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Molica S, Mauro FR. The new life of ibrutinib therapy in CLL: enhancing personalized approaches. Expert Rev Anticancer Ther 2024; 24:789-792. [PMID: 38993050 DOI: 10.1080/14737140.2024.2379921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 07/10/2024] [Indexed: 07/13/2024]
Affiliation(s)
- Stefano Molica
- Department of Hematology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, 'Sapienza' University, Rome, Italy
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Huntington SF, Cheng WY, Sarpong EM, Leng S, Farooqui MZH, Agu US, Catillon M, Lejeune D, Downes N, Matay L, Duh MS, De Nigris E. Real-world patterns and sequences of targeted therapy use in chronic lymphocytic leukemia and small lymphocytic lymphoma in the United States: a longitudinal study. Leuk Lymphoma 2024; 65:932-942. [PMID: 38696747 DOI: 10.1080/10428194.2024.2331631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/12/2024] [Indexed: 05/04/2024]
Abstract
With increasing focus on novel targeted therapies for chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), this longitudinal claims-based study evaluated real-world CLL/SLL treatment sequences, particularly sequential targeted therapy. Among patients with first-line (1 L) treatment in 2014-2017 (N = 2,612; median follow-up = 3 years), the most common 1 L treatment was chemoimmunotherapy (CIT; 44.6%), followed by CD20 (25.2%) and Bruton's tyrosine kinase inhibitors (BTKi; 21.7%). Among those with 1 L in 2018-2021 (N = 4,534; median follow-up = 1 year), these were BTKi (45.5%), CD20 (20.4%), CIT (17.5%), and B-cell lymphoma 2 inhibitor (8.3%). In 2014-2017, the proportion of patients receiving sequential targeted therapy in the first 2 LOTs was 11.2% (80.2% was BTKi→BTKi); in 2018-2021, this proportion was 34.3% (66.4% was BTKi→BTKi). Over time, there was a substantial increase in targeted therapy use in 1 L and sequential targeted therapy, particularly with BTKi→BTKi. Future studies should assess clinical outcomes to determine optimal sequences for CLL/SLL and reasons for restarting BTKi.
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Dartigeas C, Quinquenel A, Ysebaert L, Dilhuydy MS, Anglaret B, Slama B, Le Du K, Tardy S, Tchernonog E, Orfeuvre H, Voillat L, Guidez S, Malfuson JV, Dupuis S, Deslandes M, Feugier P, Leblond V. Final results on effectiveness and safety of Ibrutinib in patients with chronic lymphocytic leukemia from the non-interventional FIRE study. Ann Hematol 2024:10.1007/s00277-024-05666-3. [PMID: 38443660 DOI: 10.1007/s00277-024-05666-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
We conducted an observational study (FIRE) to understand the effectiveness and safety outcomes of ibrutinib in patients with chronic lymphocytic leukemia (CLL) in France, after a maximum follow-up of five years. Patients were included according to the French marketing authorization in 2016 (i.e. patients with relapsed or refractory CLL or to previously untreated CLL patients with deletion 17p and/or tumor protein p53 mutations unsuitable for chemoimmunotherapy) and could have initiated ibrutinib more than 30 days prior their enrolment in the study (i.e. retrospective patients) or between 30 days before and 14 days after their enrolment (i.e. prospective patients). The results showed that in the effectiveness population (N = 388), the median progression-free survival (PFS) was 53.1 (95% CI: 44.5-60.5) months for retrospective patients and 52.9 (95% CI: 40.3-60.6) months for prospective patients and no difference was shown between the PFS of patients who had at least one dose reduction versus the PFS of patients without dose reduction (p = 0.7971 for retrospective and p = 0.3163 for prospective patients). For both retrospective and prospective patients, the median overall survival was not reached. The most frequent treatment-emergent adverse event of interest was infections (57.6% retrospective; 71.4% prospective). A total of 14.6% of the retrospective patients and 22.4% of the prospective patients had an adverse event leading to death. Our findings on effectiveness were consistent with other studies and the fact that patients with dose reductions had similar PFS than patients without dose reduction is reassuring. No additional safety concerns than those already mentioned in previous studies could be noticed.Trial registration ClinicalTrials.gov, NCT03425591. Registered 1 February 2018 - Retrospectively registered.
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Affiliation(s)
- Caroline Dartigeas
- Hématologie et Thérapie Cellulaire, CHRU Hôpitaux de Tours, 2 Boulevard Tonnellé, 37044, Tours Cedex 9, France.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Véronique Leblond
- AP-HP Hôpital de La Pitié-Salpêtrière, Paris La Sorbonne, Paris, France
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Gatwood J, Dashputre A, Rajpurohit A, Gatwood K, Mackler E, Wallace L, Farris K, Rizvi-Toner A, Farley J. Impact of initiating oral anticancer agents for leukemia on adherence to medications for multiple chronic conditions. J Oncol Pharm Pract 2024; 30:342-353. [PMID: 37113049 DOI: 10.1177/10781552231171926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Increased use of oral anticancer agents (OAAs) has empowered adults with chronic lymphocytic leukemia (CLL) and chronic myelogenous leukemia (CML) to manage their therapy, but this shift may complicate medication use, particularly among adults with multiple chronic conditions (MCC). METHODS This retrospective cohort study used 2013-2018 commercial and Medicare claims data to assess medication use in adults with CML or CLL. To be included, patients must have been at least 18 years old, diagnosed with and had 2+ claims for an OAA indicated for either CML or CLL, continuously enrolled 12 months before and after OAA initiation, and treated for (2+ fills) at least two select chronic conditions. Proportion of days covered (PDC) determined medication adherence and was compared for 12 months before and after OAA initiation by Wilcoxon signed-rank tests, McNemar's tests, and difference-in-differences models. RESULTS Among CLL patients, mean OAA adherence in the first year of therapy was 79.8% (SD: 21.1) and 74.7% (SD: 24.9) for commercial and Medicare patients, respectively; mean adherence for CML patients was 84.5% (SD: 15.8) and 80.1% (SD: 20.1) for commercial and Medicare patients, respectively. Adherence and the proportion adherent (PDC ≥ 80%) to comorbid therapies was generally unchanged following OAA initiation. Consistently unremarkable changes in MCC adherence were observed in 12-month difference-in-differences models, but significant decline was observed in MCC adherence after 6 months of OAA use. CONCLUSIONS OAA initiation among adults with CML or CLL was not associated with significant, initial changes to adherence to medications for chronic diseases.
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Affiliation(s)
- Justin Gatwood
- University of Tennessee Health Science Center, Nashville, TN, USA
| | - Ankur Dashputre
- University of Tennessee Health Science Center, Nashville, TN, USA
| | | | - Katie Gatwood
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Emily Mackler
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Leah Wallace
- University of Tennessee Health Science Center, Nashville, TN, USA
| | - Karen Farris
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | | | - Joel Farley
- University of Minnesota College of Pharmacy, Minneapolis, MN, USA
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Huntington SF, de Nigris E, Puckett JT, Kamal-Bahl S, Farooqui M, Ryland K, Sarpong EM, Leng S, Yang X, Doshi JA. Real-world analysis of adverse event rates after initiation of ibrutinib among Medicare beneficiaries with chronic lymphocytic leukemia. Cancer Med 2024; 13:e6953. [PMID: 38348963 PMCID: PMC10832339 DOI: 10.1002/cam4.6953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/11/2023] [Accepted: 01/10/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND The first-generation BTK inhibitor ibrutinib is a standard-of-care therapy in the treatment of chronic lymphocytic leukemia (CLL) despite potential side effects that often lead to discontinuation. METHODS This study used 2013-2019 claims data to describe the incidence rate of adverse events (AEs) among elderly Medicare beneficiaries newly initiating ibrutinib for CLL. RESULTS The final sample contained 11,870 Medicare beneficiaries with CLL (mean age 77.2) newly initiating ibrutinib, of whom 65.2% discontinued over mean follow-up of 2.3 years. The overall incidence rate of AEs was 62.5 per 1000 patient-months for all discontinuers and 32.9 per 1000 patient-months for non-discontinuers. Discontinuers had a higher incidence rate of AEs per 1000 patient-months compared with non-discontinuers for all AEs examined, including infection (22.8 vs. 14.5), atrial fibrillation (15.1 vs. 7.0), anemia (21.9 vs. 14.5), and arthralgia/myalgia (19.5 vs. 13.6). CONCLUSION In this first real-world study of a national sample of elderly US patients treated with ibrutinib, we found a clear unmet need for improved management of ibrutinib-related AEs and/or new treatments to improve real-world outcomes in patients with CLL.
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Affiliation(s)
- Scott F Huntington
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | | | | | | | | | | | | | - Jalpa A Doshi
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Huntington SF, Manzoor BS, Puckett JT, Kamal-Bahl S, Alhasani H, Ravelo A, Jawaid D, Doshi JA. Real-world adherence and discontinuation among Medicare beneficiaries initiating venetoclax vs. BTKis in relapsed/refractory chronic lymphocytic leukemia. Leuk Lymphoma 2023; 64:2316-2323. [PMID: 37732602 DOI: 10.1080/10428194.2023.2255326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/30/2023] [Indexed: 09/22/2023]
Abstract
The treatment landscape for chronic lymphocytic leukemia (CLL) has been transformed by the availability of Bruton's tyrosine kinase inhibitors (BTKis) and the B-cell lymphoma 2 (BCL-2) inhibitor venetoclax. Despite clinical trial data supporting these novel oral agents, evidence evaluating real-world adherence is limited. This study used 2015-2019 Medicare claims data for elderly patients with relapsed/refractory CLL to assess differences in real-world adherence and discontinuation in the 12 months after treatment initiation. In the final sample of 711 venetoclax patients and 1,566 BTKi patients, we found that those initiating venetoclax tended to be younger (mean age 75.6 [SD 6.0] vs 77.6 [SD 6.9] years, p < .001) but had poorer clinical characteristics. After risk-adjustment, the venetoclax group had higher adherence (61.9% vs. 45.4%, p < .0001) and lower discontinuation when compared to the BTKi group (28.5% vs. 47.4%, p < .001). These favorable real-world findings underscore the importance of developing well-tolerated novel combinations for older adults.
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Affiliation(s)
- Scott F Huntington
- Department of Internal Medicine, Section of Hematology, Yale University, New Haven, CT, USA
| | | | | | | | | | | | | | - Jalpa A Doshi
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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7
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Huntington SF, de Nigris E, Puckett J, Kamal-Bahl S, Farooqui M, Ryland K, Sarpong E, Leng S, Yang X, Doshi JA. Ibrutinib discontinuation and associated factors in a real-world national sample of elderly Medicare beneficiaries with chronic lymphocytic leukemia. Leuk Lymphoma 2023; 64:2286-2295. [PMID: 37870435 DOI: 10.1080/10428194.2023.2256911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 09/02/2023] [Indexed: 10/24/2023]
Abstract
Prior studies evaluating ibrutinib discontinuation are limited to clinical trials and selected medical centers and hence may not reflect real-world practice. This study used Medicare claims (2013-2019) to examine ibrutinib discontinuation and associated factors among elderly patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). Over a median follow-up of 2.1 years, two-thirds (65.2%) of the 11,870 new ibrutinib initiators were discontinued, with half (45.1%) of patients discontinuing within 12 months of initiation. Factors such as advanced age, lack of Part D low-income subsidy, evidence of prior CLL/SLL treatment, and cardiovascular comorbidities (e.g. atrial fibrillation) were associated with higher risk of discontinuation. Over a median of 1.2 years from discontinuation, 40% of discontinuers initiated another CLL/SLL treatment after ibrutinib discontinuation; 25% of patients restarted ibrutinib treatment at some point over follow-up. Our findings point to a large unmet need with the widely used BTKi ibrutinib and underscore the importance of ongoing development of efficacious and well-tolerated CLL/SLL therapies.
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Affiliation(s)
- Scott F Huntington
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | | | | | | | | | | | | | | | | | - Jalpa A Doshi
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Barrientos JC, Ayed AO, Cha A, Du S, Fang B, Hall R, Marks SM, Peng E, Rhodes JM, Ryan K, Winters SB, Yeung PL, Hou JZ. Results from a Real-World Multicenter Analysis of 482 Patients with Chronic Lymphocytic Leukemia Treated with Ibrutinib: A Look at Racial Differences. Target Oncol 2023; 18:727-734. [PMID: 37728835 PMCID: PMC10517886 DOI: 10.1007/s11523-023-00988-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Despite recent approvals of lifesaving treatments for chronic lymphocytic leukemia (CLL), real-world data on the tolerability of the Bruton tyrosine kinase inhibitor ibrutinib for CLL treatment are lacking, especially in Black patients. OBJECTIVE To expand upon a previously reported retrospective chart review of ibrutinib-treated patients with CLL to increase the number of sites and the enrollment period in first-line (1L) and relapsed/refractory (R/R) settings with a subanalysis based on ethnicity. PATIENTS AND METHODS Adults with CLL who initiated ibrutinib treatment from five centers were followed for ≥ 6 months. RESULTS We identified 482 patients with CLL [405 White (153 1L, 252 R/R), 37 Black (17 1L, 20 R/R), 40 other/unidentified]. At baseline, 58.5% of all patients (68.8% of Black patients) had hypertension. At a median follow-up of 28.2 months, 31.1% of patients overall discontinued ibrutinib, 16.2% due to adverse events (12.2% 1L, 18.8% R/R). Overall, 46.0% of patients experienced ≥ 1 dose hold (40.2% 1L, 49.8% R/R), and 28.8% of patients experienced ≥ 1 dose reduction (24.9% 1L, 31.4% R/R). Among Black patients, ibrutinib was discontinued in 24.3% of patients (17.6% 1L, 30.0% R/R), 8.1% due to disease progression and 5.4% due to adverse events; 40.5% of patients experienced ≥ 1 dose hold (35.3% 1L, 45.0% R/R), and 32.4% of patients experienced ≥ 1 dose reduction (23.5% 1L, 40.0% R/R). CONCLUSIONS Toxicity and disease progression were the most common reasons for ibrutinib discontinuations in the overall population and among Black patients, respectively. Encouraging research participation of underrepresented patient groups will help clinicians better understand treatment outcomes.
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Affiliation(s)
- Jacqueline C Barrientos
- Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY and Mount Sinai Comprehensive Cancer Center, Miami, FL, USA
| | - Ayed O Ayed
- Cancer Specialists of North Florida, Jacksonville, FL, USA
| | - Agnes Cha
- Northwell Health, New Hyde Park, NY, USA
| | - Senxi Du
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Bruno Fang
- Astera Cancer Care, East Brunswick, NJ, USA
| | - Ryan Hall
- CARTI Cancer Center, Little Rock, AR, USA
| | - Stanley M Marks
- University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, 5115 Centre Ave, Pittsburgh, PA, 15232, USA
| | | | | | | | - Sharon B Winters
- University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, 5115 Centre Ave, Pittsburgh, PA, 15232, USA
| | | | - Jing-Zhou Hou
- University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, 5115 Centre Ave, Pittsburgh, PA, 15232, USA.
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Roeker LE, DerSarkissian M, Ryan K, Chen Y, Duh MS, Wahlstrom SK, Hakre S, Yu L, Guo H, Mato AR. Real-world comparative effectiveness of acalabrutinib and ibrutinib in patients with chronic lymphocytic leukemia. Blood Adv 2023; 7:4291-4301. [PMID: 37163361 PMCID: PMC10424141 DOI: 10.1182/bloodadvances.2023009739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/06/2023] [Accepted: 04/27/2023] [Indexed: 05/12/2023] Open
Abstract
Novel agents, including Bruton tyrosine kinase inhibitors (BTKis), have become the standard of care for patients with chronic lymphocytic leukemia (CLL). We conducted a real-world retrospective analysis of patients with CLL treated with acalabrutinib vs ibrutinib using the Flatiron Health database. Patients with CLL were included if they initiated acalabrutinib or ibrutinib between 1 January 2018 and 28 February 2021. The primary outcome of interest was time to treatment discontinuation (TTD). Kaplan-Meier analysis was used to estimate unweighted and weighted median TTD. A weighted Cox proportional hazards model was used to compare the TTD between cohorts. Of the 2509 patients included in the analysis, 89.6% received ibrutinib, and 14.1% received acalabrutinib. TTD was not significantly different between cohorts in the unweighted analysis. After weighting, the cohorts were balanced on all baseline characteristics except cardiovascular risk factors and baseline medications use. The median (95% confidence interval [CI]) TTD was not reached (NR; 95% CI, 25.1 to NR) for the acalabrutinib cohort and was 23.4 months (95% CI, 18.1-28.7) for the ibrutinib cohort. The discontinuation rate at 12 months was 22% for the weighted acalabrutinib cohort vs 31% for the weighted ibrutinib cohort (P = .005). After additional adjustment for prior BTKi use, the acalabrutinib cohort had a 41% lower risk of discontinuation vs ibrutinib (hazard ratio, 0.59; 95% CI, 0.43-0.81; P = .001). In the largest available study comparing BTKis, patients with CLL receiving acalabrutinib demonstrated lower rates of discontinuation and a prolonged time to discontinuation vs those receiving ibrutinib.
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Affiliation(s)
- Lindsey E. Roeker
- CLL Program, Leukemia Service, Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Kellie Ryan
- Global Medical Affairs, AstraZeneca Pharmaceuticals, Gaithersburg, MD
| | | | | | - Svea K. Wahlstrom
- US Patient Safety Surveillance, AstraZeneca Pharmaceuticals, Wilmington, DE
| | - Shweta Hakre
- US Medical Affairs, AstraZeneca Pharmaceuticals, Gaithersburg, MD
| | | | | | - Anthony R. Mato
- CLL Program, Leukemia Service, Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
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Lachaine J, Guinan K, Aw A, Banerji V, Fleury I, Owen C. Impact of Fixed-Duration Oral Targeted Therapies on the Economic Burden of Chronic Lymphocytic Leukemia in Canada. Curr Oncol 2023; 30:4483-4498. [PMID: 37232797 DOI: 10.3390/curroncol30050339] [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: 03/21/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Continuous oral targeted therapies (OTT) represent a major economic burden on the Canadian healthcare system, due to their high cost and administration until disease progression/toxicity. The recent introduction of venetoclax-based fixed-duration combination therapies has the potential to reduce such costs. This study aims to estimate the prevalence and the cost of CLL in Canada with the introduction of fixed OTT. METHODS A state transition Markov model was developed and included five health states: watchful waiting, first-line treatment, relapsed/refractory treatment, and death. The number of CLL patients and total cost associated with CLL management in Canada for both continuous- and fixed-treatment-duration OTT were projected from 2020 to 2025. Costs included drug acquisition, follow-up/monitoring, adverse event, and palliative care. RESULTS The CLL prevalence in Canada is projected to increase from 15,512 to 19,517 between 2020 and 2025. Annual costs were projected at C$880.7 and C$703.1 million in 2025, for continuous and fixed OTT scenarios, respectively. Correspondingly, fixed OTT would provide a total cost reduction of C$213.8 million (5.94%) from 2020 to 2025, compared to continuous OTT. CONCLUSIONS Fixed OTT is expected to result in major reductions in cost burden over the 5-year projection, compared to continuous OTT.
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Affiliation(s)
- Jean Lachaine
- Faculty of Pharmacy, University of Montreal, Montreal, QC H3T 1J4, Canada
- PeriPharm Inc., Montreal, QC H2Y 2H4, Canada
| | | | - Andrew Aw
- Ottawa Hospital, Ottawa, ON K1H 8L6, Canada
| | - Versha Banerji
- CancerCare Manitoba Research Institute, Winnipeg, MB R3E 0V9, Canada
- Departments of Internal Medicine and Biochemistry & Medical Genetics, Rady Faculty of Health Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB R3E 0W2, Canada
| | - Isabelle Fleury
- Maisonneuve-Rosemont Hospital, Institut Universitaire Hémato-Oncologie Transplantation Cellulaire, Montreal University, Montreal, QC H1T 2M4, Canada
| | - Carolyn Owen
- Foothills Medical Centre, Calgary, AB T2N 2T9, Canada
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Tran E, Ledbetter LE. A retrospective evaluation of direct oral anticoagulant (DOAC) management strategies in patients with cancer on active chemotherapy. J Thromb Thrombolysis 2023; 55:721-728. [PMID: 36781620 DOI: 10.1007/s11239-023-02778-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 02/15/2023]
Abstract
Use of direct oral anticoagulants (DOACs) in patients with cancer on active chemotherapy is challenging due to changes in renal or hepatic function, thrombocytopenia, chemotherapy-induced nausea and vomiting (CINV), and drug-drug interactions (DDIs) attributed to disease or treatment. The purpose of this retrospective cohort analysis was to characterize DOAC management through various interventions and evaluate the efficacy and safety of DOAC use in this patient population. A total of 58 patients with 97 unique index periods in which a patient was concomitantly on a DOAC and chemotherapy were identified. Several instances were observed in which an intervention should be made based on manufacturer guidance or clinical judgment. Of 37 instances attributed to changes in renal function, the following interventions were employed: dose adjustments (10/37), holding DOAC therapy until renal function improved (held 3/37, restarted 4/37), changing to an alternative anticoagulant (5/37), DOAC discontinuation (2/37), or no change (13/37). One change was made in response to decreased hepatic function (1/15). DOACs were held in the setting of platelet counts below 50 K/mm3 (8/20) and restarted when platelets improved above this threshold (5/20). In patients with CINV, DOAC therapy was continued (26/32) with few changes made. To manage DOAC-chemotherapy DDIs, changes in DOAC agents (4/6) and dose reductions in chemotherapy agents (2/6) were made. Thrombotic and bleeding events did not strongly correlate with renal or hepatic impairment, thrombocytopenia, CINV, or DDIs. Further guidance regarding the use of these agents in this patient population is warranted to address management strategies, efficacy, and safety. Use of direct oral anticoagulants (DOACs) in patients with cancer on active chemotherapy is challenging due to changes in renal or hepatic function, thrombocytopenia, chemotherapy-induced nausea and vomiting (CINV), and drug-drug interactions (DDIs) attributed to disease or treatment. The purpose of this retrospective cohort analysis was to characterize DOAC management and evaluate the efficacy and safety of DOAC use in this patient population. A total of 58 patients with 97 unique index periods in which a patient was concomitantly on a DOAC and chemotherapy were identified. Several instances were observed in which an intervention should be made based on manufacturer guidance or clinical judgment. Interventions employed are summarized graphically. Thrombotic and bleeding events did not strongly correlate with renal or hepatic impairment, thrombocytopenia, CINV, or DDIs. CINV chemotherapy-induced nausea and vomiting, DDIs drug-drug interactions, DOAC direct oral anticoagulant, OAC oral anticoagulant.
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Affiliation(s)
- Emmeline Tran
- Department of Clinical Pharmacy and Outcome Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Lauren E Ledbetter
- Department of Pharmacy, Wexner Medical Center, Ohio State University, Columbus, OH, USA
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12
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Sarosiek S, Gustine JN, Flynn CA, Leventoff C, Little M, White T, Meid K, Treon SP, Castillo JJ. Dose reductions in patients with Waldenström macroglobulinaemia treated with ibrutinib. Br J Haematol 2023; 201:897-904. [PMID: 36626914 DOI: 10.1111/bjh.18643] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/19/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023]
Abstract
Waldenström macroglobulinaemia (WM) is characterized by the presence of a MYD88L265P mutation. This mutation promotes growth and survival of malignant cells through Bruton tyrosine kinase (BTK) activation. Ibrutinib was the first BTK inhibitor approved for WM. Intolerance to ibrutinib frequently leads to dose reductions, though the impact of reducing ibrutinib dosing has not been systematically studied. We performed a retrospective study to determine the frequency and impact of reducing ibrutinib dosing in WM patients. With a median treatment time of 64 months, 96 (27%) of 353 WM patients required a dose reduction due to adverse events such as musculoskeletal symptoms, cardiac events, dermatologic symptoms, cytopenias, and gastrointestinal symptoms. The median time to initial dose reduction was 9.3 months (range, 0.5-74). Dose reductions were more common in those 65 years of age or older versus under 65 [hazard ratio (HR) 2.46, 95% confidence interval (CI) 1.55-3.90; p < 0.001], and in females versus males (HR 2.20, 95% CI 1.41-3.28, p < 0.001). Most patients (65%) had improvement or resolution of adverse effects after initial dose reduction. With a median follow-up of three years from dose reduction, hematologic response sustained or deepened in 79% of patients. These data suggest that dose reduction of ibrutinib is a reasonable treatment approach for patients with intolerable side effects.
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Affiliation(s)
- Shayna Sarosiek
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua N Gustine
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Catherine A Flynn
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Carly Leventoff
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Megan Little
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Timothy White
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Kirsten Meid
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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13
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Chen L, Li C, Bai H, Li L, Chen W. Use of modeling and simulation to predict the influence of triazole antifungal agents on the pharmacokinetics of zanubrutinib and acalabrutinib. Front Pharmacol 2022; 13:960186. [PMID: 36299883 PMCID: PMC9588929 DOI: 10.3389/fphar.2022.960186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Bruton’s tyrosine kinase (BTK) inhibitors are commonly used in the targeted therapy of B-cell malignancies. It is reported that myelosuppression and fungal infections might occur during antitumor therapy of BTK inhibitors, therefore a combination therapy with triazole antifungals is usually required. Objective: To evaluate the influence of different triazoles (voriconazole, fluconazole, itraconazole) on the pharmacokinetics of BTK inhibitors (zanubrutinib, acalabrutinib) and to quantify the drug-drug interactions (DDIs) between them. Methods: The physiologically-based pharmacokinetic (PBPK) models were developed based on pharmacokinetic parameters and physicochemical data using Simcyp® software. These models were validated using clinically observed plasma concentrations data which based on existing published studies. The successfully validated PBPK models were used to evaluate and predict potential DDIs between BTK inhibitors and different triazoles. BTK inhibitors and triazole antifungal agents were simulated by oral administration. Results: Simulated plasma concentration-time profiles of the zanubrutinib, acalabrutinib, voriconazole, fluconazole, and itraconazole are consistent with the clinically observed profiles which based on existing published studies, respectively. The exposures of BTK inhibitors increase by varying degrees when co-administered with different triazole antifungals. At multiple doses regimen, voriconazole, fluconazole and itraconazole may increase the area under plasma concentration-time curve (AUC) of zanubrutinib by 127%, 81%, and 48%, respectively, and may increase the AUC of acalabrutinib by 326%, 119%, and 264%, respectively. Conclusion: The PBPK models sufficiently characterized the pharmacokinetics of BTK inhibitors and triazole antifungals, and were used to predict untested clinical scenarios. Voriconazole exhibited the greatest influence on the exposures of BTK inhibitors. The dosage of zanubrutinib or acalabrutinib need to be reduced when co-administered with moderate CYP3A inhibitors.
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Affiliation(s)
- Lu Chen
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
| | - Chao Li
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
| | - Hao Bai
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
| | - Lixian Li
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
| | - Wanyi Chen
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
- Chongqing University, Chongqing, China
- *Correspondence: Wanyi Chen,
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14
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Molica S, Allsup DJ, Polliack A. Adherence to ibrutinib remains an unmet clinical need in chronic lymphocytic leukemia. Leuk Lymphoma 2022; 63:1771-1773. [DOI: 10.1080/10428194.2022.2087072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Stefano Molica
- Department Hematology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - David John Allsup
- Department Hematology, Hull University Teaching Hospitals NHS Trust, Hull, UK
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, University of Hull, Hull, UK
| | - Aaron Polliack
- Department of Hematology, Hadassah-Hebrew-University Medical Center, Jerusalem, Israel
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15
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Guo Y, Pei H, Lu B, Zhang D, Zhao Y, Wu F, Sun H, Huang J, Li P, Yi C, Zhu C, Pan Y, Wu S, Chen C, Xu X, Chen Y. Aberrantly expressed Wnt5a in nurse-like cells drives resistance to Venetoclax in chronic lymphocytic leukemia. Cell Death Dis 2022; 8:82. [PMID: 35210425 PMCID: PMC8873424 DOI: 10.1038/s41420-022-00884-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/28/2022] [Accepted: 02/10/2022] [Indexed: 11/29/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is characterized by the accumulation of neoplastic B lymphocytes with high levels of Wnt5a in the plasma. Currently, the cell source of Wnt5a remains controversial. The receptor of Wnt5a is ROR1, whose expression is associated with disease progression and resistance to venetoclax, a BCL-2 inhibitor approved for the treatment of CLL. In this study, we found that the levels of Wnt5a in the plasma of CLL patients were positively correlated with absolute monocyte counts, but not lymphocyte counts. We cultured monocyte-derived nurse-like cells (NLCs) from patients with CLL, and detected Wnt5a expressed in NLCs. Flow cytometry and transwell assays showed that the antibody neutralizing Wnt5a inhibited the enhanced survival and migration in CLL cells co-cultured with NLCs. Furthermore, we performed a drug screening with CLL cells cultured with or without NLCs with a library containing 133 FDA-approved oncology drugs by using high-throughput flow cytometry. We observed a significant resistance to venetoclax in CLL cells co-cultured with NLCs. Immunoblot revealed the activation of NF-κB with enhanced expression of MCL-1 and BCL-XL in CLL cells co-cultured with NLCs. Neutralizing Wnt5a or blocking NF-κB pathway significantly decreased the expression of MCL-1 and BCL-XL, which leads to enhanced sensitivity to venetoclax in CLL cells co-cultured with NLCs. In conclusion, our data showed that NLCs could be one of the sources of Wnt5a detected in patients with CLL, and Wnt5a-induced NF-κB activation in the CLL microenvironment results in resistance to venetoclax in CLL cells.
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Affiliation(s)
- Yao Guo
- Edmond H. Fischer Translational Medical Research Laboratory, Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Hanzhong Pei
- Edmond H. Fischer Translational Medical Research Laboratory, Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Bo Lu
- Department of Hematology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Dengyang Zhang
- Edmond H. Fischer Translational Medical Research Laboratory, Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Yuming Zhao
- Edmond H. Fischer Translational Medical Research Laboratory, Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Fuqun Wu
- Clinical laboratory, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Honghua Sun
- Clinical laboratory, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Junbin Huang
- Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Peng Li
- Edmond H. Fischer Translational Medical Research Laboratory, Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Chenju Yi
- Edmond H. Fischer Translational Medical Research Laboratory, Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Chengming Zhu
- Edmond H. Fischer Translational Medical Research Laboratory, Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Yihang Pan
- Edmond H. Fischer Translational Medical Research Laboratory, Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Shunjie Wu
- Department of Hematology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China
| | - Chun Chen
- Department of Pediatrics, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China.
| | - Xiaojun Xu
- Department of Hematology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China.
| | - Yun Chen
- Edmond H. Fischer Translational Medical Research Laboratory, Scientific Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, 518107, Guangdong, China.
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16
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Hou JZ, Ryan K, Du S, Fang B, Marks S, Page R, Peng E, Szymanski K, Winters S, Le H. Real-world ibrutinib dose reductions, holds and discontinuations in chronic lymphocytic leukemia. Future Oncol 2021; 17:4959-4969. [PMID: 34783255 DOI: 10.2217/fon-2021-0964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: A retrospective chart review of ibrutinib-treated patients with chronic lymphocytic leukemia (CLL) was conducted. Patients & methods: Adults with CLL who initiated ibrutinib were followed for ≥6 months (n = 180). Results: Twenty-five percent of first-line ibrutinib patients experienced ≥1 dose reduction, mainly due to adverse events (AEs; 79%). Treatment discontinuations and dose holds occurred in 20 and 34% of patients, respectively, most commonly due to AEs (73 and 74%). Approximately one-quarter of relapsed/refractory ibrutinib patients experienced ≥1 dose reduction, mainly due to AEs (88%). Treatment discontinuation and dose holds occurred in 40% of patients (58 and 76% due to AEs, respectively). Conclusion: Dose reductions, holds and discontinuations were frequent in patients with CLL receiving ibrutinib in routine clinical practice.
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Affiliation(s)
- Jing-Zhou Hou
- University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, Pittsburgh, PA 15232, USA
| | - Kellie Ryan
- US Medical Affairs, AstraZeneca, Gaithersburg, MD 20878, USA
| | - Senxi Du
- Keck School of Medicine, Los Angeles, CA 90033, USA
| | - Bruno Fang
- Regional Cancer Care Associates, East Brunswick, NJ 08816, USA
| | - Stanley Marks
- University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, Pittsburgh, PA 15232, USA
| | - Ray Page
- The Center of Cancer & Blood Disorders, Fort Worth, TX 76104, USA.,Quality Cancer Care Alliance Network, Tacoma, WA 98405, USA
| | - Eileen Peng
- Regional Cancer Care Associates, East Brunswick, NJ 08816, USA
| | | | - Sharon Winters
- University of Pittsburgh Medical Center (UPMC) Hillman Cancer Center, Pittsburgh, PA 15232, USA
| | - Hannah Le
- US Medical Affairs, AstraZeneca, Gaithersburg, MD 20878, USA
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17
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Eisenmann ED, Fu Q, Muhowski EM, Jin Y, Uddin ME, Garrison DA, Weber RH, Woyach JA, Byrd JC, Sparreboom A, Baker SD. Intentional Modulation of Ibrutinib Pharmacokinetics through CYP3A Inhibition. CANCER RESEARCH COMMUNICATIONS 2021; 1:79-89. [PMID: 34950932 PMCID: PMC8691714 DOI: 10.1158/2767-9764.crc-21-0076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Ibrutinib (Imbruvica; PCI-32765) is an orally administered inhibitor of Bruton's tyrosine kinase that has transformed the treatment of B-cell malignancies. However, ibrutinib has very low oral bioavailability that contributes to significant variability in systemic exposure between patients, and this has the potential to affect both efficacy and toxicity. We hypothesized that the oral bioavailability of ibrutinib is limited by CYP3A isoform-mediated metabolism, and that this pathway can be inhibited to improve the pharmacokinetic properties of ibrutinib. Pharmacokinetic studies were performed in wild-type mice and mice genetically engineered to lack all CYP3A isoforms [CYP3A(-/-)] that received ibrutinib alone or in combination with CYP3A inhibitors cobicistat or ketoconazole. Computational modeling was performed to derive doses of ibrutinib that, when given after a CYP3A inhibitor, results in therapeutically-relevant drug levels. Deficiency of CYP3A in mice was associated with a ~10-fold increase in the area under the curve of ibrutinib. This result could be phenocopied by administration of cobicistat before ibrutinib in wild-type mice, but cobicistat did not influence levels of ibrutinib in CYP3A(-/-) mice. Population pharmacokinetic and prospectively validated physiologically-based pharmacokinetic models established preclinical and clinical doses of ibrutinib that could be given safely in combination with cobicistat without negatively affecting anti-leukemic properties. These findings signify a dominant role for CYP3A-mediated metabolism in the elimination of ibrutinib, and suggest a role for pharmacological inhibitors of this pathway to intentionally modulate the plasma levels and improve the therapeutic use of this clinically important agent.
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Affiliation(s)
- Eric D. Eisenmann
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Qiang Fu
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Elizabeth M. Muhowski
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Yan Jin
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Muhammad Erfan Uddin
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Dominique A. Garrison
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Robert H. Weber
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Jennifer A. Woyach
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - John C. Byrd
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Alex Sparreboom
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio
| | - Sharyn D. Baker
- Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, Columbus, Ohio.,Corresponding Author: Sharyn D. Baker, Division of Pharmaceutics and Pharmacology, College of Pharmacy, The Ohio State University, 500 W. 12th Avenue, Columbus, OH 43210. E-mail:
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18
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Eyre TA, Hori S, Munir T. Treatment strategies for a rapidly evolving landscape in chronic lymphocytic leukemia management. Hematol Oncol 2021; 40:129-159. [PMID: 34713475 DOI: 10.1002/hon.2943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/19/2021] [Accepted: 10/21/2021] [Indexed: 12/26/2022]
Abstract
With the advent of targeted therapies for chronic lymphocytic leukemia (CLL), treatment choice has expanded and patients are living longer. Careful consideration is needed regarding treatment duration and sequence, how best to meet patients' needs, balancing toxicities while improving long-term survival and maximizing depth of response. This review addresses these considerations and discusses current targeted treatment dilemmas. Targeted therapies have dramatically transformed the CLL treatment landscape. Two treatment paradigms have emerged using B-cell lymphoma 2 inhibitors (BCL2i) and Bruton's tyrosine kinase (BTK): (i) fixed duration and (ii) continuous treatment. The BCL2i venetoclax can attain deep remissions with a fixed-duration approach, resulting in high rates of undetectable minimal residual disease (uMRD) in treatment-naïve and relapsed/refractory (R/R) patients with CLL. BTKis such as ibrutinib and acalabrutinib achieve high objective response rates and long-term disease control, although they rarely attain complete response or uMRD status as monotherapy. Numerous studies are evaluating the clinical utility of BTKi and BCL2i as combination therapies, where deep remissions have been found to occur. MRD status may also be a useful marker for deciding when to stop continuous therapy, and randomized trials on MRD-guided treatment strategies are currently ongoing. The current treatment choice between continuous or fixed-duration therapy should be based on comorbidities, risks, preferences, and treatment goals, whilst areas of emerging clinical interest include the potential utility of BTKi-BCL2i combination therapies, as well as an MRD-guided treatment strategies in the future.
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Affiliation(s)
- Toby A Eyre
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Talha Munir
- The Leeds Teaching Hospital NHS Trust, St James's University Hospital, Leeds, UK
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19
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Patel K, Pagel JM. Current and future treatment strategies in chronic lymphocytic leukemia. J Hematol Oncol 2021; 14:69. [PMID: 33902665 PMCID: PMC8074228 DOI: 10.1186/s13045-021-01054-w] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/01/2021] [Indexed: 12/21/2022] Open
Abstract
Treatment decisions for patients with chronic lymphocytic leukemia (CLL) are dependent on symptoms and classification into high-, medium-, or low-risk categories. The prognosis for CLL hinges, in part, on the presence or absence of less-favorable genetic aberrations, including del(17p), del(11q), TP53 dysfunction, and IGHV mutations, as these markers are associated with worse treatment response. Promising results from multiple clinical trials show emerging therapies targeting Burton tyrosine kinase, B-cell leukemia/lymphoma 2, and phosphatidylinositol 4,5-bisphosphate 3-kinase catalytic subunit delta result in better outcomes and prolonged progression-free survival for patients both with and without certain high-risk aberrations. Favorable outcomes using these novel oral targeted therapies, either alone or in combination with other treatments such as anti-CD20 antibodies, has led to their use almost entirely supplanting chemoimmunotherapy in the treatment of CLL. In this narrative review, we summarize the current clinical evidence for the use of targeted mono- and combination therapies for CLL, discuss new and next-generation treatment approaches currently in development, and provide insight into areas of unmet need for the treatment of patients with CLL.
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Affiliation(s)
- Krish Patel
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, 1221 Madison St, Seattle, WA, 98104, USA.
| | - John M Pagel
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, 1221 Madison St, Seattle, WA, 98104, USA
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20
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Yun X, Zhang Y, Wang X. Recent progress of prognostic biomarkers and risk scoring systems in chronic lymphocytic leukemia. Biomark Res 2020; 8:40. [PMID: 32939265 PMCID: PMC7487566 DOI: 10.1186/s40364-020-00222-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/26/2020] [Indexed: 12/13/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL) is the most prevalent adult leukemia with high heterogeneity in the western world. Thus, investigators identified a number of prognostic biomarkers and scoring systems to guide treatment decisions and validated them in the context of immunochemotherapy. A better understanding of prognostic biomarkers, including serum markers, flow cytometry outcomes, IGHV mutation status, microRNAs, chromosome aberrations and gene mutations, have contributed to prognosis in CLL. Del17p/ TP53 mutation, NOTCH1 mutation, CD49d, IGHV mutation status, complex karyotypes and microRNAs were reported to be of predictive values to guide clinical decisions. Based on the biomarkers above, classic prognostic models, such as the Rai and Binet staging systems, MDACC nomogram, GCLLSG model and CLL-IPI, were developed to improve risk stratification and tailor treatment intensity. Considering the presence of novel agents, many investigators validated the conventional prognostic biomarkers in the setting of novel agents and only TP53 mutation status/del 17p and CD49d expression were reported to be of prognostic value. Whether other prognostic indicators and models can be used in the context of novel agents, further studies are required.
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Affiliation(s)
- Xiaoya Yun
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021 Shandong China
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, Jinan, 250021 Shandong China
- School of Medicine, Shandong University, Jinan, 250012 Shandong China
- Shandong Provincial Engineering Research Center of Lymphoma, Jinan, 250021 Shandong China
- National clinical research center for hematologic diseases, Jinan, 250021 Shandong China
| | - Ya Zhang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021 Shandong China
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, Jinan, 250021 Shandong China
- School of Medicine, Shandong University, Jinan, 250012 Shandong China
- Shandong Provincial Engineering Research Center of Lymphoma, Jinan, 250021 Shandong China
- National clinical research center for hematologic diseases, Jinan, 250021 Shandong China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021 Shandong China
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No.324, Jingwu Road, Jinan, 250021 Shandong China
- School of Medicine, Shandong University, Jinan, 250012 Shandong China
- Shandong Provincial Engineering Research Center of Lymphoma, Jinan, 250021 Shandong China
- National clinical research center for hematologic diseases, Jinan, 250021 Shandong China
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