Differences in outcome in adolescents with acute lymphoblastic leukemia: a consequence of better regimens? Better doctors? Both?

New developments in ALL in AYA

The outcome for adolescents and young adults (AYA) with acute lymphoblastic leukemia (ALL) has improved, mostly based on the use of pediatric-inspired intensive protocols. Due to increasing disease resistance and treatment-related toxicity with age, further improvements are now expected from the expanding knowledge of ALL biology, more accurate risk stratification, and the early introduction of targeted small molecules and immunotherapy. In the last decade, the rate of AYA with B-cell precursor ALL with undetermined genetic drivers ("B-other") has shrunk from 40% to fewer than 10%. The high-risk subgroup of Philadelphia-like ALL is the most frequent entity diagnosed in this age range, offering a multitude of potentially actionable targets. The timely and accurate identification of these targets remains challenging, however. Early minimal residual disease (MRD) monitoring has become a standard of care for the risk stratification and identification of patients likely to benefit from an allogeneic hematopoietic stem cell transplantation. Recently approved immunotherapies are moving frontline to eradicate MRD, to improve the outcome of high-risk patients, and, eventually, to reduce treatment burden. Comprehensive care programs dedicated to AYA with cancer aim at improving inclusion in specific clinical trials and at giving access to appropriate psychosocial support, fertility preservation, and survivorship programs.

Why Do Children with Acute Lymphoblastic Leukemia Fare Better Than Adults?

It is a new and exciting time for acute lymphoblastic leukemia (ALL). While nearly 50 years ago, only one in nine children with ALL survived with chemotherapy, nowadays nearly 90% of children have a chance of long-term survival. Adults with ALL, as well as the special category of adolescents and young adult (AYA) patients, are catching up with the new developments seen in children, but still their prognosis is much worse. A plethora of factors are regarded as responsible for the differences in treatment response, such as age, ethnicity, disease biology, treatment regimens and toxicities, drug tolerance and resistance, minimal residual disease evaluation, hematopoietic stem cell transplantation timing and socio-economic factors. Taking these factors into account, bringing pediatric-like protocols to adult patient management and incorporating new agents into frontline treatment could be the key to improve the survival rates in adults and AYA.

Outcome of young adult patients with very-high-risk acute lymphoblastic leukemia treated with pediatric-type chemotherapy - a single institute experience

BACKGROUND/PURPOSE

Adult patients of acute lymphoblastic leukemia (ALL) with very high-risk (VHR) characteristics have an inferior outcome, and allogeneic hematopoietic stem cell transplantation (HSCT) is usually performed. In contrast, VHR pediatric patients can be treated effectively with minimal residual disease (MRD)-guided pediatric protocols and HSCT are not always needed.

METHODS

We retrospectively reviewed young adult ALL VHR patients treated with the pediatric-type (TPOG-ALL-2002 VHR) regimen in our institute from 2008 to 2019 and compared the event-free survival (EFS) with patients treated with an adult-type regimen (Hyper-CVAD alternating with high dose methotrexate and cytarabine).

RESULTS

We identified 16 patients treated with the TPOG and 11 treated with the Hyper-CVAD regimen. Philadelphia chromosome-positive (n = 10) and T-cell immunophenotype (n = 11) are the most common VHR features. Compared with the Hyper-CVAD group, patients treated with the TPOG regimen showed a trend toward better EFS with a hazard ratio (HR) of 0.42 (p = 0.16). Compared with untransplanted patients, HSCT showed a positive trend in the Hyper-CVAD (HR 0.22, p = 0.12) but not in the TPOG group (p = 0.37). Untransplanted patients treated initially with the hyper-CVAD regimen had a significantly worse outcome than the TPOG regimen (HR 4.19, p < 0.05). In the TPOG group, patients with negative MRD at the end of consolidation had a significantly better outcome (HR 0.12, p = 0.03).

CONCLUSION

Young adult VHR patients can be effectively treated with the TPOG-ALL-2002 protocol, and those who achieved MRD negativity before the end of consolidation have a good outcome without allogeneic HSCT.

Comparison of CALGB 10403 (Alliance) and COG AALL0232 toxicity results in young adults with acute lymphoblastic leukemia

Adolescents and young adults (AYAs) with acute lymphoblastic leukemia have improved outcomes when treated with pediatric-inspired regimens. CALGB 10403 was the largest prospective study to evaluate the feasibility of using a pediatric regimen in AYAs with acute lymphoblastic leukemia up to 40 years of age. This article presents the toxicity events observed in the CALGB 10403 study and compares these toxicities vs those observed among AYAs treated on the same arm of the companion Children's Oncology Group (COG) AALL0232 study. Toxicities in CALGB 10403 were similar to those observed in COG AALL0232. Some grade 3 to 4 adverse events were more often reported in CALGB 10403 compared with COG AALL0232 (hyperglycemia, hyperbilirubinemia, transaminase elevation, and febrile neutropenia). Adverse events correlated with body mass index ≥30 kg/m2 and some with increasing age. The mortality rate in CALGB 10403 was low (4%) and similar to that in the COG AALL0232 trial. A caveat to this analysis is that only 39% of CALGB 10403 patients completed all planned protocol treatment. In COG AALL0232, although 74% of patients aged <18 years completed treatment, only 57% of patients aged ≥18 years completed treatment. This scenario suggests that issues associated with age and treating physician may be a factor. Due to its improved survival rates compared with historical controls, the CALGB 10403 regimen is now a standard of care. The hope is that the rate of protocol completion will increase as more familiarity is gained with this regimen. These trials were registered at www.clinicaltrials.gov as #NCT00558519 (CALGB 10403) and #NCT00075725 (COG AALL0232).

Pediatric randomized trial EORTC CLG 58951: Outcome for adolescent population with acute lymphoblastic leukemia

Over the years, the prognosis of adolescents treated for acute lymphoblastic leukemia (ALL) has improved. However, this age group still represents a challenge with an overall survival (OS) of 60% compared to 85% in younger children. Herein, we report the outcome of adolescents treated in the European Organisation for Research and Treatment of Cancer (EORTC) 58951 clinical trial. EORTC 58951 clinical trial included patients with de novo ALL between 1998 and 2008. For this study, we analyzed data of all adolescents between 15 and under 18. Data from 97 adolescents were analyzed, 70 had B-lineage and 27 had T-lineage ALL. The 8-year event-free survival (EFS) and OS for the B-cell precursor ALL cases were 72.3% (59.4%-81.7%) and 80.8% (67.4%-89.1%), respectively. For the T-lineage, the 8-year EFS and OS were 57.4% (36.1%-74.0%) and 59.0% (36.1%-76.2%), respectively. "B-other" ALL, defined as BCP-ALL lacking any known recurrent genetic abnormalities were more frequent in our adolescent population (52.8%) than in younger children (27.1%). Outcome of adolescents in the EORTC 58951 study is supporting the findings that adolescents have better outcome in pediatric compared to adults' trials. Nevertheless, in pediatric studies, adolescents still have a worse prognosis than younger children. Despite the fact that specific unfavorable characteristics may be linked to the adolescent population, a careful study and characterization of adolescents "B-other" genetic abnormalities in ALL is critical to improve the outcome of this population.

Acute myelogenous leukemia in adolescents and young adults

The incidence of acute myelogenous leukemia (AML) increases progressively with age. Favorable genetic mutations are most prevalent in children, and unfavorable profiles increase proportionately in adolescents and young adults (AYA) and into later adulthood. Survival rates of AYA have improved over recent decades to 50-60%, but their accrual to clinical trials remains poor. In contrast to AYA with acute lymphoblastic leukemia, the prognostic benefit for AYA with AML enrolled in pediatric compared with adult trials is minor and only seen when different protocols are used. The distinctive needs of AYA, including intensive psychological services, call for their treatment within specialized centers that offer complex supportive care.

Acute lymphoblastic leukemia in adolescent and young adults: treat as adults or as children?

Adolescent and young adult (AYA) patients with acute lymphoblastic leukemia (ALL) are recognized as a unique population with specific characteristics and needs. In adolescents age 15 to 20 years, the use of fully pediatric protocols is supported by many comparative studies of pediatric and adult cooperative groups. In young adults, growing evidence suggests that pediatric-inspired or even fully pediatric approaches may also dramatically improve outcomes, leading to long-term survival rates of almost 70%, despite diminishing indications of hematopoietic stem-cell transplantation. In the last decade, better knowledge of the ALL oncogenic landscape according to age distribution and minimal residual disease assessments has improved risk stratification. New targets have emerged, mostly in the heterogeneous B-other group, particularly in the Philadelphia-like ALL subgroup, which requires both in-depth molecular investigations and specific evaluations of targeted treatments. The remaining gap in the excellent results reported in children has many other contributing factors that should not be underestimated, including late or difficult access to care and/or trials, increased acute toxicities, and poor adherence to treatment. Specific programs should be designed to take into account those factors and finally ameliorate survival and quality of life for AYAs with ALL.

Infection-related mortality in Hispanic and non-Hispanic children with cancer

BACKGROUND

Hispanic children with cancer experience poorer survival than their White counterparts. Infection is a known cause of cancer-related mortality; however, little is known about the risk of infection-related death among Hispanic children with cancer. We examine the association of Hispanic ethnicity with infection-related mortality and life-threatening events among children with cancer.

PROCEDURE

For a cohort of all pediatric cancer patients diagnosed from 1986 to 2012 and treated at a single tertiary care center, we obtained national death records to determine all-cause mortality and infection-related mortality, as well as intensive care unit (ICU) admissions as a surrogate for life-threatening events. Cox proportional hazard models assessed all-cause mortality and infection-related mortality using ethnicity as the main independent variable. ICU admission rates were modeled using a zero-inflated Poisson regression model. Models were adjusted for gender, diagnosis year, age, residential location, and diagnosis.

RESULTS

Of 6,198 patients, 741 (12%) were Hispanic. Mean follow-up was 11 years (SD = 8.04). There were 1,205 deaths, with 193 attributable to infection. Differences in all-cause mortality between Hispanic and non-Hispanic patients did not reach significance (hazard ratio [HR] = 1.14, 95% confidence interval [CI]: 0.96-1.36). However, Hispanic patients were 68% (HR = 1.68, 95% CI: 1.16-2.43) more likely to have an infection-related cause of death. Hispanic ethnicity was statistically associated with a higher rate of ICU admissions (rate ratio = 1.32, 95% CI: 1.12-1.56).

CONCLUSION

Hispanic pediatric cancer patients were more likely to have an infection-related death and higher rates of ICU admissions than non-Hispanic patients. Infection may be an overlooked contributor to poorer outcomes among Hispanic patients.

How should we treat the AYA patient with newly diagnosed ALL?

Adolescent and young adult (AYA) patients with acute lymphoblastic leukaemia (ALL) are recognized as a unique population with specific characteristics and needs. In adolescents aged 15-20 years old, the use of full paediatric protocols is supported by many comparative studies of paediatric and adult cooperative groups. In young adults, growing evidence suggests that paediatric-inspired approaches may also improve outcomes and lead to long-term survival rates of almost 70%. In the last decade, better knowledge of ALL oncogenic landscape, age distribution, and minimal residual disease prognostic impact have improved risk stratification. New targets have emerged mostly in the heterogeneous subgroup of Philadelphia-like ALL and will require both in-depth molecular investigations and specific evaluations in rare subgroups of ALL. The remaining gap with the excellent results reported in children has many other contributing factors that should not be underestimated including late or difficult access to care, or poor adherence to treatment.

Delays in postremission chemotherapy for Philadelphia chromosome negative acute lymphoblastic leukemia are associated with inferior outcomes in patients who undergo allogeneic transplant: An analysis from ECOG 2993/MRC UK ALLXII

Adults with acute lymphoblastic leukemia (ALL) have a poorer prognosis than children due to a high risk of relapse. One explanation may be variable adherence to dose-intense chemotherapy. However, little is known about risk factors for delays in therapy and their impact on survival. We conducted an analysis of ECOG 2993/UKALLXII trial to study delays in postremission chemotherapy in adults with newly diagnosed ALL. Logistic regression was used to identify risk factors for a very long delay (VLD, >4 weeks) in start of intensification therapy. Cox regression was used to evaluate the impact of delays on overall survival (OS) and event-free survival (EFS). We evaluated 1076 Philadelphia chromosome negative (Ph-) patients who completed induction chemotherapy, achieved complete remission, and started intensification. Factors independently associated with VLD included duration of hospitalization (odds ratio [OR] = 1.2, P < 0.001) during Phase I; thrombocytopenia during Phase I (OR = 1.16, P = 0.004) or Phase II (OR 1.13, P = 0.001); chemotherapy dose reductions during Induction Phase I (OR = 1.72, P < 0.014); female sex (OR = 1.53, P = 0.010); Black (OR = 3.24, P = 0.003) and Asian (OR = 2.26, P = 0.021) race; and increasing age (OR = 1.31, P < 0.001). In multivariate Cox regression, patients who underwent allogeneic stem cell transplant (alloHCT) had significantly worse OS (HR 1.4, P = 0.03) and EFS (HR 1.4, P = 0.02) after experiencing a VLD compared to alloHCT patients who experienced ≤4 weeks delay. Specific populations (female, older, Black, and Asian patients) were more likely to experience delays in chemotherapy, as were those with significant toxicity during induction. VLDs in therapy negatively affected outcomes in patients undergoing allografting. Am. J. Hematol. 91:1107-1112, 2016. © 2016 Wiley Periodicals, Inc.

Asparaginase Erwinia chrysanthemi as a component of a multi-agent chemotherapeutic regimen for the treatment of patients with acute lymphoblastic leukemia who have developed hypersensitivity to E. coli-derived asparaginase

Asparaginase has been a mainstay of therapy in the treatment of acute lymphoblastic leukemia since the 1970s. There are two major preparations available and FDA approved in the United States today, one derived from Escherichia coli and the other from Erwinia chrysanthemi. Erwinia asparaginase is antigenically distinct from and has a considerably shorter biological half-life than E coli asparaginase. Erwinia asparaginase has been used in cases of hypersensitivity to E. coli-derived asparaginases, which has been reported in up to 30% of patients. While PEG asparaginase is increasingly used in front-line therapy for ALL, hypersensitivity still occurs with this preparation, and a change to a non-cross-reactive preparation may be necessary.

Adolescent and young adult patients with cancer: a milieu of unique features

Adolescent and young adult (AYA) patients with cancer are a unique category of patients who, depending on age at time of diagnosis, might receive treatment from oncologists specializing either in the treatment of children or adults. In the USA, AYA oncology generally encompasses patients 15-39 years of age. AYA patients with cancer typically present with diseases that span the spectrum from 'paediatric' cancers (such as acute lymphoblastic leukaemia [ALL] and brain tumours) to 'adult' tumours (such as breast cancer and melanoma), as well as cancers that are largely unique to their age group (such as testicular cancer and bone tumours). Research indicates that outcomes of AYA patients with cancer are influenced not only by the treatment provided, but also by factors related to 'host' biology. In addition to the potential biological and cancer-specific differences between AYAs and other patients with cancer, AYA patients also often have disparate access to clinical trials and suffer from a lack of age-appropriate psychosocial support services and health services, which might influence survival as well as overall quality of life. In this Review, these issues are discussed, with a focus on two types of AYA cancer--ALL and melanoma--highlighting findings arising from the use of emerging technologies, such as whole-genome sequencing.

Outcome of Adolescents with Acute Lymphoblastic Leukemia Treated by Pediatrics versus Adults Protocols

Objective. Several studies showed better outcome in adolescents and young adults with acute lymphoblastic leukemia (ALL) treated with pediatrics protocols than similarly aged patients treated with adults protocols, while other studies showed similar outcome of both protocols. We conducted this study to compare the outcome of our pediatrics and adults therapeutic protocols in treatment of adolescents ALL. Patients and Methods. We retrospectively reviewed files of 86 consecutive adolescent ALL patients aged 15–18 years who attended to outpatients clinic from January 2003 to January 2010. 32 out of 86 were treated with pediatrics adopted BFM 90 high risk protocol while 54 were treated with adults adopted BFM protocol. We analyzed the effect of different treatment protocols on achieving complete remission (CR), disease-free survival (DFS), and overall survival (OS). Results. The 2 patients groups have almost similar characteristics. The CR was significantly higher in pediatrics protocol 96% versus 89% (P = 0.001). Despite the fact that the toxicity profiles were higher in pediatrics protocol, they were tolerable. Moreover, the pediatrics protocol resulted in superior outcome in EFS 67% versus 39% (P = 0.001), DFS 65% versus 41% (P = 0.000), and OS 67% versus 45% (P = 0.000). Conclusion. Our study's findings recommend using intensified pediatrics inspired protocol to treat adolescents with acute lymphoblastic leukemia.

Should all adults with acute lymphocytic leukemia receive allogeneic stem cell transplantation in first remission?

SUMMARY 

The role of allogeneic hematopoietic stem cell transplantation (AHCT) in patients with Philadelphia-chromosome negative acute lymphocytic leukemia (Ph- ALL) in first remission is controversial. Some studies suggest that AHCT in first remission yields a statistically significant small improvement in overall survival. However, novel therapies and monitoring strategies may tip the balance away from immediate consolidation with AHCT for a majority of adults with Ph- ALL. Here we compare data for AHCT with recent therapeutic and diagnostic advances for patients with newly diagnosed and with relapsed and refractory Ph- ALL. We conclude that AHCT remains appropriate for a specific group of these patients, but that a majority will do as well if not better with an initial nontransplant-based consolidation strategy.

Acute lymphoblastic leukemia in adolescents and young adults

The cure rate of acute lymphoblastic leukemia (ALL) in children is 80%, compared to less than half in adults. A major proportion of this cure rate drop occurs in adolescents and young adults (AYAs). The age range defining this population varies between studies, biological characteristics are different from both younger children and older adults, and AYAs are treated either by pediatric or adult oncologists, who often apply different treatment approaches to the same ALL patient population. The outcome of AYAs aged 15-21 years treated by more contemporary pediatric protocols is similar to that of younger children but is inferior when using adult regimens. This motivated studying AYA patients, including those above the age of 21 years, with pediatric or 'pediatrics-inspired' regimens that intensified nonmyelosuppressive drugs such as vincristine, steroids and asparaginase, with very promising preliminary results. Discovering new mutations in AYA ALL will help stratify patients into risk subgroups and identify targets for novel agents. This, together with fine-tuning pediatric chemotherapy principles will hopefully finally decrease the cure rate gap between children and AYAs - and even older adults.

Clinical management of medulloblastoma in adults

Although medulloblastoma is the most common malignant brain tumor in children, 30% of cases occur in adults. Recent therapeutic advances in the treatment of average-risk childhood medulloblastoma have emphasized the reduction of treatment-related toxicity while improving progression-free survival. However, lessons learned from the pediatric experience have not been widely applied to the adult population in Phase II or randomized clinical trials. This review will compare adult and pediatric medulloblastoma, highlight case series of adults treated at major academic institutions, and suggest directions for the contemporary management of adults with medulloblastoma.

L-asparaginase: an effective agent in the treatment of acute lymphoblastic leukemia

L-asparaginase (L-ASNase) is an enzyme used most effectively in the treatment of acute lymphoblastic leukemia (ALL) for more than 30 years. It catalyzes the hydrolysis of amino acid l-asparagine to aspartic acid and ammonia, which leads to cell death. Clinical trials have been conducted using L-ASNase in combination with other drugs and radiotherapy, which have led to great success in the treatment of ALL. Treatments consist of induction therapy and central nervous system therapy. The achievement of complete remission in patients is associated with a few side-effects of using L-asparaginase, including pancreatitis, coagulation abnormalities and allergic reactions. Sometimes tumor cells may develop resistance to L-ASNase. To overcome these difficulties, the drug is modified by pegylation or immobilization, and also treatment protocols can be modified to increase the efficiency of the drug.

The inferior prognosis of adolescents with acute lymphoblastic leukaemia (ALL) is caused by a higher rate of treatment-related mortality and not an increased relapse rate--a population-based analysis of 25 years of the Austrian ALL-BFM (Berlin-Frankfurt-Münster) Study Group

Adolescents aged 15-18 years with acute lymphoblastic leukaemia (ALL) have been historically reported to have a poorer prognosis than younger children. We retrospectively analysed the characteristics and outcome of 67 adolescents included in a population-based series of 1125 non-infant cases that were enrolled into four Austrian ALL-BFM (Berlin-Frankfurt-Münster) multicentre trials at paediatric institutions within a 25-year period. Five-year event-free survival (EFS) and overall survival (OS) were 66 ± 6% and 76 ± 5% respectively, and thus lower than in younger children (83 ± 1%, 91 ± 1%; P < 0·001). This was not due to an increased cumulative incidence of relapse (CIR) (5-year CIR: 19 ± 5% vs. 13 ± 1%; P = 0·284), but due to an increased incidence of treatment-related death [5-year cumulative incidence of death (CID): 15 ± 4% vs. 3 ± 0%; P < 0·001] as a first event. Furthermore, while 44/67 (66%) non-high-risk adolescents had favourable 5-year EFS and OS rates (76 ± 7%, 89 ± 5%), 18/67 (27%) high-risk adolescents had an inferior outcome (5-year EFS: 56 ± 12%, OS 61 ± 11%, P < 0·05). Among the latter patients the CID was significantly higher than in younger high-risk children (22 ± 10% vs. 6 ± 2%; P = 0·020). Given that adolescent age is an independent risk factor for death as a first event, this specific age group may need particular vigilance when receiving intense BFM-type chemotherapy, as relapse-free survival is similar to younger children.

Adherence to leukemia maintenance therapy: a comparative study among children, adolescents, and adults

This study describes patient adherence to leukemia maintenance therapy and the factors associated with nonadherence, with a particular focus on the different age groups concerned. Sixty-four in-depth interviews were performed in three centers among 31 parents of children, 12 parents of adolescents, 12 adolescents, and 9 adult patients. Adherence was determined through a multimethod approach based on patient and/or parent responses to three self-administered questions and patient and/or parent interviews. The results were compared with physician evaluation of adherence. Factors explaining nonadherence were investigated in the in-depth interviews and by statistical analysis of self-administered questionnaires. Intentional nonadherence occurred rarely (4/52 patients, 8%) following poor tolerance of the maintenance therapy. Despite a high motivation to follow the maintenance therapy, repeated forgetfulness (8/52, 15%) was not rare and rarely detected by physicians. Nonadherence increased with age, but also existed among children. Outings, the administration of therapy at bedtime, the lack of monitoring, a low socioeconomic status, and the hepatic side effects of the treatment were also associated with nonadherence. Declared nonadherence of leukemia maintenance therapy is not negligible and should be screened at follow-up consultations using three simple questions.

Novel therapeutic approaches for acute lymphoblastic leukemia

Therapy for ALL in adults remains a tremendous challenge for clinicians. The use of pediatric-intensive regimens in young and middle-aged adults shows promise in improving outcomes. The addition of monoclonal antibody therapy to chemotherapy appears to hold great promise in lessening relapse rates. The anti-CD20 antibody, rituximab, which has been of such benefit in patients with non-Hodgkin lymphoma, now seems poised to bring significant benefit to adults with ALL. Other monoclonal antibody approaches are in earlier stages of development, but will likely be of significant benefit. The BiTE antibody, blinatumomab, represents an exciting new approach in this arena. As new molecular abnormalities are identified in ALL, these will certainly become new targets for drug development. The increasing use of MRD testing by molecular or flow cytometric techniques will also be invaluable in further refining prognostication in ALL in helping with the selection of patients most likely to benefit from BMT. Several new small molecules and chemotherapeutic agents will, it is hoped, also find a niche in the therapy for ALL. Early examples including NOTCH1 inhibitors; hypomethylating agents such as decitabine, folic acid, antagonists, flavopiridol, bortezomib, and mTOR inhibitors will all hopefully find a role in the therapy for this challenging disorder. Although many challenges remain, there is hope that the therapy for adults with ALL can make significant progress in the next few years, in comparison with the relative plateau that has been experienced over the last several decades.

Pharmacotherapeutic advances in the treatment of acute lymphoblastic leukaemia in adults

Acute lymphoblastic leukaemia (ALL) in adults is a challenging malignancy in that many patients will show evidence of initial chemotherapy responsiveness but will subsequently relapse. The disease is heterogeneous and outcomes vary dramatically depending on the prognostic factors present in an individual patient. An important determinant of outcome is the age of the patient. The stunning success of therapy in paediatric ALL has led to the use of intensive paediatric regimens in adolescents and young adults with what appear to be improved outcomes. For patients who relapse or have high-risk features, blood and marrow transplantation (BMT) continues to play an important role in the therapeutic armamentarium. The use of reduced-intensity conditioning regimens for allogeneic BMT suggests that outcomes may be improved by this approach. Monoclonal antibodies are showing benefit as single agents in the relapsed setting or in combination with chemotherapy in newly diagnosed patients. In recent years, several new chemotherapeutic agents have shown promise as single agents and are being incorporated into multi-agent chemotherapy. The development of tyrosine kinase inhibitors for Philadelphia chromosome-positive leukaemias has significantly improved outcomes. The molecular revolution has led to the identification of new aberrant molecular pathways in the pathogenesis of ALL, and drugs targeting these aberrancies are in various stages of development preclinically and clinically. These developments bring the hope that therapeutic outcomes in adult ALL can begin to approach those seen in the paediatric setting.

Adolescents and Young Adults with Acute Lymphoblastic Leukemia

During the last decade, increasing attention has been paid to a unique group of patients with acute lymphoblastic leukemia (ALL) who lie at the crossroad of therapeutic care by pediatric and adult hematologists/oncologists. ALL is a disease that affects infants, children, adolescents, and adult patients. With current therapies, the vast majority of children with ALL are now long-term survivors; unfortunately, the same good results have not yet been obtained for adults with ALL. This review will describe current controversies surrounding the treatment of adolescents and young adults with ALL—a group who finds themselves in the transition from “pediatric” to “adult” treatment approaches. The review focuses on recent insights into disease biology, prognostic factors, and treatment outcomes that have led to a series of prospective clinical trials specifically designed for adolescents and younger adults (AYAs) with ALL. These trials have been designed to provide important new clinical, psychosocial, and biological insights, and to further improve the survival of this challenging and unique group of patients.

L-asparaginase treatment in acute lymphoblastic leukemia: a focus on Erwinia asparaginase

Asparaginases are a cornerstone of treatment protocols for acute lymphoblastic leukemia (ALL) and are used for remission induction and intensification treatment in all pediatric regimens and in the majority of adult treatment protocols. Extensive clinical data have shown that intensive asparaginase treatment improves clinical outcomes in childhood ALL. Three asparaginase preparations are available: the native asparaginase derived from Escherichia coli (E. coli asparaginase), a pegylated form of this enzyme (PEG-asparaginase), and a product isolated from Erwinia chrysanthemi, ie, Erwinia asparaginase. Clinical hypersensitivity reactions and silent inactivation due to antibodies against E. coli asparaginase, lead to inactivation of E. coli asparaginase in up to 60% of cases. Current treatment protocols include E. coli asparaginase or PEG-asparaginase for first-line treatment of ALL. Typically, patients exhibiting sensitivity to one formulation of asparaginase are switched to another to ensure they receive the most efficacious treatment regimen possible. Erwinia asparaginase is used as a second- or third-line treatment in European and US protocols. Despite the universal inclusion of asparaginase in such treatment protocols, debate on the optimal formulation and dosage of these agents continues. This article provides an overview of available evidence for optimal use of Erwinia asparaginase in the treatment of ALL.

Approaches to treatment for acute lymphoblastic leukemia in adolescents and young adults

Acute lymphoblastic leukemia affects infants, children, adolescents, and adults. Although most children have a high likelihood of cure, outcomes in adults have much room for improvement. In between lies the adolescent and young adult population, not only in terms of age but also in clinical success rates. This review describes biology, prognostic factors, and treatment approaches in adolescents and young adults with acute lymphoblastic leukemia. Assessing the outcomes in adult and pediatric clinical trials that enroll adolescents and young adults can be especially useful in determining how best to treat these patients. Current new treatment strategies are also discussed.

Central nervous system prophylaxis in adults with acute lymphoblastic leukemia: current and emerging therapies

Central nervous system (CNS) recurrence continues to be a significant complication in the treatment of adult patients with acute lymphoblastic leukemia (ALL). Preventing CNS recurrence has been a therapeutic challenge and has not been addressed critically in many clinical trials. Adult studies modeled on childhood ALL studies have used multiple treatment modalities, including radiation therapy, systemic therapy, intrathecal therapy, and combinations thereof. Cranial irradiation is effective but is offset by substantial toxicity, including neurologic sequelae. Systemic chemotherapy, especially with cytarabine (AraC) and methotrexate, has demonstrated promise in decreasing CNS recurrence, but therapeutic levels of drugs in the cerebrospinal fluid (CSF) are not maintained. Intrathecal chemotherapy with or without high-dose systemic therapy is the most common approach to CNS prophylaxis. Liposomal AraC recently has become available and confers prolonged levels of free AraC in the CSF, a critical requirement for CNS prophylactic therapy. This review discusses the various modalities used for CNS prophylaxis in patients with ALL and the emerging trends, with specific emphasis on the outcome in terms of event-free survival and toxicity.

Temporal trends in cause-specific late mortality among 5-year survivors of childhood cancer

PURPOSE

Five-year survival rates for childhood cancer have improved over the past four decades. However, it is unknown whether changes in primary cancer therapy have improved rates of long-term (> 5 years from diagnosis) durable remissions and reduced treatment-related deaths. We investigated changes in patterns of late mortality over time and cause-specific attribution of late-mortality among 5-year survivors.

PATIENTS AND METHODS

Using data from the Surveillance, Epidemiology and End Results (SEER) population-based registry, we assessed all-cause and cause-specific (recurrence/progression of primary disease, external cause, and nonrecurrence/nonexternal cause) late mortality during four consecutive time periods from 1974 through 2000 among 26,643 5-year survivors of childhood cancer.

RESULTS

All-cause late mortality improved during more recent eras, dropping from 7.1% (95% CI, 6.4% to 7.8%) among children diagnosed during 1974 to 1980 to 3.9% (95% CI, 3.3% to 4.4%) among children diagnosed during 1995 to 2000 (P < .001), largely because of reduced mortality from recurrence or progression. While there was no significant reduction in mortality attributable to other health conditions (including treatment-related health conditions), analysis controlling for demographic characteristics identified a trend toward reduced risk during more recent eras (P = .007). Disparity by race/ethnicity was identified, with higher mortality among non-Hispanic blacks than among non-Hispanic whites for all-cause and nonrecurrence/nonexternal -cause late mortality.

CONCLUSION

While overall patterns of mortality from other health conditions do not differ over time, adjustment for demographic characteristics provides evidence that risk of treatment-related mortality may be lower in more recent eras. Disparities in health care utilization among survivors should be explored.

Acute lymphoblastic leukemia in adolescents and young adults

Today, long-term survival is achieved in more than 80% of children 1 to 10 years old with acute lymphoblastic leukemia (ALL). However, cure rates for adults and adolescents and young adults (AYA) with ALL remain relatively low, at only 40% to 50%. Age is a continuous prognostic variable in ALL, with no single age at which prognosis deteriorates markedly. Within childhood ALL populations, older children have shown inferior outcomes, whereas younger adults have shown superior outcomes among adult ALL patients. The type of treatment (pediatric-based versus adult-based) for AYA has recently been a matter of debate. In this article the biology and treatment of ALL in AYA is reviewed.

Therapy of Philadelphia chromosome-negative acute lymphoblastic leukemia in adults: new paradigms

Although the outcomes for adults with acute lymphoblastic leukemia (ALL) lag behind the stunningly successful results seen in children, new paradigms and new discoveries bring hope that this disparity will steadily lessen. The adoption of the use of pediatric intensity-type regimens in adolescents and young adults show promise in improving outcomes in this population. Recent donor-versus-no-donor comparisons in the allogeneic transplant setting highlight a potent graft-versus-leukemia effect in ALL, and the application of reduced intensity conditioning transplants may exploit this effect while reducing nonrelapse mortality. New therapeutic targets, such as CD22 in precusor B-cell ALL and mutations in NOTCH1 in T-cell ALL, are being exploited in clinical trials. Finally, use of molecular techniques and flow cytometry to quantitate minimal residual disease will allow further stratifications of patients by risk, identification of new therapeutic targets and will lessen drug toxicity through the use of pharmacogenomics.

Implementation of a pharmacist-initiated pharmaceutical handover for oncology and haematology patients being transferred to critical care units

GOALS OF WORK

An information gap with respect to specific therapies was identified when patients were transferred from the oncology and haematology unit (OHU) to the critical care units. The goal was to implement and evaluate the effectiveness of a pharmacist-initiated pharmaceutical handover (PIPH) for patients being transferred from the OHU to the critical care units at a major teaching hospital.

PATIENTS AND METHODS

A PIPH process for the specific therapies of mouthcare, chemotherapy regimen, growth factors and antibiotics was developed. The PIPH was delivered in written format or combined written and verbal format. The impact of the PIPH was by assessment of recorded clinical pharmacist interventions. Data were analysed to evaluate any difference in the number of interventions relating to and the time to administration of the specific therapies.

MAIN RESULTS

Data were available for 30 patient transfers in the pre-implementation group, with 22 transfers available in the post-implementation period. The number of interventions relating to the specific therapies was significantly reduced in the post-implementation group (144 vs 26; p < 0.0001). A significantly greater proportion of the specific therapies were administered on time in the post-implementation group (57% vs 96%; p < 0.0001).

CONCLUSIONS

Clinical pharmacists in the specialty area of oncology and haematology can improve the continuum of care when their patients are transferred to other units. By providing an accurate handover about specific therapies, there is an overall improvement in the prescribing and timely administration of these therapies.

Treating octogenarian and nonagenarian acute myeloid leukemia patients--predictive prognostic models

BACKGROUND

Treating the octogenarian and nonagenarian patients who have acute myeloid leukemia (AML) with intensive chemotherapy is controversial. Several models to predict outcome were proposed, including the use of a comorbidity index. However, it is unclear whether the Charlson comorbidity index (CCI) or the hematopoietic cell transplant comorbidity index (HCTCI) is more sensitive.

METHODS

The authors analyzed their experience with 92 patients aged >or=80 years who had AML. Patients' pretreatment characteristics and their treatment outcomes were recorded.

RESULTS

All patients were offered intensive treatment; 59 patients (64%) were treated intensively with a variety of regimens, whereas 33 patients (36%) elected to receive supportive care. The CCI and the HCTCI had similar predictive ability for outcome in both groups. A multivariate analyses of prognostic factors identified near-normal albumin (48% of patients; 1-year survival rate, >27%) as a favorable factor for the whole cohort, age <83 years (47% of patients; 1-year survival rate, >25%) and nonmonocytic morphology (75% of patients; 1-year survival rate, >26%) as favorable factors for the intensively treated cohort, and bone marrow blasts <46% (50% of patients; 1-year survival rate, >19%) as a favorable factor for patients who received supportive care.

CONCLUSIONS

This retrospective analysis was developed to assist in treatment decisions for octogenarian and nonagenarian patients with AML. The findings will need validation in a prospective study.

Indications for hematopoietic cell transplantation in acute leukemia

Based on available data, all adults with AML under age 60 years with matched siblings should be considered for allogeneic transplantation in first remission, except for those with favorable risk cytogenetics and possibly those whose disease has normal cytogenetics and is FLT3/ITD negative and NPM1 positive. Patients with matched siblings not transplanted in first remission should be followed closely so that transplantation in early first relapse can be considered. Those without matched siblings should receive a MUD transplant in first CR if they have higher risk disease. All others should receive standard chemotherapy and consider a matched unrelated transplant or autologous transplant, should they relapse. RIC allogeneic transplantation using either a matched family member or a MUD can be considered for patients age 60 years or greater with AML in second or subsequent remission, or AML in first remission with intermediate or high risk disease.

Where should adolescents with ALL be treated?

Currently, 50% of adolescents with ALL are treated by adult teams and 50% by paediatric teams (following either adult or paediatric protocols). The aim of this paper is to review the results obtained with first-line chemotherapy and with haematopoietic SCT (HSCT) in adolescents with ALL. Disease biology and host factors are responsible for the differences observed between adolescents and other age categories. The outcome of adolescents with ALL after first-line chemotherapy is poorer as compared with children, although better as compared with adults. Recent studies have shown that adolescents who were enrolled in paediatric trials achieved better results than those who were enrolled in adult trials. This is most likely because of several differences, including protocol design, dose intensity and use of HSCTs, as well as better compliance to treatment and better supportive care. Disparities in the attitude towards treatment between paediatric and adult wards might also contribute to the better outcome that is observed in paediatric institutions. Indications for HSCT in children with ALL are well defined by international protocols. Only very high-risk paediatric patients are eligible for HSCT in CR1, whereas in adult trials, allogeneic or autologous HSCT are frequently offered, even to standard-risk patients in CR1. The outcome of adolescents given HSCT is poorer than in children, though better than in adults. Improving both psychosocial support during therapy and physical exercise habits represent further challenges for teams involved in the treatment of adolescents. Cooperation between paediatric and adult haematologists would surely improve the ability to recruit as many patients as possible and would promote progress in the research on adolescents. In conclusion, redefining age limits according to risk-based strategies, as well as encouraging multi-centre cooperation, should be taken into consideration to improve the outcome of this age category. Adolescents should be referred to research treatment teams that have experience in the management of paediatric ALL and they should be enrolled in international cooperative studies.

Evolving paradigms in the therapy of Philadelphia chromosome–negative acute lymphoblastic leukemia in adults

Important studies challenging previous approaches to the treatment of adults with Philadelphia chromosome–negative acute lymphoblastic leukemia (ALL) have emerged in the past decade. Donor versus no donor comparisons of allogeneic transplant highlight a potent graft-versus-leukemia effect in ALL, and the application of reduced-intensity conditioning transplants may exploit this effect while reducing non-relapse mortality. The adoption of the use of pediatric intensity-type regimens in adolescents and young adults shows promise to improve outcomes in this population. New therapeutic targets such as mutations in NOTCH1 in T-cell ALL and CD22 in pre-B ALL are being exploited in clinical trials. The application of molecular techniques and flow cytometry to quantitate minimal residual disease will allow further stratification of patients by risk. Although the outcomes of adults with ALL lag behind the stunningly successful results seen in children, new paradigms and new discoveries bring hope that this disparity will steadily lessen.

Progress in the treatment of adults with acute lymphoblastic leukemia

PURPOSE OF REVIEW

Despite improvements in the achievement of complete remission and progress in the supportive care of adults with acute lymphoblastic leukemia during the last decade, the majority of patients have eventually relapsed with overall survival in adult acute lymphoblastic leukemia of only 30-40%. However, the recent approach of adapting therapy according to biologic features appears to be resulting in significant progress for specific subsets of adults with acute lymphoblastic leukemia.

RECENT FINDINGS

The present review highlights some of these new risk-adapted approaches focusing on recent advances in treatment of Philadelphia chromosome positive acute lymphoblastic leukemia and mature B-cell acute lymphoblastic leukemia using biologically targeted therapies, and new approaches to treatment of acute lymphoblastic leukemia in older adolescents and young adults, adopting therapeutic strategies employed in the successful treatment of children with acute lymphoblastic leukemia. A recent study that examines the role of allogeneic stem cell transplant for adults with acute lymphoblastic leukemia in first remission will also be reviewed.

SUMMARY

The subset-specific approach to therapy of adult acute lymphoblastic leukemia is beginning to result in promising improvements in survival. Future improvements in survival of adults with acute lymphoblastic leukemia will depend on participation in large cooperative group trials using biologically defined protocols for this relatively rare and heterogeneous group of diseases.

What determines the outcomes for adolescents and young adults with acute lymphoblastic leukemia treated on cooperative group protocols? A comparison of Children's Cancer Group and Cancer and Leukemia Group B studies

We performed a retrospective comparison of presenting features, planned treatment, complete remission (CR) rate, and outcome of 321 adolescents and young adults (AYAs) ages 16 to 20 years with newly diagnosed acute lymphoblastic leukemia (ALL) who were treated on consecutive trials in either the Children's Cancer Group (CCG) or the Cancer and Leukemia Group B (CALGB) from 1988 to 2001. CR rates were identical, 90% for both CALGB and CCG AYAs. CCG AYAs had a 63% event-free survival (EFS) and 67% overall survival (OS) at 7 years in contrast to the CALGB AYAs, in which 7-year EFS was only 34% (P < .001; relative hazard rate [RHR] = 2.2) and OS was 46% (P < .001; RHR = 1.9). While CALGB AYAs aged 16 to 17 years achieved similar outcomes to all CCG AYAs with a 7-year EFS of 55%, the EFS for 18- to 20-year-old CALGB patients was only 29%. Comparison of the regimens showed that CCG AYAs received earlier and more intensive central nervous system prophylaxis and higher cumulative doses of nonmyelosuppressive agents. There were no differences in outcomes of those who reached maintenance therapy on time compared with those who were delayed. Based on these observations, a prospective study for AYAs with ALL using the more successful approach of the CCG has been initiated.

Comparison of the results of the treatment of adolescents and young adults with standard-risk acute lymphoblastic leukemia with the Programa Español de Tratamiento en Hematología pediatric-based protocol ALL-96

PURPOSE

Retrospective studies have shown that adolescents and young adults with acute lymphoblastic leukemia (ALL) treated with pediatric protocols have better outcomes than similarly aged patients treated with adult protocols, but prospective studies comparing adolescents and young adults using pediatric schedules are scarce. The ALL-96 protocol was addressed to compare the toxicity and results of a pediatric-based protocol in adolescents (age 15-18 years) and young adults (age 19-30 years) with standard-risk (SR) ALL.

PATIENTS AND METHODS

Adolescents (n = 35) and young adults (n = 46) received a standard five-drug/5-week induction course followed by two cycles of early consolidation, maintenance with monthly reinforcement cycles up to 1 year in continuous complete remission (CR) and 1 year with standard maintenance chemotherapy up to 2 years in CR.

RESULTS

Adolescents and young adults were comparable in the main pretreatment ALL characteristics. The CR rate was 98% and. after a median follow-up of 4.2 years, 6-year event-free survival (EFS) and overall survival (OS) were 61% (95% CI, 51% to 72%) and 69% (95% CI, 59% to 79%), respectively, with no differences between adolescents and young adults. The hematologic toxicity in consolidation and reinforcement cycles was higher in young adults than in adolescents. Slow response to induction therapy was the only parameter associated with poor EFS (34% v 67%) and OS (40% v 76%).

CONCLUSION

The response to the pediatric ALL-96 protocol was identical in adolescents and young adults despite a slight increase in hematologic toxicity observed in adults. This justifies the age-unrestricted use of pediatric regimens to treat patients with SR ALL.

The changing scene of adult acute lymphoblastic leukemia

PURPOSE OF REVIEW

The review focuses on the most recent advances in the diagnostic and prognostic work-up of adult acute lymphoblastic leukemia (ALL) and its implications in the clinical management of the disease.

RECENT FINDINGS

ALL can be identified on the basis of morphologic, cytochemical and immunophenotypic criteria; modern management of ALL is also based on cytogenetic and genetic evaluations. New technologies, such as gene expression profile analysis, may allow us to further unravel the intrinsic biology of the disease, to improve diagnostic and prognostic stratification, and to design innovative therapeutic strategies. In potentially all cases, specific markers of the disease can be found and utilized together with the rearrangement of immunoglobulin and T-cell receptor genes to monitor minimal residual disease during clinical follow-up. These biologically-defined subgroups of patients may have a different clinical course, response to treatment and variable prognosis.

SUMMARY

Recent biologic advancements are progressively realising the possibility of designing targeted and individualized therapeutic strategies according to the more refined, molecularly defined features of leukemic cells and the presence or absence of residual disease in adult ALL.

In adults with standard-risk acute lymphoblastic leukemia, the greatest benefit is achieved from a matched sibling allogeneic transplantation in first complete remission, and an autologous transplantation is less effective than conventional consolidation/maintenance chemotherapy in all patients: final results of the International ALL Trial (MRC UKALL XII/ECOG E2993)

An international collaboration was set up to prospectively evaluate the role of allogeneic transplantation for adults with acute lymphoblastic leukemia (ALL) and compare autologous transplantation with standard chemotherapy. Patients received 2 phases of induction and, if in remission, were assigned to allogeneic transplantation if they had a compatible sibling donor. Other patients were randomized to chemotherapy for 2.5 years versus an autologous transplantation. A donor versus no-donor analysis showed that Philadelphia chromosome-negative patients with a donor had a 5-year improved overall survival (OS), 53% versus 45% (P = .01), and the relapse rate was significantly lower (P < or = .001). The survival difference was significant in standard-risk patients, but not in high-risk patients with a high nonrelapse mortality rate in the high-risk donor group. Patients randomized to chemotherapy had a higher 5-year OS (46%) than those randomized to autologous transplantation (37%; P = .03). Matched related allogeneic transplantations for ALL in first complete remission provide the most potent antileukemic therapy and considerable survival benefit for standard-risk patients. However, the transplantation-related mortality for high-risk older patients was unacceptably high and abrogated the reduction in relapse risk. There is no evidence that a single autologous transplantation can replace consolidation/maintenance in any risk group. This study is registered at http://clinicaltrials.gov as NCT00002514.