registration: clinicaltrials.gov, NCT04791137.
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Affiliation(s)
- Simon E. Blackwell
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Felix D. Schönbrodt
- Department of Psychology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Marcella L. Woud
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Andre Wannemüller
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Büsra Bektas
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Max Braun Rodrigues
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Josefine Hirdes
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Michael Stumpp
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Jürgen Margraf
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
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4
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Rezazadeh A, Deininger M, Atallah E. Proposals for Clinical Trials in Chronic Myelomonocytic Leukemia. Curr Treat Options Oncol 2023:10.1007/s11864-023-01105-z. [PMID: 37300657 DOI: 10.1007/s11864-023-01105-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] [Accepted: 04/19/2023] [Indexed: 06/12/2023]
Abstract
OPINION STATEMENT Chronic myelomonocytic leukemia (CMML) is a clonal hematologic malignancy of mostly older individuals that exhibits both myelodysplastic and myeloproliferative features. CMML presentation and outcome are variable, reflecting genetic and clinical heterogeneity. Hypomethylating agents are the mainstay of therapy but induce complete remissions in less than 20% of patients and do not prolong survival compared to hydroxyurea. Allogeneic stem cell transplant (ASCT) is potentially curative, but few patients qualify due to advanced age and/or comorbidities. Work of the past several years has identified key molecular pathways that drive disease proliferation and transformation to acute leukemia, including JAK/STAT and MAPK signaling and epigenetic dysregulation. There is increasingly compelling evidence that inflammation is a major driver of CMML progression. Thus far however, this mechanistic knowledge has not yet been translated into improved outcomes, suggesting that fundamentally new approaches are required. In this review, we discuss the disease course, new classifications, and current treatment landscape of CMML. We review ongoing clinical studies and discuss options for rationally based future clinical trials.
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Affiliation(s)
| | | | - Ehab Atallah
- Medical College of Wisconsin, Milwaukee, WI, USA
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5
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Mussai F, De Santo C, Cheng P, Thomas IF, Ariti C, Upton L, Scarpa U, Stavrou V, Sydenham M, Burnett AK, Knapper SK, Mehta P, McMullin MF, Copland M, Russell NH, Dennis M. A randomised evaluation of low-dose Ara-C plus pegylated recombinant arginase BCT-100 versus low dose Ara-C in older unfit patients with acute myeloid leukaemia: Results from the LI-1 trial. Br J Haematol 2023; 200:573-578. [PMID: 36413792 DOI: 10.1111/bjh.18560] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/31/2022] [Accepted: 10/31/2022] [Indexed: 11/23/2022]
Abstract
The survival of acute myeloid leukaemia (AML) patients aged over 60 has been suboptimal historically, whether they are treated using hypomethylating agents, low-dose cytarabine (LDAC) or venetoclax-based regimens. Progress is being made, however, for subgroups with favourable molecular or cytogenetic findings. Arginine metabolism plays a key role in AML pathophysiology. We report the only randomised study of LDAC with recombinant arginase BCT-100 versus LDAC alone in older AML patients unsuitable for intensive therapy. Eighty-three patients were randomised to the study. An overall response rate was seen in 19.5% (all complete remission [CR]) and 15% (7.5% each in CR and CR without evidence of adequate count recovery [CRi]) of patients in the LDAC+BCT-100 and LDAC arms respectively (odds ratio 0.73, confidence interval 0.23-2.33; p = 0.592). No significant difference in overall or median survival between treatment arms was seen. The addition of BCT-100 to LDAC was well tolerated.
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Affiliation(s)
- Francis Mussai
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Carmela De Santo
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Paul Cheng
- Bio-Cancer Treatment International, Hong Kong City, Hong Kong
| | - Ian F Thomas
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Cono Ariti
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Laura Upton
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Ugo Scarpa
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Victoria Stavrou
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Mia Sydenham
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Alan K Burnett
- Paul O'Gorman Leukaemia Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, UK
| | | | | | | | - Mhairi Copland
- Centre for Trials Research, Cardiff University, Cardiff, UK
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6
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Morales-Ortega A, Farfán-Sedano AI, San Martín-López JV, Escribá-Bárcena A, Jaenes-Barrios B, Madroñal-Cerezo E, Llarena-Barroso C, Mesa-Plaza N, Frutos-Pérez B, Ruiz-Giardín JM, Duarte-Millán MÁ, Piedrabuena-García SI, Carpintero-García L, Canalejo-Castrillero E, Mora-Hernández B, García-Parra CJ, Magro-García HA, Algaba-García A, Hernández-Muniesa B, Nasarre-López B, Ontañón-Nasarre A, Domínguez-García MJ, Gómez-Santos D, Prieto-Menchero S, García de Tena J, Bermejo F, García-Gil M, Gonzalo-Pascua S, Bernal-Bello D. Baricitinib or imatinib in hospitalized COVID-19 patients: Results from COVINIB, an exploratory randomized clinical trial. J Med Virol 2023; 95:e28495. [PMID: 36639911 DOI: 10.1002/jmv.28495] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/02/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023]
Abstract
Baricitinib and imatinib are considered therapies for coronavirus disease 2019 (COVID-19), but their ultimate clinical impact remains to be elucidated, so our objective is to determine whether these kinase inhibitors provide benefit when added to standard care in hospitalized COVID-19 patients. Phase-2, open-label, randomized trial with a pick-the-winner design conducted from September 2020 to June 2021 in a single Spanish center. Hospitalized adults with COVID-19 pneumonia and a symptom duration ≤10 days were assigned to 3 arms: imatinib (400 mg qd, 7 days) plus standard-care, baricitinib (4 mg qd, 7 days) plus standard-care, or standard-care alone. Primary outcome was time to clinical improvement (discharge alive or a reduction of 2 points in an ordinal scale of clinical status) compared on a day-by-day basis to identify differences ≥15% between the most and least favorable groups. Secondary outcomes included oxygenation and ventilatory support requirements, additional therapies administered, all-cause mortality, and safety. One hundred and sixty-five patients analyzed. Predefined criteria for selection of the most advantageous arm were met for baricitinib, but not for imatinib. However, no statistically significant differences were observed in formal analysis, but a trend toward better results in patients receiving baricitinib was found compared to standard care alone (hazard ratio [HR] for clinical improvement: 1.41, 95% confidence intervals [CI]: 0.96-2.06; HR for discontinuing oxygen: 1.46, 95% CI: 0.94-2.28). No differences were found regarding additional therapies administered or safety. Baricitinib plus standard care showed better results for hospitalized COVID-19 patients, being the most advantageous therapeutic strategy among those proposed in this exploratory clinical trial.
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Affiliation(s)
- Alejandro Morales-Ortega
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain.,Department of Medicine, Universidad de Alcalá, Madrid, Spain
| | | | | | | | | | - Elena Madroñal-Cerezo
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Cristina Llarena-Barroso
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Nieves Mesa-Plaza
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Begoña Frutos-Pérez
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | | | | | | | - Eduardo Canalejo-Castrillero
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain.,Department of Medical Specialties and Public Health, Universidad Rey Juan Carlos, Madrid, Spain
| | - Belén Mora-Hernández
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | | | - Alicia Algaba-García
- Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | - Berta Nasarre-López
- Clinical Research Program, Spanish National Cancer Research Centre (CNIO)-Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Ana Ontañón-Nasarre
- Department of Hospital Pharmacy, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | - Dulce Gómez-Santos
- Department of Radiology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | | | | | - Fernando Bermejo
- Department of Medical Specialties and Public Health, Universidad Rey Juan Carlos, Madrid, Spain.,Department of Gastroenterology, Hospital Universitario de Fuenlabrada, Madrid, Spain.,Instituto de Investigación Sanitaria Hospital La Paz (IdiPAZ), Madrid, Spain
| | - Mario García-Gil
- Department of Hospital Pharmacy, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Sonia Gonzalo-Pascua
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain.,Department of Medical Specialties and Public Health, Universidad Rey Juan Carlos, Madrid, Spain
| | - David Bernal-Bello
- Department of Internal Medicine, Hospital Universitario de Fuenlabrada, Madrid, Spain
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7
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Dennis M, Copland M, Kaur H, Kell J, Nikolousis E, Mehta P, Palanicawandar R, Potter V, Raj K, Thomas I, Wilson A. Management of older patients with frailty and acute myeloid leukaemia: A British Society for Haematology good practice paper. Br J Haematol 2022; 199:205-221. [PMID: 36000944 DOI: 10.1111/bjh.18369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Mike Dennis
- The Christie NHS Foundation Trust, Manchester, UK
| | - Mhairi Copland
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Harpreet Kaur
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Priyanka Mehta
- University Hospitals of Bristol and Weston NHS Trust, Bristol, UK
| | | | | | - Kavita Raj
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Andrew Wilson
- University College London Hospitals NHS Foundation Trust, London, UK
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8
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Wu J, Pan H, Hsu CW. Two-stage screened selection designs for randomized phase II trials with time-to-event endpoints. Biom J 2022; 64:1207-1218. [PMID: 35661226 DOI: 10.1002/bimj.202100305] [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: 09/26/2021] [Revised: 04/05/2022] [Accepted: 04/12/2022] [Indexed: 11/09/2022]
Abstract
Phase II exploratory multiarm studies that randomize among new treatments are found to be broadly useful and appear to be of value both scientifically and logistically, especially in the areas of unmet needs, for example, pediatric cancer. This multiarm design also has a faster recruitment rate because it provides patients with more treatment choices than traditional two-arm randomized controlled trials do. In contrast to direct formal comparisons in multiarm multistage designs, for example, umbrella or platform designs, the screened selection design (SSD) recommends using a promising treatment arm by ranking according to the effect size, which often needs lesser sample sizes than the former. In this paper, the usefulness of the phase II SSD design is exemplified by three real trials. However, the existing SSD methods can only deal with binary endpoints. Motivated by the real trials in the authors' respective institutions, we propose using the two-stage SSD and its variant for randomized phase II trials with the time-to-event endpoint. The proposed methods not only provide a high probability of selecting a superior treatment arm but also control the type I error rate for testing the efficacy of each treatment arm versus a common external control. Sample size calculations have been derived and simulation studies demonstrate desirable operating characteristics. The proposed design has been used for designing three real trials. An R package frequentistSSD has been developed and is freely accessible for practitioners.
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Affiliation(s)
- Jianrong Wu
- Biostatistics Shared Resource Facility, Comprehensive Cancer Center University of New Mexico, Albuquerque, NM, USA
| | - Haitao Pan
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Chia-Wei Hsu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
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9
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Wei AH, Seymour JF. Enhancing our chances of picking a winner in higher-risk myelodysplastic syndromes. Br J Haematol 2022; 198:415-418. [PMID: 35544384 DOI: 10.1111/bjh.18240] [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: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022]
Abstract
Hypomethylating agents remain the current standard of care for patients with higher-risk myelodysplastic syndromes. Adès et al. report outcomes from a randomised 'pick-a-winner' study design that examined the addition of either lenalidomide, valproic acid or idarubicin in combination with azacitidine, compared to azacitidine alone. Commentary on: Adès et al. A randomised phase II study of azacitidine (AZA) alone or with lenalidomide (LEN), valproic acid (VPA) or idarubicin (IDA) in higher-risk MDS: GFM's 'pick a winner' trial, with the impact of somatic mutations. Br J Haematol 2022 (Online ahead of print). doi: 10.1111/bjh.18193.
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Affiliation(s)
- Andrew H Wei
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital and the University of Melbourne, Melbourne, Victoria, Australia.,The Walter and Eliza Hall Institute of Medical Research, Parkville, Melbourne, Victoria, Australia
| | - John F Seymour
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital and the University of Melbourne, Melbourne, Victoria, Australia
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10
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Short NJ, Borthakur G, Pemmaraju N, Dinardo CD, Kadia TM, Jabbour E, Konopleva M, Macaron W, Ning J, Ma J, Pierce S, Alvarado Y, Sasaki K, Takahashi K, Estrov Z, Masarova L, Issa GC, Montalban-Bravo G, Andreeff M, Burger JA, Miller D, Alexander L, Naing A, Garcia-Manero G, Ravandi F, Daver N. A multi-arm phase Ib/II study designed for rapid, parallel evaluation of novel immunotherapy combinations in relapsed/refractory acute myeloid leukemia. Leuk Lymphoma 2022; 63:2161-2170. [PMID: 35442137 DOI: 10.1080/10428194.2022.2062345] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We conducted a phase Ib/II multi-arm, parallel cohort study to simultaneously evaluate various immunotherapeutic agents and combinations in relapsed/refractory acute myeloid leukemia (AML). Overall, 50 patients were enrolled into one of 6 arms: (A) single agent PF-04518600 (OX40 agonist monoclonal antibody), (B) azacitidine + venetoclax + gemtuzumab ozogamicin (GO), (C) azacitidine + avelumab (anti-PD-L1 monoclonal antibody) + GO, (D) azacitidine + venetoclax + avelumab, (E) azacitidine + avelumab + PF-04518600, and (F) glasdegib + GO. Among all regimens evaluated, azacitidine + venetoclax + GO appeared most promising. In this arm, the CR/CRi rates among venetoclax-naïve and prior venetoclax-exposed patients were 50% and 22%, respectively, and the 1-year OS rate was 31%. This study shows the feasibility of a conducting a multi-arm trial to efficiently and simultaneously evaluate novel therapies in AML, a needed strategy in light of the plethora of emerging therapies. This trial was registered at www.clinicaltrials.gov as NCT03390296.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney D Dinardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Walid Macaron
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Junsheng Ma
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yesid Alvarado
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Michael Andreeff
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Darla Miller
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lynette Alexander
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Aung Naing
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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11
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Adès L, Duployez N, Guerci-Bresler A, Laribi K, Peterlin P, Vey N, Thepot S, Wickenhauser S, Zerazhi H, Stamatoullas A, Wattel E, Recher C, Toma A, Dimicoli-Salazar S, Braun T, Beyne-Rauzy O, Marolleau JP, Cheze S, Park S, Cluzeau T, Nimubona S, Bordessoule D, Benramdane R, Quesnel B, Amé S, de Botton S, Chermat F, Preudhomme C, Chevret S, Fenaux P. A randomised phase II study of azacitidine (AZA) alone or with Lenalidomide (LEN), Valproic acid (VPA) or Idarubicin (IDA) in higher-Risk MDS or low blast AML: GFM's "pick a winner" trial, with the impact of somatic mutations. Br J Haematol 2022; 198:535-544. [PMID: 35438802 DOI: 10.1111/bjh.18193] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022]
Abstract
In order to improve the outcome observed with azacitidine (AZA) in higher-risk Myelodysplastic syndrome (MDS), its combination with other drugs in MDS must be evaluated. So far, no combination has not been shown to be more effective than AZA alone. AZA-PLUS was a phase II trial that, in a "pick a winner" approach, randomly assigned patients with higher-risk MDS, CMML and low blast count AML to: AZA; AZA plus lenalidomide; AZA plus Valproic Acid or AZA plus Idarubicin. 322 patients were included. After six cycles, 69 (21.4%) CR + PR were observed with no benefit from any combination. Median EFS and OS were 17.2 and 19.7 months in the whole cohort, respectively, with no difference across randomised arms. Infection and rates of hospitalisation during the first six cycles were higher in the AZA-LEN And AZA-IDA arm, related to increased myelosuppression. Factors associated with better response were IPSS, favourable or intermediate karyotype, haemoglobin, lower circulating blast count, fibrinogen level and lower LDH, while poorer survival was seen in therapy-related MDS and, in the case of TP53, PTPN11 or CSF3R mutation. The combinations used did not improve the outcome obtained with AZA alone. However, our "pick a winner" randomised strategy may remain useful with potentially more active drugs to be tested in combination with AZA.
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Affiliation(s)
- Lionel Adès
- Hématologie Sénior Hôpital Saint Louis, Assistance publique hôpitaux de paris, and Université de Paris Cité, Paris, France
| | - Nicolas Duployez
- Lille University Hospital, Lille and INSERM UMR-S 1277, Lille, France
| | | | | | - Pierre Peterlin
- Hematology Department, Nantes University Hospital, Nantes, France
| | | | - Sylvain Thepot
- Hematology Department, Angers University Hospital, Angers, France
| | | | - Hacene Zerazhi
- Hematology Department, Centre Hospitalier d'Avignon, Avignon, Fran, France
| | | | - Eric Wattel
- Hematology Department, Lyon University Hospital, Lyon, France
| | - Christian Recher
- Hematology Department, Toulouse University Hospital, Toulouse, France
| | - Andrea Toma
- Hematology Department, Creteil, University Hospital, Creteil, France
| | | | - Thorsten Braun
- Hematology Department, Hôpital Avicenne Assistance publique hôpitaux de paris, and Université Paris 13, Bobigny, France
| | - Odile Beyne-Rauzy
- Hematology Department, Toulouse University Hospital, Toulouse, France
| | | | - Stéphane Cheze
- Hematology Department, Caen, University Hospital, Caen, France
| | - Sophie Park
- Hematology Department, Grenoble, University Hospital, Grenoble, France
| | - Thomas Cluzeau
- Hematology Department, Nice, University Hospital, Nice, France
| | | | | | - Riad Benramdane
- Department of Hematology, Centre Hospitalier, Pontoise, France
| | - Bruno Quesnel
- Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020, UMR-S 1277, Lille, France
| | - Shanti Amé
- Hematology Department, Strasbourg, University Hospital, Strasbourg, France
| | | | | | - Claude Preudhomme
- Lille University Hospital, Lille and INSERM UMR-S 1277, Lille, France
| | - Sylvie Chevret
- Biostatistics and Clinical Epidemiology Research Team (ECSTRRA), INSERM UMR-1153 (CRESS), Université de Paris, Paris, France
| | - Pierre Fenaux
- Hématologie Sénior Hôpital Saint Louis, Assistance publique hôpitaux de paris, and Université de Paris Cité, Paris, France
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12
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Dennis M, Thomas IF, Ariti C, Upton L, Burnett AK, Gilkes A, Radia R, Hemmaway C, Mehta P, Knapper S, Clark RE, Copland M, Russell N, Hills RK. Randomized evaluation of quizartinib and low-dose ara-C vs low-dose ara-C in older acute myeloid leukemia patients. Blood Adv 2021; 5:5621-5625. [PMID: 34597366 PMCID: PMC8714727 DOI: 10.1182/bloodadvances.2021005038] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/02/2021] [Indexed: 11/20/2022] Open
Abstract
Survival for older patients with acute myeloid leukemia (AML) unsuitable for intensive chemotherapy is unsatisfactory. Standard nonintensive therapies have low response rates and only extend life by a few months. Quizartinib is an oral Fms-like tyrosine kinase 3 (FLT3) inhibitor with reported activity in wild-type patients. As part of the AML LI trial, we undertook a randomized evaluation of low-dose ara-C (LDAC) with or without quizartinib in patients not fit for intensive chemotherapy. Overall, survival was not improved (202 patients), but in the 27 FLT3-ITD patients, the addition of quizartinib to LDAC improved response (P = .05) with complete remission/complete remission with incomplete haematological recovery for quizartinib + LDAC in 5/13 (38%) vs 0/14 (0%) in patients receiving LDAC alone. Overall survival (OS) in these FLT3-ITD+ patients was also significantly improved at 2 years for quizartinib + LDAC (hazard ratio 0.36; 95% confidence intervals: 0.16, 0.85, P = .04). Median OS was 13.7 months compared with 4.2 months with LDAC alone. This is the first report of an FLT3-targeted therapy added to standard nonintensive chemotherapy that has improved survival in this population. Quizartinib merits consideration for future triplet-based treatment approaches. This trial was registered at www.clinicaltrials.gov as ISRCTN #ISRCTN40571019 and EUDRACT @2011-000749-19.
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Affiliation(s)
| | - Ian F. Thomas
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Cono Ariti
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Laura Upton
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Alan K. Burnett
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Amanda Gilkes
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Rohini Radia
- Department of Haematology, Nottingham University Hospital, Nottingham, United Kingdom
| | | | - Priyanka Mehta
- Department of Haematology, Queen's Hospital, Romford, United Kingdom
- Department of Haematology, University Hospitals Bristol, Bristol, United Kingdom
| | - Steven Knapper
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Richard E. Clark
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom; and
| | - Mhairi Copland
- Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Nigel Russell
- Department of Haematology, Nottingham University Hospital, Nottingham, United Kingdom
| | - Robert K. Hills
- Nuffield Department of Population Health, Oxford, United Kingdom
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13
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Hills RK. High on-treatment platelet reactivity-an OPTIMAl solution, or a better solution? Br J Haematol 2021; 196:272-273. [PMID: 34734417 DOI: 10.1111/bjh.17944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Robert K Hills
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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14
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Lazarevic VL. Acute myeloid leukaemia in patients we judge as being older and/or unfit. J Intern Med 2021; 290:279-293. [PMID: 33780573 DOI: 10.1111/joim.13293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 11/29/2022]
Abstract
The definition of older age in AML is arbitrary. In the context of the clinical studies, it starts with age ≥60 or ≥65 years and in recent years ≥70 or 75, depending on the selection of the studied population. In clinical practice, with older age, we often mean that the patient is unfit for intensive chemotherapy. Higher age overlaps with categories such as worse performance status, unfitness, comorbidities, poor-risk cytogenetics, adverse mutation patterns, age-related clonal haematopoiesis and specific disease ontogeny. Intensive induction therapy can result in prolonged overall survival, at least in a subset of elderly patients aged up to 75 years despite the reluctance of some physicians and patients to use treatment regimens perceived as toxic. Venetoclax and azacitidine combination is the new standard of comparison for persons unfit for intensive therapy. New oral hypomethylating agent CC-486 as maintenance therapy led to a prolonged overall survival in a randomized trial of patients ≥55 years of age who were in first complete remission, but not eligible for allogeneic stem cell transplantation. Any therapy is better than no therapy, but a substantial proportion of older patients still receive only palliative care. Making a decision for AML diagnosed in older age should be individualized and shared through the dialog with the patient and relatives or cohabitants, considering medical issues and social factors including personal goals. Although we are witnesses of the advances in basic research and therapy, we are still a very long way from curing older patients with AML.
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Affiliation(s)
- V Lj Lazarevic
- From the, Department of Hematology, Oncology and Radiation Physics, Stem Cell Center, Skåne University Hospital, Lund University, Lund, Sweden
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15
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Dennis M, Burnett A, Hills R, Thomas I, Ariti C, Severinsen MT, Hemmaway C, Greaves P, Clark RE, Copland M, Russell N. A randomised evaluation of low-dose cytosine arabinoside (ara-C) plus tosedostat versus low-dose ara-C in older patients with acute myeloid leukaemia: results of the LI-1 trial. Br J Haematol 2021; 194:298-308. [PMID: 33961292 DOI: 10.1111/bjh.17501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/29/2021] [Accepted: 04/01/2021] [Indexed: 11/26/2022]
Abstract
Older patients with acute myeloid leukaemia (AML) account for nearly half of those with the disease. Because they are perceived to be unfit for, unwilling to receive, or unlikely to benefit from conventional chemotherapy they represent an important unmet need. Tosedostat is a selective oral aminopeptidase inhibitor, which in phase I/II trials showed acceptable toxicity and encouraging efficacy. We report the only randomised study of low-dose cytosine arabinoside (LDAC) combined with tosedostat (LDAC-T) versus LDAC in untreated older patients not suitable for intensive treatment. A total of 243 patients were randomised 1:1 as part of the 'Pick-a-Winner' LI-1 trial. There was a statistically non-significant increase in the complete remission (CR) rate with the addition of tosedostat, LDAC-T 19% versus LDAC 12% [odds ratio (OR) 0·61, 95% confidence interval (CI) 0·30-1·23; P = 0·17]. For overall response (CR+CR with incomplete recovery of counts), there was little evidence of a benefit to the addition of tosedostat (25% vs. 18%; OR 0·68, 95% CI 0·37-1·27; P = 0·22). However, overall survival (OS) showed no difference (2-year OS 16% vs. 12%, hazard ratio 0·97, 95% CI 0·73-1·28; P = 0·8). Exploratory analyses failed to identify any subgroup benefitting from tosedostat. Despite promising pre-clinical, early non-randomised clinical data with acceptable toxicity and an improvement in response, we did not find evidence that the addition of tosedostat to LDAC produced a survival benefit in this group of patients with AML. International Standard Randomised Controlled Trial Number: ISRCTN40571019.
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Affiliation(s)
- Mike Dennis
- Department of Haematology, Christie Hospital NHS Trust, Manchester, UK
| | - Alan Burnett
- Paul O'Gorman Leukaemia Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Robert Hills
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ian Thomas
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Cono Ariti
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Marianne T Severinsen
- Department of Haematology, Clinical Cancer Research Centre, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Claire Hemmaway
- Department of Haematology, Auckland City Hospital, Auckland, New Zealand
| | - Paul Greaves
- Department of Haematology, Queen's Hospital, Romford, UK
| | - Richard E Clark
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Mhairi Copland
- Paul O'Gorman Leukaemia Centre, Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Nigel Russell
- Department of Haematology, Nottingham University Hospitals, Nottingham, UK
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16
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Saxena K, Konopleva M. New Treatment Options for Older Patients with Acute Myeloid Leukemia. Curr Treat Options Oncol 2021; 22:39. [PMID: 33743079 DOI: 10.1007/s11864-021-00841-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT The treatment of acute myeloid leukemia (AML) has evolved considerably over the past several years. Advances in the field have historically benefited younger patients; however, a growing understanding of the molecular basis of leukemogenesis has brought multiple targeted agents to the clinic for patients of all ages. These therapies have expanded the therapeutic landscape for elderly patients from more than best supportive care and low-intensity monotherapy. In general, we currently utilize a backbone regimen of a hypomethylating agent (HMA) or low-intensity chemotherapy with the BCL-2 inhibitor venetoclax for the majority of elderly patients with newly diagnosed AML. For patients with targetable mutations, we employ a doublet/triplet strategy of HMA + a targeted inhibitor +/- venetoclax, often in the context of a clinical trial. CPX-351 is reserved for patients with secondary or therapy-related AML. In this review, we will outline our approach to the treatment of elderly patients with AML, with particular emphasis on recently approved agents and emerging novel therapies.
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Affiliation(s)
- Kapil Saxena
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 463, Houston, TX, 77030, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 428, Houston, TX, 77030, USA.
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17
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Craddock C. Acute myeloid leukaemia therapeutic innovation and clinical trials: past, present and future. Br J Haematol 2020; 191:568-572. [PMID: 33190247 DOI: 10.1111/bjh.17146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/26/2020] [Indexed: 11/28/2022]
Abstract
Outcomes in acute myeloid leukaemia have improved steadily over the last six decades thanks to advances in disease classification, risk stratification and the advent of new drug and transplant therapies. Over this period the UK has made a major contribution to this international effort, both through its delivery of large prospective randomised trials with integrated genomic and measurable residual disease assessments and its pioneering role in the development of allogeneic stem cell transplantation as a potent anti-leukaemic therapy.
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Affiliation(s)
- Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
- CRUK Cancer Trials Unit, University of Birmingham, Edgbaston, Birmingham, UK
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18
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Hills RK. Evaluating sixty years of UK trials research in acute myeloid leukaemia: lessons for trial design, past, present and future. Br J Haematol 2019; 188:29-35. [DOI: 10.1111/bjh.16357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Robert K. Hills
- Nuffield Department of Population Health University of Oxford Oxford UK
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19
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Neven A, Mauer M, Hasan B, Sylvester R, Collette L. Sample size computation in phase II designs combining the A'Hern design and the Sargent and Goldberg design. J Biopharm Stat 2019; 30:305-321. [PMID: 31331234 DOI: 10.1080/10543406.2019.1641817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This work focuses on the modification of two classical phase II trials designs, the A'Hern design, a single-arm single-stage design, and the Sargent and Goldberg design introduced in the context of flexible screening designs. In the first part of the paper, we have proposed a drift-adjusted A'Hern design, a hybrid design combining the A'Hern design and the Sargent and Goldberg design. Indeed, classical single-arm phase II designs such as the A'Hern design are still widely used in oncology. Conducting randomized comparative phase II trials may be challenging in many settings due to the increased sample size and this despite larger type 1 errors. Randomized non-comparative phase II designs first introduced by Herson and Carter include a simultaneous randomized standard-treatment reference arm to detect any drift in the reference arm assumption, but the trial is analyzed against historical controls as if it were a single-arm study. However, not incorporating at all an internal control arm in the trial design has been criticized in the literature. Our new design takes into account the observed response rate in a non-comparative reference arm to reduce the trial's risk of a false-positive conclusion. In the second part, we have proposed an alternative strategy to determining the sample size of the screened selection design. The latter, introduced in recent years by Yap et al. and Wu et al., extended the Sargent and Goldberg design to include a comparison to a historical control. However, their sample size computations may have potential weaknesses, which motivated us to revisit the existing approaches. A detailed simulation study has been carried out to evaluate the operating characteristics of the drift-adjusted A'Hern design and the different sample size strategies of the screened selection designs.
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Affiliation(s)
- Anouk Neven
- EORTC Headquarters, Statistics Department, Brussels, Belgium
| | - Murielle Mauer
- EORTC Headquarters, Statistics Department, Brussels, Belgium
| | - Baktiar Hasan
- EORTC Headquarters, Statistics Department, Brussels, Belgium
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20
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Percival MM, Estey EH. Current treatment strategies for measurable residual disease in patients with acute myeloid leukemia. Cancer 2019; 125:3121-3130. [DOI: 10.1002/cncr.32354] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/13/2019] [Accepted: 05/30/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Mary‐Elizabeth M. Percival
- Division of Hematology, Department of Medicine University of Washington Seattle Washington
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle Washington
| | - Elihu H. Estey
- Division of Hematology, Department of Medicine University of Washington Seattle Washington
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle Washington
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21
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Ventz S, Cellamare M, Parmigiani G, Trippa L. Adding experimental arms to platform clinical trials: randomization procedures and interim analyses. Biostatistics 2019; 19:199-215. [PMID: 29036330 DOI: 10.1093/biostatistics/kxx030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 05/07/2017] [Indexed: 11/14/2022] Open
Abstract
Multi-arm clinical trials use a single control arm to evaluate multiple experimental treatments. In most cases this feature makes multi-arm studies considerably more efficient than two-arm studies. A bottleneck for implementation of a multi-arm trial is the requirement that all experimental treatments have to be available at the enrollment of the first patient. New drugs are rarely at the same stage of development. These limitations motivate our study of statistical methods for adding new experimental arms after a clinical trial has started enrolling patients. We consider both balanced and outcome-adaptive randomization methods for experimental designs that allow investigators to add new arms, discuss their application in a tuberculosis trial, and evaluate the proposed designs using a set of realistic simulation scenarios. Our comparisons include two-arm studies, multi-arm studies, and the proposed class of designs in which new experimental arms are added to the trial at different time points.
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Affiliation(s)
- Steffen Ventz
- Department of Computer Science and Statistics, University of Rhode Island, 9 Greenhouse Road, Kingston, RI 02881, USA
| | - Matteo Cellamare
- Harvard T. H. Chan School of Public Health, 655 Huntington Ave, Boston, MA 02115, USA, Department of Statistical Sciences, Sapienza University, Piazzale Aldo Moro 5, 00185 Roma, Italy, and Department of Biostatistics, Harvard T. H. Chan School of Public Health, 655 Huntington Ave, Boston, MA, 02115, USA
| | - Giovanni Parmigiani
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02115, USA and Department of Biostatistics, Harvard T. H. Chan School of Public Health, 655 Huntington Ave, Boston, MA, 02115, USA
| | - Lorenzo Trippa
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02115, USA and Department of Biostatistics, Harvard T. H. Chan School of Public Health, 655 Huntington Ave, Boston, MA, 02115, USA
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23
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Patriarca F, Masciulli A, Bacigalupo A, Bregante S, Pavoni C, Finazzi MC, Bosi A, Russo D, Narni F, Messina G, Alessandrino EP, Carella AM, Milone G, Bruno B, Mammoliti S, Bruno B, Fanin R, Bonifazi F, Rambaldi A. Busulfan- or Thiotepa-Based Conditioning in Myelofibrosis: A Phase II Multicenter Randomized Study from the GITMO Group. Biol Blood Marrow Transplant 2018; 25:932-940. [PMID: 30579966 DOI: 10.1016/j.bbmt.2018.12.064] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 12/06/2018] [Indexed: 01/28/2023]
Abstract
We report a randomized study comparing fludarabine in combination with busulfan (FB) or thiotepa (FT), as conditioning regimen for hematopoietic stem cell transplantation (HSCT) in patients with myelofibrosis. The primary study endpoint was progression-free survival (PFS). Sixty patients were enrolled with a median age of 56 years and an intermediate-2 or high-risk score in 65%, according to the Dynamic International Prognostic Staging System (DIPSS). Donors were HLA-identical sibling (n = 25), matched unrelated (n = 25) or single allele mismatched unrelated (n = 10). With a median follow-up of 22 months (range, 1 to 68 months), outcomes at 2 years after HSCT in the FB arm versus the FT arm were as follows: PFS, 43% versus 55% (P = .28); overall survival (OS), 54% versus 70% (P = .17); relapse/progression, 36% versus 24% (P = .24); nonrelapse mortality (NRM), 21% in both arms (P = .99); and graft failure, 14% versus 10% (P = .96). A better PFS was observed in patients with intermediate-1 DIPSS score (P = .03). Both neutrophil engraftment and platelet engraftment were significantly influenced by previous splenectomy (hazard ratio [HR], 2.28; 95% confidence interval [CI], 1.16 to 4.51; P = .02) and splenomegaly at transplantation (HR, 0.51; 95% CI, 0.27 to 0.94; P = .03). In conclusion, the clinical outcome after HSCT was comparable when using either a busulfan or thiotepa based conditioning regimen.
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Affiliation(s)
| | | | | | | | | | | | - Alberto Bosi
- Hematology, University of Florence, Florence, Italy
| | - Domenico Russo
- ASST Hospital of Brescia, DSCS, Brescia University, Brescia, Italy
| | | | | | | | | | | | - Benedetto Bruno
- "Citta' della Salute e della Scienza" University Hospital, DBMSS, University of Torino, Torino, Italy
| | - Sonia Mammoliti
- Trial Clinical Office, Gruppo Italiano Trapianto Midollo Osseo (GITMO), Genoa, Italy
| | - Barbara Bruno
- Trial Clinical Office, Gruppo Italiano Trapianto Midollo Osseo (GITMO), Genoa, Italy
| | - Renato Fanin
- Udine University Hospital, DAME, University of Udine, Udine, Italy
| | - Francesca Bonifazi
- Institute of Hematology "Seragnoli", University Hospital "S. Orsola Malpighi", Bologna, Italy
| | - Alessandro Rambaldi
- "Papa Giovanni XXIII" Hospital, Bergamo, Italy; Department of Hematology-Oncology, University of Milano, Milan, Italy
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24
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Tang R, Shen J, Yuan Y. ComPAS: A Bayesian drug combination platform trial design with adaptive shrinkage. Stat Med 2018; 38:1120-1134. [PMID: 30419609 DOI: 10.1002/sim.8026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 10/05/2018] [Accepted: 10/13/2018] [Indexed: 12/27/2022]
Abstract
Combining different treatment regimens provides an effective approach to induce a synergistic treatment effect and overcome resistance to monotherapy. The challenge is that, given the large number of existing monotherapies, the number of possible combinations is huge and new potentially more efficacious compounds may become available any time during drug development. To address this challenge, we propose a flexible Bayesian drug combination platform design with adaptive shrinkage (ComPAS), which allows for dropping futile combinations, graduating effective combinations, and adding new combinations during the course of the trial. A new adaptive shrinkage method is developed to adaptively borrow information across combinations and efficiently identify the efficacious combinations based on Bayesian model selection and hierarchical models. Simulation studies show that ComPAS identifies the effective combinations with higher probability than some existing designs. ComPAS provides an efficient and flexible platform to accelerate drug development in a seamless and timely fashion.
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Affiliation(s)
- Rui Tang
- Shire Pharmaceuticals Inc, Cambridge, Massachusetts
| | | | - Ying Yuan
- Department of Biostatistics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
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25
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Pickles T, Christensen R, Tam LS, Simon LS, Choy EH. Early phase and adaptive design clinical trials in rheumatoid arthritis: a systematic review of early phase trials. Rheumatol Adv Pract 2018; 2:rky045. [PMID: 31431982 PMCID: PMC6649924 DOI: 10.1093/rap/rky045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 09/17/2018] [Indexed: 12/21/2022] Open
Abstract
Objective Adaptive designs can enable highly sophisticated and efficient early phase trials, but the clinical inference from these trials is surrounded by complexity, and currently there is a paucity but steadily increasing amount of use of these designs in all fields of medicine. We aim to review early phase trials in RA to discover those that have used adaptive designs and benchmark trial characteristics. Methods From an OVID search for journal articles reporting the results of early phase trials in rheumatology, 35 studies were found, with 9 subsequently excluded; 11 were added from manual searches and 19 from searching the references. Study characteristics were extracted from the 56 papers (describing 62 trials), including the number of arms, number of patients, the primary outcome and when it was measured. Result One early phase trial using an adaptive design was found. The benchmark early phase trial in RA is a phase II double-blinded randomized trial, with four arms (one control and three intervention), each with 34 patients, and ACR20 measured at 16 weeks as the primary outcome. Conclusion The one adaptive design reviewed here, and a simulation study found in the search, both indicate that adaptive designs can be applied to early phase trials in RA. We have described the benchmark, which the efficiency of early phase trials using an adaptive design needs to exceed. These efficient designs could drive down numbers required, time for data collection and thus cost. Changes have been suggested, but more needs to be done.
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Affiliation(s)
- Tim Pickles
- Cardiff Regional Experimental Arthritis Treatment and Evaluation (CREATE) Centre, Division of Infection and Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University.,Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Lai-Shan Tam
- Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | | | - Ernest H Choy
- Cardiff Regional Experimental Arthritis Treatment and Evaluation (CREATE) Centre, Division of Infection and Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University
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Burnett AK. Treatment of Older Patients With Newly Diagnosed AML Unfit for Traditional Therapy. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:553-557. [PMID: 30007570 DOI: 10.1016/j.clml.2018.06.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/26/2018] [Indexed: 11/28/2022]
Abstract
Older patients with acute myeloid leukemia represent at least one half of those with the disease for whom randomized clinical trials of new treatments are in development. These patients represent an appropriate population in which to evaluate new treatments against the current standards of care, which could be azacitidine, decitabine, or low-dose cytarabine. However, despite the identification of treatments that can deliver a worthwhile increase in remission, none has yet delivered a survival superiority when assessed in a randomized setting, although some recent efforts provide encouragement.
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Affiliation(s)
- Alan K Burnett
- (Retired), Cardiff University Ty Mawr, Blackwaterfoot, United Kingdom.
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Ventz S, Alexander BM, Parmigiani G, Gelber RD, Trippa L. Designing Clinical Trials That Accept New Arms: An Example in Metastatic Breast Cancer. J Clin Oncol 2017; 35:3160-3168. [DOI: 10.1200/jco.2016.70.1169] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Purpose The majority of randomized oncology trials are two-arm studies that test the efficacy of new therapies against a standard of care, thereby assigning a large proportion of patients to nonexperimental therapies. In contrast, multiarm studies efficiently share a common control arm while evaluating multiple experimental therapies. A major bottleneck for traditional multiarm trials is the requirement that all therapies—often drugs from different companies—have to be available at the same time when the trial starts. We evaluate the potential gains of a platform design—the rolling-arms design—that adds and removes arms on a rolling basis. Methods We define the rolling-arms design with the goal of minimizing the complexity of random assignment and data analyses of a platform trial. We then evaluate its potential advantages in hormone receptor–positive, human epidermal growth factor receptor 2–negative advanced breast cancer. Multiple pharmaceutical companies currently test CDK4/6 inhibitors in combination with letrozole in independent two-arm trials. We conducted a simulation study to quantify the reduction in sample size, number of patients treated with the standard of care, and the average time to treatment discovery if these therapies had been tested in a rolling-arms trial. Results A rolling-arms platform design with two to five experimental treatments can reduce the overall sample size requirement by up to 30% compared with standard two-arm studies. It assigns up to 60% fewer patients to the control arm compared with five independent trials that test distinct treatments. Moreover, under realistic scenarios, effective experimental treatments are discovered up to 15 months earlier compared with separate two-arm trials. Conclusion The rolling-arms platform design is applicable to a broad variety of diseases, and under realistic scenarios, it is substantially more efficient than standard two-arm randomized trials.
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Affiliation(s)
- Steffen Ventz
- Steffen Ventz, University of Rhode Island, Kingstown, RI; Brian M. Alexander, Giovanni Parmigiani, Richard D. Gelber, and Lorenzo Trippa, Dana-Farber Cancer Institute; Brian M. Alexander and Richard D. Gelber, Harvard Medical School; Giovanni Parmigiani, Richard D. Gelber, and Lorenzo Trippa, Harvard TH Chan School of Public Health; Richard D. Gelber, Frontier Science Foundation, Boston, MA
| | - Brian M. Alexander
- Steffen Ventz, University of Rhode Island, Kingstown, RI; Brian M. Alexander, Giovanni Parmigiani, Richard D. Gelber, and Lorenzo Trippa, Dana-Farber Cancer Institute; Brian M. Alexander and Richard D. Gelber, Harvard Medical School; Giovanni Parmigiani, Richard D. Gelber, and Lorenzo Trippa, Harvard TH Chan School of Public Health; Richard D. Gelber, Frontier Science Foundation, Boston, MA
| | - Giovanni Parmigiani
- Steffen Ventz, University of Rhode Island, Kingstown, RI; Brian M. Alexander, Giovanni Parmigiani, Richard D. Gelber, and Lorenzo Trippa, Dana-Farber Cancer Institute; Brian M. Alexander and Richard D. Gelber, Harvard Medical School; Giovanni Parmigiani, Richard D. Gelber, and Lorenzo Trippa, Harvard TH Chan School of Public Health; Richard D. Gelber, Frontier Science Foundation, Boston, MA
| | - Richard D. Gelber
- Steffen Ventz, University of Rhode Island, Kingstown, RI; Brian M. Alexander, Giovanni Parmigiani, Richard D. Gelber, and Lorenzo Trippa, Dana-Farber Cancer Institute; Brian M. Alexander and Richard D. Gelber, Harvard Medical School; Giovanni Parmigiani, Richard D. Gelber, and Lorenzo Trippa, Harvard TH Chan School of Public Health; Richard D. Gelber, Frontier Science Foundation, Boston, MA
| | - Lorenzo Trippa
- Steffen Ventz, University of Rhode Island, Kingstown, RI; Brian M. Alexander, Giovanni Parmigiani, Richard D. Gelber, and Lorenzo Trippa, Dana-Farber Cancer Institute; Brian M. Alexander and Richard D. Gelber, Harvard Medical School; Giovanni Parmigiani, Richard D. Gelber, and Lorenzo Trippa, Harvard TH Chan School of Public Health; Richard D. Gelber, Frontier Science Foundation, Boston, MA
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Chung C, Ma H. Driving Toward Precision Medicine for Acute Leukemias: Are We There Yet? Pharmacotherapy 2017; 37:1052-1072. [DOI: 10.1002/phar.1977] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
| | - Hilary Ma
- MD Anderson Cancer Center; Houston Texas
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Krug U, Gale RP, Berdel WE, Müller-Tidow C, Stelljes M, Metzeler K, Sauerland MC, Hiddemann W, Büchner T. Therapy of older persons with acute myeloid leukaemia. Leuk Res 2017; 60:1-10. [PMID: 28618329 DOI: 10.1016/j.leukres.2017.05.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 05/24/2017] [Accepted: 05/27/2017] [Indexed: 12/20/2022]
Abstract
Most persons age≥60 y with acute myeloid leukaemia (AML) die from their disease. When interpreting clinical trials data from these persons one must be aware of substantial selection biases. Randomized trials of post-remission treatments can be performed upfront or after achieving defined landmarks. Both strategies have important limitations. Selection of the appropriate treatment is critical. Age, performance score, co-morbidities and frailty provide useful data to treatment selection. If an intensive remission induction therapy is appropriate, therapy with cytarabine and an anthracycline is the most common regimen. Non-intensive therapies consist of the hypo-methylating drugs azacitidine and decitabine, low-dose cytarabine and supportive care. Feasibility of doing an allotransplant in older persons with AML is increasing. However, only very few qualify. Results of cytogenetic testing are risk factor in young and old persons with AML. Adverse abnormalities are more frequent in older persons. Although data about the frequency of mutations in older persons with AML is increasing their prognostic impact is less clear than in younger subjects. Neither differences in the distribution of cytogenetic risk, mutations, nor differences in clinical risk factors between younger and older persons with AML completely explain the age-dependent outcome. Many drugs are in clinical development in older persons with AML. Their potential role in the treatment of older persons with AML remains to be defined.
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Affiliation(s)
- Utz Krug
- Klinikum Leverkusen, Department of Medicine 3, Am Gesundheitspark 11, 51375 Leverkusen, Germany.
| | - Robert Peter Gale
- Haematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, UK.
| | - Wolfgang E Berdel
- University Hospital Münster, Department of Medicine A, Albert-Schweitzer-Campus 1, Geb. A1, 48129 Münster, Germany.
| | - Carsten Müller-Tidow
- University Hospital Heidelberg, Department of Medicine V, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany.
| | - Matthias Stelljes
- University Hospital Münster, Department of Medicine A, Albert-Schweitzer-Campus 1, Geb. A1, 48129 Münster, Germany.
| | - Klaus Metzeler
- University Hospital Großhadern, IIIrd Medical Department, Marchioninistraße 15, 81377 München, Germany.
| | - M Cristina Sauerland
- University of Münster, Institute of Biostatistics and Clinical Research, Schmeddingstr 56, 48149 Münster, Germany.
| | - Wolfgang Hiddemann
- University Hospital Großhadern, IIIrd Medical Department, Marchioninistraße 15, 81377 München, Germany.
| | - Thomas Büchner
- University Hospital Münster, Department of Medicine A, Albert-Schweitzer-Campus 1, Geb. A1, 48129 Münster, Germany
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Floc'h N, Ashton S, Taylor P, Trueman D, Harris E, Odedra R, Maratea K, Derbyshire N, Caddy J, Jacobs VN, Hattersley M, Wen S, Curtis NJ, Pilling JE, Pease EJ, Barry ST. Optimizing Therapeutic Effect of Aurora B Inhibition in Acute Myeloid Leukemia with AZD2811 Nanoparticles. Mol Cancer Ther 2017; 16:1031-1040. [DOI: 10.1158/1535-7163.mct-16-0580] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/11/2016] [Accepted: 03/08/2017] [Indexed: 11/16/2022]
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Halpern AB, Culakova E, Walter RB, Lyman GH. Association of Risk Factors, Mortality, and Care Costs of Adults With Acute Myeloid Leukemia With Admission to the Intensive Care Unit. JAMA Oncol 2017; 3:374-381. [PMID: 27832254 DOI: 10.1001/jamaoncol.2016.4858] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Adults with acute myeloid leukemia (AML) commonly require support in the intensive care unit (ICU), but risk factors for admission to the ICU and adverse outcomes remain poorly defined. Objective To examine risk factors, mortality, length of stay, and cost associated with admission to the ICU for patients with AML. Design, Setting, and Participants This study extracted information from the University HealthSystem Consortium database on patients 18 years or older with AML who were hospitalized for any cause between January 1, 2004, and December 31, 2012. The University HealthSystem Consortium database contains demographic, clinical, and cost variables prospectively abstracted by certified coders from discharge summaries. Outcomes were analyzed using univariate and multivariable statistical techniques. Data analysis was performed from November 15, 2013, to August 15, 2016. Main Outcomes and Measures Primary outcomes were admission to the ICU and inpatient mortality among patients requiring ICU care. Secondary outcomes included length of stay in the ICU, total hospitalization length of stay, and cost. Results Of the 43 249 patients with AML (mean [SD] age, 59.5 [16.6] years; 23 939 men and 19 310 women), 11 277 (26.1%) were admitted to the ICU. On multivariable analysis (with results reported as odds ratios [95% CIs]), independent risk factors for admission to the ICU included age younger than 80 years (1.56 [1.42-1.70]), hospitalization in the South (1.81 [1.71-1.92]), hospitalization at a low- or medium-volume hospital (1.25 [1.19-1.31]), number of comorbidities (10.64 [8.89-12.62] for 5 vs none), sepsis (4.61 [4.34-4.89]), invasive fungal infection (1.24 [1.11-1.39]), and pneumonia (1.73 [1.63-1.82]). In-hospital mortality was higher for patients requiring ICU care (4857 of 11 277 [43.1%] vs 2959 of 31 972 [9.3%]). On multivariable analysis, independent risk factors for death in patients requiring ICU care included age 60 years or older (1.16 [1.06-1.26]), nonwhite race/ethnicity (1.18 [1.07-1.30]), hospitalization on the West coast (1.19 [1.06-1.34]), number of comorbidities (18.76 [13.7-25.67] for 5 vs none), sepsis (2.94 [2.70-3.21]), invasive fungal infection (1.20 [1.02-1.42]), and pneumonia (1.13 [1.04-1.24]). Mean costs of hospitalization were higher for patients requiring ICU care ($83 354 vs $41 973) and increased with each comorbidity, from $50 543 for patients with no comorbidities to $124 820 for those with 5 or more comorbidities. Conclusions and Relevance Admission to the ICU is associated with high mortality and cost that increase proportionally with the comorbidity burden in adults with AML. Several demographic factors and medical characteristics identify patients at risk for admission to the ICU and mortality and provide an opportunity for testing primary prevention strategies.
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Affiliation(s)
- Anna B Halpern
- Hematology/Oncology Fellowship Program, Fred Hutchinson Cancer Research Center/University of Washington, Seattle
| | - Eva Culakova
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington3Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington5Division of Hematology, Department of Medicine, University of Washington, Seattle6Department of Epidemiology, University of Washington, Seattle
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington3Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington4Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington7Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
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Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel. Blood 2016; 129:424-447. [PMID: 27895058 DOI: 10.1182/blood-2016-08-733196] [Citation(s) in RCA: 4026] [Impact Index Per Article: 503.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/15/2016] [Indexed: 12/13/2022] Open
Abstract
The first edition of the European LeukemiaNet (ELN) recommendations for diagnosis and management of acute myeloid leukemia (AML) in adults, published in 2010, has found broad acceptance by physicians and investigators caring for patients with AML. Recent advances, for example, in the discovery of the genomic landscape of the disease, in the development of assays for genetic testing and for detecting minimal residual disease (MRD), as well as in the development of novel antileukemic agents, prompted an international panel to provide updated evidence- and expert opinion-based recommendations. The recommendations include a revised version of the ELN genetic categories, a proposal for a response category based on MRD status, and criteria for progressive disease.
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Marx KR, Kantarjian H, Ravandi F. Vosaroxin: innovative anticancer quinolone for the treatment of acute myelogenous leukemia. Expert Opin Orphan Drugs 2016. [DOI: 10.1080/21678707.2016.1194753] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Khwaja A, Bjorkholm M, Gale RE, Levine RL, Jordan CT, Ehninger G, Bloomfield CD, Estey E, Burnett A, Cornelissen JJ, Scheinberg DA, Bouscary D, Linch DC. Acute myeloid leukaemia. Nat Rev Dis Primers 2016; 2:16010. [PMID: 27159408 DOI: 10.1038/nrdp.2016.10] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute myeloid leukaemia (AML) is a disorder characterized by a clonal proliferation derived from primitive haematopoietic stem cells or progenitor cells. Abnormal differentiation of myeloid cells results in a high level of immature malignant cells and fewer differentiated red blood cells, platelets and white blood cells. The disease occurs at all ages, but predominantly occurs in older people (>60 years of age). AML typically presents with a rapid onset of symptoms that are attributable to bone marrow failure and may be fatal within weeks or months when left untreated. The genomic landscape of AML has been determined and genetic instability is infrequent with a relatively small number of driver mutations. Mutations in genes involved in epigenetic regulation are common and are early events in leukaemogenesis. The subclassification of AML has been dependent on the morphology and cytogenetics of blood and bone marrow cells, but specific mutational analysis is now being incorporated. Improvements in treatment in younger patients over the past 35 years has largely been due to dose escalation and better supportive care. Allogeneic haematopoietic stem cell transplantation may be used to consolidate remission in those patients who are deemed to be at high risk of relapse. A plethora of new agents - including those targeted at specific biochemical pathways and immunotherapeutic approaches - are now in trial based on improved understanding of disease pathophysiology. These advances provide good grounds for optimism, although mortality remains high especially in older patients.
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Affiliation(s)
- Asim Khwaja
- Department of Haematology, University College London, UCL Cancer Institute, 72 Huntley Street, London WC1E 6DD, UK
| | - Magnus Bjorkholm
- Department of Medicine, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Rosemary E Gale
- Department of Haematology, University College London, UCL Cancer Institute, 72 Huntley Street, London WC1E 6DD, UK
| | - Ross L Levine
- Human Oncology and Pathogenesis Program, Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Craig T Jordan
- Division of Hematology, University of Colorado Denver, Denver, Colorado, USA
| | - Gerhard Ehninger
- Department of Internal Medicine, Technical University Dresden, Dresden, Germany
| | | | - Eli Estey
- Division of Hematology, University of Washington and Clinical Research Division Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | | | - David A Scheinberg
- Molecular Pharmacology Program, Experimental Therapeutics Center, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Didier Bouscary
- Institut Cochin, Département Développement Reproduction Cancer, CNRS UMR8104, INSERM U1016, Paris, France.,Service d'Hématologie, Hôpital Cochin, AP-HP, Paris, France.,Université Paris Descartes, Faculté de Médecine Sorbonne Paris Cité, Paris, France
| | - David C Linch
- Department of Haematology, University College London, UCL Cancer Institute, 72 Huntley Street, London WC1E 6DD, UK
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Abstract
Acute myeloid leukemia in older patients has historically had a dismal 10-15% long-term survival rate. Although patient frailty plays a role in this disappointing outcome, the primary driver of poor results remains the resistance of disease to current therapies. The optimal management of this difficult-to-treat disease should include a careful consideration of disease, patient and treatment factors. Disease factors include cytogenetic and molecular features and the history of an antecedent hematological disorder. Patient factors include age, performance status, comorbid conditions and individual patient preference. We favor intensive induction in most fit older patients but alternatives such as hypomethylating agents and low-dose cytarabine may be considered in patients with other comorbidities. Enrollment of patients into well designed clinical trials addressing important questions remains of utmost importance in order to advance the understanding and treatment of this disease although the best means of drug development remains a challenging dilemma.
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Affiliation(s)
- Jay Yang
- a Division of Hematology/Oncology, Department of Oncology , Barbara Ann Karmanos Cancer Center and Wayne State University School of Medicine , Detroit , MI 48201 , USA
| | - Charles A Schiffer
- a Division of Hematology/Oncology, Department of Oncology , Barbara Ann Karmanos Cancer Center and Wayne State University School of Medicine , Detroit , MI 48201 , USA
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Bower H, Andersson TML, Björkholm M, Dickman PW, Lambert PC, Derolf ÅR. Continued improvement in survival of acute myeloid leukemia patients: an application of the loss in expectation of life. Blood Cancer J 2016; 6:e390. [PMID: 26849011 PMCID: PMC4771966 DOI: 10.1038/bcj.2016.3] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/17/2015] [Indexed: 01/24/2023] Open
Abstract
We evaluated temporal trends in survival of Swedish acute myeloid leukemia (AML) patients diagnosed between 1973 and 2011 using relative survival ratios (RSRs) and a measure called the loss in expectation of life (LEL). RSRs increased most for patients <60 years at diagnosis during the first calendar periods, but between 1997-2005 and 2006-2011 the most pronounced increase was for those aged 61-70 years at diagnosis; RSR changed from 0.16 (95% confidence interval (CI): 0.13-0.19) to 0.28 (95% CI: 0.23-0.33), respectively. The LEL for males aged 35 years at diagnosis was 41.0 (95% CI: 40.1-41.8) years in 1975 and 19.5 (95% CI: 16.4-22.5) years in 2011. For males aged 65 years, the corresponding figures were 13.8 (95% CI: 13.7-14.0) and 12.0 (95% CI: 11.3-12.8). Conditional LEL estimates suggested that patients who survive 5 years postdiagnosis have shorter remaining lifespan than the general population. The proportion of expected life lost (PELL) suggested that male 65-year-old patients lost 75% of their life expectancy in 2005 and 66% if they were diagnosed in 2011. Survival continued to increase to 2011, with larger improvements in those aged 61-70 years at diagnosis. The LEL and PELL are intuitive measures that may be useful in communicating survival statistics to patients, clinicians and health-care providers.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Child
- Child, Preschool
- Female
- History, 20th Century
- History, 21st Century
- Humans
- Incidence
- Infant
- Infant, Newborn
- Leukemia, Myeloid, Acute/epidemiology
- Leukemia, Myeloid, Acute/history
- Leukemia, Myeloid, Acute/mortality
- Life Expectancy
- Male
- Middle Aged
- Population Surveillance
- Registries
- Spatio-Temporal Analysis
- Sweden/epidemiology
- Young Adult
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Affiliation(s)
- H Bower
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - T M-L Andersson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - M Björkholm
- Department of Medicine, Division of Hematology, Karolinska University Hospital Solna and Karolinska Institutet, Stockholm, Sweden
| | - P W Dickman
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - P C Lambert
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Å R Derolf
- Department of Medicine, Division of Hematology, Karolinska University Hospital Solna and Karolinska Institutet, Stockholm, Sweden
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McGregor AK, Moulton D, Bown N, Cuthbert G, Bourn D, Mathew S, Dang R, Mounter P, Jones G. Incidence and outcomes for adults diagnosed with acute myeloid leukemia in the north of England: a real world study. Leuk Lymphoma 2015; 57:1575-84. [PMID: 26666339 DOI: 10.3109/10428194.2015.1108413] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We conducted a retrospective population-based study of patients diagnosed with acute myeloid leukemia (AML) in northern England (population 3.1 million) in order to assess the impact of age and genetics on outcome. Four hundred and sixteen patients were diagnosed with AML, between 2007 and 2011. In those aged ≤60 years (n = 20) with acute promyelocytic leukemia (APL) overall survival (OS) was 100%. For non-APL patients aged ≤60 years, OS for those with favorable, intermediate and adverse cytogenetics was not reached, 17 and 9.8 months, respectively (p = 0.0001). Of particular note, intensively treated patients aged >60 years with intermediate cytogenetics and FLT3-/NPM1+ status had a five-year survival of 60% versus median OS of 11 months for other subsets (p = 0.04). Population-based studies reduce selection bias and have utility in studying rarer diseases, particularly in populations that recruit poorly to trials. The highly favorable outcome in our subgroup of intensively-treated FLT3-/NPM1+ older patients merits further study.
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Affiliation(s)
- Andrew Kenneth McGregor
- a Department of Hematology , The Newcastle Upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne , UK
| | - Deborah Moulton
- a Department of Hematology , The Newcastle Upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne , UK
| | - Nick Bown
- b Northern Genetics Service, The Newcastle upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne , UK
| | - Gavin Cuthbert
- b Northern Genetics Service, The Newcastle upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne , UK
| | - David Bourn
- b Northern Genetics Service, The Newcastle upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne , UK
| | - Susanna Mathew
- c Department of Hematology , City Hospitals Sunderland NHS Foundation Trust , Sunderland, UK
| | - Raymond Dang
- d Department of Hematology , South Tees Hospitals NHS Foundation Trust , Middlesbrough , UK
| | - Philip Mounter
- e Department of Hematology , North Tees and Hartlepool NHS Foundation Trust , Stockton , UK
| | - Gail Jones
- a Department of Hematology , The Newcastle Upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne , UK
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Norkin M, Richards AI. Sapacitabine in the treatment of acute myeloid leukemia. Expert Rev Anticancer Ther 2015; 15:1261-6. [DOI: 10.1586/14737140.2015.1102064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cohen DR, Todd S, Gregory WM, Brown JM. Adding a treatment arm to an ongoing clinical trial: a review of methodology and practice. Trials 2015; 16:179. [PMID: 25897686 PMCID: PMC4457999 DOI: 10.1186/s13063-015-0697-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 03/31/2015] [Indexed: 01/26/2023] Open
Abstract
Incorporating an emerging therapy as a new randomisation arm in a clinical trial that is open to recruitment would be desirable to researchers, regulators and patients to ensure that the trial remains current, new treatments are evaluated as quickly as possible, and the time and cost for determining optimal therapies is minimised. It may take many years to run a clinical trial from concept to reporting within a rapidly changing drug development environment; hence, in order for trials to be most useful to inform policy and practice, it is advantageous for them to be able to adapt to emerging therapeutic developments. This paper reports a comprehensive literature review on methodologies for, and practical examples of, amending an ongoing clinical trial by adding a new treatment arm. Relevant methodological literature describing statistical considerations required when making this specific type of amendment is identified, and the key statistical concepts when planning the addition of a new treatment arm are extracted, assessed and summarised. For completeness, this includes an assessment of statistical recommendations within general adaptive design guidance documents. Examples of confirmatory ongoing trials designed within the frequentist framework that have added an arm in practice are reported; and the details of the amendment are reviewed. An assessment is made as to how well the relevant statistical considerations were addressed in practice, and the related implications. The literature review confirmed that there is currently no clear methodological guidance on this topic, but that guidance would be advantageous to help this efficient design amendment to be used more frequently and appropriately in practice. Eight confirmatory trials were identified to have added a treatment arm, suggesting that trials can benefit from this amendment and that it can be practically feasible; however, the trials were not always able to address the key statistical considerations, often leading to uninterpretable or invalid outcomes. If the statistical concepts identified within this review are considered and addressed during the design of a trial amendment, it is possible to effectively assess a new treatment arm within an ongoing trial without compromising the original trial outcomes.
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Affiliation(s)
- Dena R Cohen
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, Reading, RG6 6AX, UK.
| | - Walter M Gregory
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Julia M Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
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Vosaroxin and vosaroxin plus low-dose Ara-C (LDAC) vs low-dose Ara-C alone in older patients with acute myeloid leukemia. Blood 2015; 125:2923-32. [PMID: 25805811 DOI: 10.1182/blood-2014-10-608117] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 03/06/2015] [Indexed: 01/06/2023] Open
Abstract
The development of new treatments for older patients with acute myeloid leukemia is an active area, but has met with limited success. Vosaroxin, a quinolone-derived intercalating agent has several properties that could prove beneficial. Initial clinical studies showed it to be well-tolerated in older patients with relapsed/refractory disease. In vitro data suggested synergy with cytarabine (Ara-C). To evaluate vosaroxin, we performed 2 randomized comparisons within the "Pick a Winner" program. A total of 104 patients were randomized to vosaroxin vs low-dose Ara-C (LDAC) and 104 to vosaroxin + LDAC vs LDAC. When comparing vosaroxin with LDAC, neither response rate (complete recovery [CR]/complete recovery with incomplete count recovery [CRi], 26% vs 30%; odds ratio [OR], 1.16 (0.49-2.72); P = .7) nor 12-month survival (12% vs 31%; hazard ratio [HR], 1.94 [1.26-3.00]; P = .003) showed benefit for vosaroxin. Likewise, in the vosaroxin + LDAC vs LDAC comparison, neither response rate (CR/CRi, 38% vs 34%; OR, 0.83 [0.37-1.84]; P = .6) nor survival (33% vs 37%; HR, 1.30 [0.81-2.07]; P = .3) was improved. A major reason for this lack of benefit was excess early mortality in the vosaroxin + LDAC arm, most obviously in the second month following randomization. At its first interim analysis, the Data Monitoring and Ethics Committee recommended closure of the vosaroxin-containing trial arms because a clinically relevant benefit was unlikely.
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43
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Crooks MG, Hart SP. Biomarkers in idiopathic pulmonary fibrosis: picking the winners for trials. THE LANCET RESPIRATORY MEDICINE 2015; 3:421-2. [PMID: 25770675 DOI: 10.1016/s2213-2600(15)00084-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 02/25/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Michael G Crooks
- Academic Respiratory Medicine, Centre for Cardiovascular and Metabolic Research, Hull York Medical School, Castle Hill Hospital, Cottingham HU16 5JQ, UK
| | - Simon P Hart
- Academic Respiratory Medicine, Centre for Cardiovascular and Metabolic Research, Hull York Medical School, Castle Hill Hospital, Cottingham HU16 5JQ, UK.
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Current challenges in clinical development of "targeted therapies": the case of acute myeloid leukemia. Blood 2015; 125:2461-6. [PMID: 25762181 DOI: 10.1182/blood-2015-01-561373] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/02/2015] [Indexed: 12/31/2022] Open
Abstract
A fundamental difficulty in testing "targeted therapies" in acute myeloid leukemia (AML) is the limitations of preclinical models in capturing inter- and intrapatient genomic heterogeneity. Clinical trials typically focus on single agents despite the routine emergence of resistant subclones and experience in blast-phase chronic myeloid leukemia and acute promyelocytic leukemia arguing against this strategy. Inclusion of only relapsed-refractory, or unfit newly diagnosed, patients risks falsely negative results. There is uncertainty as to whether eligibility should require demonstration of the putative target and regarding therapeutic end points. Although use of in vivo preclinical models employing primary leukemic cells is first choice, newer preclinical models including "organoids" and combinations of pharmacologic and genetic approaches may better align models with human AML. We advocate earlier inclusion of combinations ± chemotherapy and of newly diagnosed patients into clinical trials. When a drug plausibly targets a pathway uniquely related to a specific genetic aberration, eligibility should begin with this subset, including patients with other malignancies, with subsequent extension to other patients. In other cases, a more open-minded approach to initial eligibility would facilitate quicker identification of responsive subsets. Complete remission without minimal residual disease seems a particularly useful short-term end point. Genotypic and phenotypic studies should be prespecified and performed routinely to distinguish responders from nonresponders.
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A randomised comparison of the novel nucleoside analogue sapacitabine with low-dose cytarabine in older patients with acute myeloid leukaemia. Leukemia 2015; 29:1312-9. [PMID: 25676423 DOI: 10.1038/leu.2015.38] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 12/01/2014] [Accepted: 12/10/2014] [Indexed: 11/08/2022]
Abstract
The development of new treatments for older patients with acute myeloid leukaemia (AML) is an active area, but has met with limited success. Sapacitabine is a novel orally administered nucleoside analogue that has shown encouraging activity in unrandomised early-stage trials. We randomised 143 untreated patients with AML or with high-risk myelodysplastic syndrome (>10% marrow blasts) between sapacitibine and low-dose ara-C (LDAC) in our 'Pick a Winner' trial design. At the planned interim analysis there was no difference between LDAC and sapacitibine in terms of remission rate (CR/CRi, 27% vs 16% hazard ratio (HR) 1.98(0.90-4.39) P=0.09), relapse-free survival (10% vs 14% at 2 years, HR 0.73(0.33-1.61) P=0.4) or overall survival (OS; 12% vs 11% at 2 years, HR 1.24(0.86-1.78) P=0.2). Sapacitibine was well tolerated, apart from more grade 3/4 diarrhoea. On the basis of these findings sapacitibine did not show sufficient evidence of benefit over LDAC for the trial to be continued.
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46
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Mussai FJ, Yap C, Mitchell C, Kearns P. Challenges of clinical trial design for targeted agents against pediatric leukemias. Front Oncol 2015; 4:374. [PMID: 25610810 PMCID: PMC4285052 DOI: 10.3389/fonc.2014.00374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 12/15/2014] [Indexed: 12/16/2022] Open
Abstract
The past 40 years have seen significant improvements in both event-free and overall survival for children with acute lymphoblastic and acute myeloid leukemia (ALL and AML, respectively). Serial national and international clinical trials have optimized the use of conventional chemotherapeutic drugs and, along with improvements in supportive care that have enabled the delivery of more intensive regimens, have been responsible for the major improvements in patient outcome seen over the past few decades. However, the benefits of dose intensification have likely now been maximized, and over the same period, the identification of new cytotoxic drugs has been limited. Therefore, challenges remain if survival is to be improved further. In pediatric ALL, 5-year-survival rates of over 85% have been achieved with risk-stratified therapy, but a notable minority of patients will still not be cured. In pediatric AML, different challenges remain. A slower improvement in overall survival has taken place in this patient population. Despite the obvious morphological heterogeneity of AML blasts, biological stratification is comparatively limited, and translation into risk-stratified therapeutic approaches has only best characterized by the use of retinoic acid for t(15;17)-positive AML. Even where prognostic markers have been identified, limited therapeutic options or multi-drug resistance of AML blasts has limited the impact on patient benefit. For both, the acute morbidities of current treatment remain significant and may be life-threatening alone. In addition, the Childhood Cancer Survivor Study (CCSS) highlighted many leukemia survivors develop one or more chronic medical conditions attributable to treatment (1, 2). As the biology of leukemogenesis has become better understood, key molecules and intracellular pathways have been identified that offer the possibility of targeting directly the leukemia cells while sparing normal cells. Consequently, there is now a drive to develop novel leukemia-specific or "targeted" therapies. These new classes of drugs will have mechanisms of action, toxicities, and therapeutic indices quite different from conventional cytotoxic drugs previously encountered, thus rendering current clinical trial methodologies inappropriate. Clinical trial methods will need to be adapted to accommodate these features of these new classes of drugs. This review will address the challenges and some of the techniques for developing clinical trials for targeted therapies.
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Affiliation(s)
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, School of Cancer Sciences, University of Birmingham, Birmingham, UK
| | - Christopher Mitchell
- Department of Paediatric Oncology, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Pamela Kearns
- Cancer Research UK Clinical Trials Unit, School of Cancer Sciences, University of Birmingham, Birmingham, UK
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Abstract
Acute myeloid leukemia (AML) in older patients presents a notable therapeutic challenge to the clinical hematologist. The clinical biology of AML among patients is highly heterogeneous. Interpatient variations are relevant for prognosis and treatment choice. Outcome of treatment for patients of advanced age is often compromised by comorbid conditions and an enhanced susceptibility to toxicities from therapy. Here we present selected clinical vignettes that highlight distinct representative situations derived from clinical practice. The vignettes are specifically discussed in light of the perspective of treating older patients with leukemia. We review the clinical significance of various cytogenetic and molecular features of the disease, and we examine the various currently available treatment options as well as the emerging prognostic algorithms that may offer guidance in regard to personalized therapy recommendations. The dilemmas in tailoring treatment selection in this category of patients with AML are the central theme in this discussion.
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Roboz GJ. Epigenetic targeting and personalized approaches for AML. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:44-51. [PMID: 25696833 DOI: 10.1182/asheducation-2014.1.44] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Acute myeloid leukemia (AML) is a genetically heterogeneous clonal hematopoietic stem cell disorder and the majority of patients with AML die from their disease. The treatment paradigms for AML were developed decades ago and, although there have been improvements in the outcomes of selected younger patients and those with specific cytogenetic and molecular genetic characteristics, the overall survival for older patients remains dismal. Over the last few years, next-generation sequencing technologies have identified recurrent mutations in genes encoding proteins involved in the epigenetic regulation of transcription in most patients with AML. This discovery has led to new insights into the role of the epigenome in AML and opens the possibility of epigenetically targeted therapies. This chapter describes how epigenetic dysregulation plays a role in AML and highlights current and future treatment strategies that attempt to exploit epigenetic targets.
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Affiliation(s)
- Gail J Roboz
- Leukemia Program, Weill Medical College of Cornell University and New York Presbyterian Hospital, New York, NY
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Abstract
PURPOSE OF REVIEW Future advances in childhood cancer treatment will pivot on developing biology-driven new drug development pathways that build on current knowledge of oncogenic pathways; however, we need to address major barriers to accessing new drugs for clinical evaluation in childhood cancers. RECENT FINDINGS Through legislative change, substantial incentives to the pharmaceutical industry to invest in the ultra-rare diseases, such as childhood cancers, have encouraged greater engagement with paediatric oncology drug development consortia. Disappointingly, this has not translated into paediatric-focussed drug development. Adult disease-driven drug development will continue to dominate until biology/target-driven approaches prevail.There are specific challenges to undertaking early drug development trials in children with incurable disease. The balance between risk and benefit for a child participating in trials wherein the chance of clinical benefit is indeterminate has the potential for unrealistic optimism by both physicians and families. Importantly, innovative trial designs that assess safety and maximize information on potential efficacy from small patient numbers are needed. SUMMARY International collaboration in early phase trial consortia addresses these challenges. Academic networks concentrating early phase trials expertise and delivery of innovative trial designs will maximize appropriate selection of drugs that can translate into therapeutic advantage when incorporated into standard care.
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Affiliation(s)
- Pamela Kearns
- aUniversity of Birmingham bBirmingham Children's Hospital, Birmingham, West Midlands, UK
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Fenaux P, Seymour JF, Santini V, Silverman L, Gore S, List A, Sanz G, Mufti GJ, Estey E, Swern AS, Beach C, Hellstrom-Lindberg E. Challenges of phase III trial design for novel treatments in diseases with no standard treatment: The AZA-001 myelodysplasia study model. Leuk Res 2014; 38:258-62. [DOI: 10.1016/j.leukres.2013.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 10/17/2013] [Accepted: 10/19/2013] [Indexed: 11/26/2022]
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