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Hillmen P, Pitchford A, Bloor A, Broom A, Young M, Kennedy B, Walewska R, Furtado M, Preston G, Neilson JR, Pemberton N, Sidra G, Morley N, Cwynarski K, Schuh A, Forconi F, Elmusharaf N, Paneesha S, Fox CP, Howard DR, Hockaday A, Brown JM, Cairns DA, Jackson S, Greatorex N, Webster N, Shingles J, Dalal S, Patten PEM, Allsup D, Rawstron A, Munir T. Ibrutinib and rituximab versus fludarabine, cyclophosphamide, and rituximab for patients with previously untreated chronic lymphocytic leukaemia (FLAIR): interim analysis of a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol 2023; 24:535-552. [PMID: 37142374 DOI: 10.1016/s1470-2045(23)00144-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND The approval of Bruton tyrosine kinase (BTK) inhibitors in patients with previously untreated chronic lymphocytic leukaemia (CLL) was based on trials which compared ibrutinib with alkylating agents in patients considered unfit for fludarabine, cyclophosphamide, and rituximab, the most effective chemoimmunotherapy in CLL. We aimed to assess whether ibrutinib and rituximab is superior to fludarabine, cyclophosphamide, and rituximab in terms of progression-free survival. METHODS This study is an interim analysis of FLAIR, which is an open-label, randomised, controlled, phase 3 trial in patients with previously untreated CLL done at 101 UK National Health Service hospitals. Eligible patients were between 18 and 75 years of age with a WHO performance status of 2 or less and disease status requiring treatment according to International Workshop on CLL criteria. Patients with greater than 20% of their CLL cells having the chromosome 17p deletion were excluded. Patients were randomly assigned (1:1) by means of minimisation (Binet stage, age, sex, and centre) with a random element in a web-based system to ibrutinib and rituximab (ibrutinib administered orally at 420 mg/day for up to 6 years; rituximab administered intravenously at 375 mg/m2 on day 1 of cycle 1 and at 500 mg/m2 on day 1 of cycles 2-6 of a 28-day cycle) or fludarabine, cyclophosphamide, and rituximab (fludarabine 24 mg/m2 per day orally on day 1-5, cyclophosphamide 150 mg/m2 per day orally on days 1-5; rituximab as above for up to 6 cycles). The primary endpoint was progression-free survival, analysed by intention to treat. Safety analysis was per protocol. This study is registered with ISRCTN, ISRCTN01844152, and EudraCT, 2013-001944-76, and recruiting is complete. FINDINGS Between Sept 19, 2014, and July 19, 2018, of 1924 patients assessed for eligibility, 771 were randomly assigned with median age 62 years (IQR 56-67), 565 (73%) were male, 206 (27%) were female and 507 (66%) had a WHO performance status of 0. 385 patients were assigned to fludarabine, cyclophosphamide, and rituximab and 386 patients to ibrutinib and rituximab. After a median follow-up of 53 months (IQR 41-61) and at prespecified interim analysis, median progression-free survival was not reached (NR) with ibrutinib and rituximab and was 67 months (95% CI 63-NR) with fludarabine, cyclophosphamide, and rituximab (hazard ratio 0·44 [95% CI 0·32-0·60]; p<0·0001). The most common grade 3 or 4 adverse event was leukopenia (203 [54%] patients in the fludarabine, cyclophosphamide, and rituximab group and 55 [14%] patients in the ibrutinib and rituximab group. Serious adverse events were reported in 205 (53%) of 384 patients receiving ibrutinib and rituximab compared with 203 (54%) of 378 patients receiving fludarabine, cyclophosphamide, and rituximab. Two deaths in the fludarabine, cyclophosphamide, and rituximab group and three deaths in the ibrutinib and rituximab group were deemed to be probably related to treatment. There were eight sudden unexplained or cardiac deaths in the ibrutinib and rituximab group and two in the fludarabine, cyclophosphamide, and rituximab group. INTERPRETATION Front line treatment with ibrutinib and rituximab significantly improved progression-free survival compared with fludarabine, cyclophosphamide, and rituximab but did not improve overall survival. A small number of sudden unexplained or cardiac deaths in the ibrutinib and rituximab group were observed largely among patients with existing hypertension or history of cardiac disorder. FUNDING Cancer Research UK and Janssen.
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Affiliation(s)
- Peter Hillmen
- Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Alexandra Pitchford
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Adrian Bloor
- The Christie Hospital NHS Foundation Trust, Manchester, UK
| | | | - Moya Young
- Kent and Canterbury Hospital, Canterbury, UK
| | | | | | | | | | | | | | - Gamal Sidra
- United Lincolnshire Hospitals NHS Trust, Lincoln, UK
| | | | - Kate Cwynarski
- University College London Hospitals, NHS Foundation Trust, London, UK
| | - Anna Schuh
- Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | | | - Christopher P Fox
- Nottingham University Hospitals NHS Trust, Nottingham, UK; School of Medicine, University of Nottingham, Nottingham, UK
| | - Dena R Howard
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Anna Hockaday
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julia M Brown
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David A Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sharon Jackson
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Natasha Greatorex
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Nichola Webster
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Jane Shingles
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Surita Dalal
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Piers E M Patten
- Comprehensive Cancer Centre, King's College London, London, UK; Department of Haematology, King's College Hospital, London, UK
| | | | - Andrew Rawstron
- Haematological Malignancy Diagnostic Service, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Talha Munir
- Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds, UK.
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Tam C, Kuss B, Opat S, Boulos J, Marlton P. Management of patients with previously untreated chronic lymphocytic leukaemia with obinutuzumab and chlorambucil. Intern Med J 2018; 47 Suppl 4:5-10. [PMID: 28685928 DOI: 10.1111/imj.13493] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Patients with chronic lymphocytic leukaemia (CLL) are generally older, with many considered 'unfit' for fludarabine-cyclophosphamide-rituximab therapy. In these patients, the combination of obinutuzumab-chlorambucil may be an appropriate therapeutic choice. Obinutuzumab-chlorambucil has been demonstrated to improve overall survival rates compared to chlorambucil alone and to improve progression-free survival and overall response rates compared to rituximab-chlorambucil. This combination can lead to certain toxicities that need to be addressed through appropriate patient selection, pre-medication and management. In this paper, we discuss evidence-based and author-recommended practical management of first-line CLL patients receiving obinutuzumab-chlorambucil.
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Affiliation(s)
- Constantine Tam
- Department of Haematology, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Bryone Kuss
- Department of Haematology, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Stephen Opat
- Department of Haematology, Monash Medical Centre and Monash University, Melbourne, Victoria, Australia
| | - Joy Boulos
- Roche Products Limited, Sydney, New South Wales, Australia
| | - Paula Marlton
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,University of Queensland School of Medicine, Brisbane, Queensland, Australia
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Collett L, Howard DR, Munir T, McParland L, Oughton JB, Rawstron AC, Hockaday A, Dimbleby C, Phillips D, McMahon K, Hulme C, Allsup D, Bloor A, Hillmen P. Assessment of ibrutinib plus rituximab in front-line CLL (FLAIR trial): study protocol for a phase III randomised controlled trial. Trials 2017; 18:387. [PMID: 28830517 PMCID: PMC5568356 DOI: 10.1186/s13063-017-2138-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 08/04/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Treatment of chronic lymphocytic leukaemia (CLL) has seen a substantial improvement over the last few years. Combination immunochemotherapy, such as fludarabine, cyclophosphamide and rituximab (FCR), is now standard first-line therapy. However, the majority of patients relapse and require further therapy, and so new, effective, targeted therapies that improve remission rates, reduce relapses, and have fewer side effects, are required. The FLAIR trial will assess whether ibrutinib plus rituximab (IR) is superior to FCR in terms of progression-free survival (PFS). METHODS/DESIGN FLAIR is a phase III, multicentre, randomised, controlled, open, parallel-group trial in patients with previously untreated CLL. A total of 754 participants will be randomised on a 1:1 basis to receive standard therapy with FCR or IR. Participants randomised to FCR will receive a maximum of six 28-day treatment cycles. Participants randomised to IR will receive six 28-day cycles of rituximab, and ibrutinib taken daily for 6 years until minimal residual disease (MRD) negativity has been recorded for the same amount of time as it took to become MRD negative, or until disease progression. The primary endpoint is PFS according to the International Workshop on CLL (IWCLL) criteria. Secondary endpoints include: overall survival; proportion of participants with undetectable MRD; response to therapy by IWCLL criteria; safety and toxicity; health-related quality of life (QoL); and cost-effectiveness. DISCUSSION The trial aims to provide evidence for the future first-line treatment of CLL patients by assessing whether IR is superior to FCR in terms of PFS, and whether toxicity rates are favourable. TRIAL REGISTRATION ISRCTN01844152 . Registered on 8 August 2014, EudraCT number 2013-001944-76 . Registered on 26 April 2013.
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MESH Headings
- Adenine/analogs & derivatives
- Adolescent
- Adult
- Aged
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/economics
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/economics
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cost-Benefit Analysis
- Disease Progression
- Disease-Free Survival
- Drug Costs
- Female
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/economics
- Leukemia, Lymphocytic, Chronic, B-Cell/mortality
- Male
- Middle Aged
- Neoplasm, Residual
- Piperidines
- Protein Kinase Inhibitors/administration & dosage
- Protein Kinase Inhibitors/adverse effects
- Protein Kinase Inhibitors/economics
- Pyrazoles/administration & dosage
- Pyrazoles/adverse effects
- Pyrazoles/economics
- Pyrimidines/administration & dosage
- Pyrimidines/adverse effects
- Pyrimidines/economics
- Quality of Life
- Rituximab/administration & dosage
- Rituximab/adverse effects
- Rituximab/economics
- Surveys and Questionnaires
- Time Factors
- Treatment Outcome
- United Kingdom
- Young Adult
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Affiliation(s)
- Laura Collett
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Dena R. Howard
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Talha Munir
- St James’ Institute of Oncology, St James’ University Hospital, Leeds, UK
| | - Lucy McParland
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jamie B. Oughton
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Andy C. Rawstron
- Haematological Malignancy Diagnostic Service, St James’ Institute of Oncology, St James’ University Hospital, Leeds, UK
| | - Anna Hockaday
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Claire Dimbleby
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David Phillips
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Kathryn McMahon
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Claire Hulme
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - David Allsup
- Hull York Medical School, Department of Haematology, Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull and East Yorkshire Hospitals NHS Trust, Cottingham, UK
| | - Adrian Bloor
- Department of Haematology, The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK
| | - Peter Hillmen
- St James’ Institute of Oncology, St James’ University Hospital, Leeds, UK
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Butler LA, Tam CS, Seymour JF. Dancing partners at the ball: Rational selection of next generation anti-CD20 antibodies for combination therapy of chronic lymphocytic leukemia in the novel agents era. Blood Rev 2017; 31:318-327. [PMID: 28499646 DOI: 10.1016/j.blre.2017.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 05/02/2017] [Indexed: 02/06/2023]
Abstract
The anti-CD20 antibodies represent a major advancement in the therapeutic options available for chronic lymphocytic leukemia. The addition of rituximab, ofatumumab and obinutuzumab to various chemotherapy regimens has led to considerable improvements in both response and survival. Ocaratuzumab, veltuzumab and ublituximab are currently being explored within the trial setting. We review the current status of these antibodies, and discuss how their mechanisms of action may impact on the choice of combinations with novel small molecule agents.
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Affiliation(s)
- L A Butler
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia
| | - C S Tam
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; St. Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065, Australia; Faculty of Medicine, University of Melbourne, Building 181, Grattan Street, Parkville, VIC 3052, Australia
| | - J F Seymour
- Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, VIC 3000, Australia; Faculty of Medicine, University of Melbourne, Building 181, Grattan Street, Parkville, VIC 3052, Australia.
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Korycka-Wołowiec A, Wołowiec D, Robak T. Ofatumumab for treating chronic lymphocytic leukemia: a safety profile. Expert Opin Drug Saf 2015; 14:1945-59. [DOI: 10.1517/14740338.2015.1113253] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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A review of monoclonal antibody therapies in lymphoma. Crit Rev Oncol Hematol 2015; 97:72-84. [PMID: 26318093 DOI: 10.1016/j.critrevonc.2015.08.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 07/03/2015] [Accepted: 08/05/2015] [Indexed: 12/27/2022] Open
Abstract
Monoclonal antibodies (moAb) represent a novel way of delivering therapy through specific target antigens expressed on lymphoma cells and minimizes the collateral damage that is common with conventional chemotherapy. The paradigm of this approach is the targeting of CD20 by rituximab. Since its FDA approval in 1997, rituximab has become the standard of care in almost every line of therapy in most B-cell lymphomas. This review will briefly highlight some of the key rituximab trials while looking more closely at the evidence that is bringing other antibodies, including next generation anti-CD20 moAbs, and anti-CD30 moAbs, among others to the forefront of lymphoma therapy.
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Rituximab, fludarabine, and cyclophosphamide versus fludarabine and cyclophosphamide for treatment of chronic lymphocytic leukemia: A systematic review with meta-analysis. Crit Rev Oncol Hematol 2015; 94:261-9. [DOI: 10.1016/j.critrevonc.2015.02.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 02/02/2015] [Accepted: 02/26/2015] [Indexed: 01/07/2023] Open
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Police RL, Trask PC, Wang J, Olivares R, Khan S, Abbe A, Colosia A, Njue A, Sherrill B, Ruiz-Soto R, Kaye JA, Hamadani M. Randomized Controlled Trials in Relapsed/Refractory Chronic Lymphocytic Leukemia: A Systematic Review and Meta-Analysis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:199-207. [DOI: 10.1016/j.clml.2014.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 09/24/2014] [Indexed: 10/24/2022]
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Brunhofer-Bolzer G, Le T, Dyckmanns N, Knaus HA, Pausz C, Freund P, Jäger U, Erker T, Vanura K. SAR-guided development and characterization of a potent antitumor compound toward B-cell neoplasms with no detectable cytotoxicity toward healthy cells. J Med Chem 2015; 58:1244-53. [PMID: 25562417 DOI: 10.1021/jm501848m] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute hematological diseases (leukemias and aggressive lymphomas) can be cured in approximately half of the patients, while the other patients die from their disease. Chronic leukemias and indolent lymphomas can be well controlled for years in most cases. However, the cure rate of these patients is low and the course of the disease is characterized by frequent recurrence. Therefore, novel agents for monotherapies or combination therapies still need to be explored. The presented study describes the identification of the chalcone derivative 15 on different types of human malignant cells of the lymphoid and myeloid lineage. Further experiments performed with compound 15 on peripheral blood mononuclear cells (PBMCs) of chronic lymphocytic leukemia (CLL) patients clearly stated a higher cytotoxicity in PBMC from CLL patients compared to healthy donors (HD). The newly identified chalcone derivative 15 showed a higher therapeutic potential than fludarabine, a drug already in use in lymphoma treatment.
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Affiliation(s)
- Gerda Brunhofer-Bolzer
- Department of Medicinal Chemistry, University of Vienna , Althanstrasse 14, 1090 Vienna, Austria
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Chao MP. Treatment challenges in the management of relapsed or refractory non-Hodgkin's lymphoma - novel and emerging therapies. Cancer Manag Res 2013; 5:251-69. [PMID: 24049458 PMCID: PMC3775637 DOI: 10.2147/cmar.s34273] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Over the last few decades, advances in immunochemotherapy have led to dramatic improvement in the prognosis of non-Hodgkin's lymphoma (NHL). Despite these advances, relapsed and refractory disease represents a major treatment challenge. For both aggressive and indolent subtypes of NHL, there is no standard of care for salvage regimens, with prognosis after relapse remaining relatively poor. Nevertheless, there are multiple emerging classes of targeted therapies for relapsed/refractory disease, including monoclonal antibodies, antibody- drug conjugates, radioimmunotherapy, small-molecule inhibitors of cell-growth pathways, and novel chemotherapy agents. This review will discuss treatment challenges of NHL, current available salvage regimens for relapsed/refractory NHL, and the safety and efficacy of novel emerging therapies.
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Affiliation(s)
- Mark P Chao
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University, Stanford, CA, USA
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