1
|
Russell NH, Wilhelm-Benartzi C, Othman J, Dillon R, Knapper S, Batten LM, Canham J, Hinson EL, Betteridge S, Overgaard UM, Gilkes A, Potter N, Mehta P, Kottaridis P, Cavenagh J, Hemmaway C, Arnold C, Freeman SD, Dennis M. Fludarabine, Cytarabine, Granulocyte Colony-Stimulating Factor, and Idarubicin With Gemtuzumab Ozogamicin Improves Event-Free Survival in Younger Patients With Newly Diagnosed AML and Overall Survival in Patients With NPM1 and FLT3 Mutations. J Clin Oncol 2024:JCO2300943. [PMID: 38215358 DOI: 10.1200/jco.23.00943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/07/2023] [Accepted: 10/20/2023] [Indexed: 01/14/2024] Open
Abstract
PURPOSE To determine the optimal induction chemotherapy regimen for younger adults with newly diagnosed AML without known adverse risk cytogenetics. PATIENTS AND METHODS One thousand thirty-three patients were randomly assigned to intensified (fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin [FLAG-Ida]) or standard (daunorubicin and Ara-C [DA]) induction chemotherapy, with one or two doses of gemtuzumab ozogamicin (GO). The primary end point was overall survival (OS). RESULTS There was no difference in remission rate after two courses between FLAG-Ida + GO and DA + GO (complete remission [CR] + CR with incomplete hematologic recovery 93% v 91%) or in day 60 mortality (4.3% v 4.6%). There was no difference in OS (66% v 63%; P = .41); however, the risk of relapse was lower with FLAG-Ida + GO (24% v 41%; P < .001) and 3-year event-free survival was higher (57% v 45%; P < .001). In patients with an NPM1 mutation (30%), 3-year OS was significantly higher with FLAG-Ida + GO (82% v 64%; P = .005). NPM1 measurable residual disease (MRD) clearance was also greater, with 88% versus 77% becoming MRD-negative in peripheral blood after cycle 2 (P = .02). Three-year OS was also higher in patients with a FLT3 mutation (64% v 54%; P = .047). Fewer transplants were performed in patients receiving FLAG-Ida + GO (238 v 278; P = .02). There was no difference in outcome according to the number of GO doses, although NPM1 MRD clearance was higher with two doses in the DA arm. Patients with core binding factor AML treated with DA and one dose of GO had a 3-year OS of 96% with no survival benefit from FLAG-Ida + GO. CONCLUSION Overall, FLAG-Ida + GO significantly reduced relapse without improving OS. However, exploratory analyses show that patients with NPM1 and FLT3 mutations had substantial improvements in OS. By contrast, in patients with core binding factor AML, outcomes were excellent with DA + GO with no FLAG-Ida benefit.
Collapse
Affiliation(s)
- Nigel H Russell
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Jad Othman
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
| | - Richard Dillon
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
| | - Steven Knapper
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Leona M Batten
- Centre for Trials Research, Cardiff University, Cardiff, United Kindgom
| | - Joanna Canham
- Centre for Trials Research, Cardiff University, Cardiff, United Kindgom
| | - Emily L Hinson
- Centre for Trials Research, Cardiff University, Cardiff, United Kindgom
| | - Sophie Betteridge
- Centre for Trials Research, Cardiff University, Cardiff, United Kindgom
| | | | - Amanda Gilkes
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Nicola Potter
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
| | - Priyanka Mehta
- University Hospitals of Bristol and Weston NHS Trust, Bristol, United Kingdom
| | | | - Jamie Cavenagh
- Department of Haematology, St Bartholomew's Hospital, London, United Kingdom
| | | | | | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Mike Dennis
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| |
Collapse
|
2
|
Othman J, Wilhelm-Benartzi C, Dillon R, Knapper S, Freeman SD, Batten LM, Canham J, Hinson EL, Wych J, Betteridge S, Villiers W, Kleeman M, Gilkes A, Potter N, Overgaard UM, Mehta P, Kottaridis P, Cavenagh J, Hemmaway C, Arnold C, Dennis M, Russell NH. A randomized comparison of CPX-351 and FLAG-Ida in adverse karyotype AML and high-risk MDS: the UK NCRI AML19 trial. Blood Adv 2023; 7:4539-4549. [PMID: 37171402 PMCID: PMC10425682 DOI: 10.1182/bloodadvances.2023010276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023] Open
Abstract
Liposomal daunorubicin and cytarabine (CPX-351) improved overall survival (OS) compared with 7+3 chemotherapy in older patients with secondary acute myeloid leukemia (AML); to date, there have been no randomized studies in younger patients. The high-risk cohort of the UK NCRI AML19 trial (ISRCTN78449203) compared CPX-351 with FLAG-Ida in younger adults with newly diagnosed adverse cytogenetic AML or high-risk myelodysplastic syndromes (MDS). A total of 189 patients were randomized (median age, 56 years). Per clinical criteria, 49% of patients had de novo AML, 20% had secondary AML, and 30% had high-risk MDS. MDS-related cytogenetics were present in 73% of the patients, with a complex karyotype in 49%. TP53 was the most common mutated gene, in 43%. Myelodysplasia-related gene mutations were present in 75 (44%) patients. The overall response rate (CR + CRi) after course 2 was 64% and 76% for CPX-351 and FLAG-Ida, respectively. There was no difference in OS (13.3 months vs 11.4 months) or event-free survival in multivariable analysis. However, relapse-free survival was significantly longer with CPX-351 (median 22.1 vs 8.35 months). There was no difference between the treatment arms in patients with clinically defined secondary AML or those with MDS-related cytogenetic abnormalities; however, an exploratory subgroup of patients with MDS-related gene mutations had significantly longer OS with CPX-351 (median 38.4 vs 16.3 months). In conclusion, the OS of younger patients with adverse risk AML/MDS was not significantly different between CPX-351 and FLAG-Ida.
Collapse
Affiliation(s)
- Jad Othman
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | - Richard Dillon
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Steve Knapper
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Sylvie D. Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Leona M. Batten
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Joanna Canham
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Emily L. Hinson
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Julie Wych
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - Sophie Betteridge
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | - William Villiers
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
| | - Michelle Kleeman
- Genomics Facility, NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, United Kingdom
| | - Amanda Gilkes
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Nicola Potter
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
| | | | - Priyanka Mehta
- Bristol Haematology and Oncology Centre, University Hospitals of Bristol and Weston NHS Trust, Bristol, United Kingdom
| | | | - Jamie Cavenagh
- Department of Haemato-Oncology, Barts Health NHS Trust, St Bartholomew’s Hospital, London, United Kingdom
| | - Claire Hemmaway
- Department of Haematology, Auckland Hospital, Auckland, New Zealand
| | - Claire Arnold
- Clinical Haematology, Belfast City Hospital, Belfast, Northern Ireland
| | - Mike Dennis
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Nigel H. Russell
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - UK National Cancer Research Institute Acute Myeloid Leukaemia Working Group
- Department of Medical and Molecular Genetics, Kings College London, London, United Kingdom
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
- School of Medicine, Cardiff University, Cardiff, United Kingdom
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
- Genomics Facility, NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, United Kingdom
- Copenhagen University Hospital, Copenhagen, Denmark
- Bristol Haematology and Oncology Centre, University Hospitals of Bristol and Weston NHS Trust, Bristol, United Kingdom
- Department of Haematology, University College Hospital, London, United Kingdom
- Department of Haemato-Oncology, Barts Health NHS Trust, St Bartholomew’s Hospital, London, United Kingdom
- Department of Haematology, Auckland Hospital, Auckland, New Zealand
- Clinical Haematology, Belfast City Hospital, Belfast, Northern Ireland
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| |
Collapse
|
3
|
Johnston S, Puhalla S, Wheatley D, Ring A, Barry P, Holcombe C, Boileau JF, Provencher L, Robidoux A, Rimawi M, McIntosh SA, Shalaby I, Stein RC, Thirlwell M, Dolling D, Morden J, Snowdon C, Perry S, Cornman C, Batten LM, Jeffs LK, Dodson A, Martins V, Modi A, Osborne CK, Pogue-Geile KL, Cheang MCU, Wolmark N, Julian TB, Fisher K, MacKenzie M, Wilcox M, Huang Bartlett C, Koehler M, Dowsett M, Bliss JM, Jacobs SA. Randomized Phase II Study Evaluating Palbociclib in Addition to Letrozole as Neoadjuvant Therapy in Estrogen Receptor-Positive Early Breast Cancer: PALLET Trial. J Clin Oncol 2019; 37:178-189. [PMID: 30523750 DOI: 10.1200/jco.18.01624] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE CDK4/6 inhibitors are used to treat estrogen receptor (ER)-positive metastatic breast cancer (BC) in combination with endocrine therapy. PALLET is a phase II randomized trial that evaluated the effects of combination palbociclib plus letrozole as neoadjuvant therapy. PATIENTS AND METHODS Postmenopausal women with ER-positive primary BC and tumors greater than or equal to 2.0 cm were randomly assigned 3:2:2:2 to letrozole (2.5 mg/d) for 14 weeks (A); letrozole for 2 weeks, then palbociclib plus letrozole to 14 weeks (B); palbociclib for 2 weeks, then palbociclib plus letrozole to 14 weeks (C); or palbociclib plus letrozole for 14 weeks. Palbociclib 125 mg/d was administered orally on a 21-days-on, 7-days-off schedule. Core-cut biopsies were taken at baseline and 2 and 14 weeks. Coprimary end points for letrozole versus palbociclib plus letrozole groups (A v B + C + D) were change in Ki-67 (protein encoded by the MKI67 gene; immunohistochemistry) between baseline and 14 weeks and clinical response (ordinal and ultrasound) after 14 weeks. Complete cell-cycle arrest was defined as Ki-67 less than or equal to 2.7%. Apoptosis was characterized by cleaved poly (ADP-ribose) polymerase. RESULTS Three hundred seven patients were recruited. Clinical response was not significantly different between palbociclib plus letrozole and letrozole groups ( P = .20; complete response + partial response, 54.3% v 49.5%), and progressive disease was 3.2% versus 5.4%, respectively. Median log-fold change in Ki-67 was greater with palbociclib plus letrozole compared with letrozole (-4.1 v -2.2; P < .001) in the 190 evaluable patients (61.9%), corresponding to a geometric mean change of -97.4% versus -88.5%. More patients on palbociclib plus letrozole achieved complete cell-cycle arrest (90% v 59%; P < .001). Median log-fold change (suppression) of cleaved poly (ADP-ribose) polymerase was greater with palbociclib plus letrozole versus letrozole (-0.80 v -0.42; P < .001). More patients had grade 3 or greater toxicity on palbociclib plus letrozole (49.8% v 17.0%; P < .001) mainly because of asymptomatic neutropenia. CONCLUSION Adding palbociclib to letrozole significantly enhanced the suppression of malignant cell proliferation (Ki-67) in primary ER-positive BC, but did not increase the clinical response rate over 14 weeks, which was possibly related to a concurrent reduction in apoptosis.
Collapse
Affiliation(s)
- Stephen Johnston
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Shannon Puhalla
- 2 Univeristy of Pittsburgh Medical Center Cancer Center, Pittsburgh, PA
| | - Duncan Wheatley
- 3 Royal Cornwall Hospitals National Health Service Foundation Trust, Treliske, United Kingdom
| | - Alistair Ring
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Peter Barry
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Chris Holcombe
- 4 Royal Liverpool and Broadgreen University Hospitals National Health Service Trust, Liverpool, United Kingdom
| | | | - Louise Provencher
- 6 Centre Hospitalier Université de Quebec-Universite Laval, Quebec City, Quebec, Canada
| | - André Robidoux
- 7 Centre Hospitalier Université de Montréal, Montreal, Quebec, Canada
| | | | | | - Ibrahim Shalaby
- 10 Joe Arrington Cancer Research and Treatment Center, Lubbock, TX
| | - Robert C Stein
- 11 National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, United Kingdom
- 12 University College London Hospitals National Health Service Foundation Trust, London, United Kingdom
| | | | - David Dolling
- 14 The Institute of Cancer Research, London, United Kingdom
| | - James Morden
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Claire Snowdon
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Sophie Perry
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Chester Cornman
- 15 National Surgical Adjuvant Breast and Bowel Project Foundation, Pittsburgh, PA
| | - Leona M Batten
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Lisa K Jeffs
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Andrew Dodson
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Vera Martins
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | - Arjun Modi
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
| | | | | | | | - Norman Wolmark
- 15 National Surgical Adjuvant Breast and Bowel Project Foundation, Pittsburgh, PA
| | - Thomas B Julian
- 16 Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Kate Fisher
- 17 International Drug Development Institute, Brussels, Belgium
| | | | - Maggie Wilcox
- 18 Independent Cancer Patients Voice, London, United Kingdom
| | | | | | - Mitch Dowsett
- 1 The Royal Marsden National Health Service Foundation Trust, London, United Kingdom
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Judith M Bliss
- 14 The Institute of Cancer Research, London, United Kingdom
| | - Samuel A Jacobs
- 15 National Surgical Adjuvant Breast and Bowel Project Foundation, Pittsburgh, PA
| |
Collapse
|
4
|
Batten LM, Bhattacharya IS, Moretti L, Haviland JS, Emson MA, Miller SE, Jefford M, MacKenzie M, Wilcox M, Hyslop M, Todd R, Snowdon CF, Bliss JM. Patient advocate involvement in the design and conduct of breast cancer clinical trials requiring the collection of multiple biopsies. Res Involv Engagem 2018; 4:22. [PMID: 30026963 PMCID: PMC6047125 DOI: 10.1186/s40900-018-0108-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/03/2018] [Indexed: 06/08/2023]
Abstract
PLAIN ENGLISH SUMMARY Breast cancer is a diverse and varied disease. Recent research has shown that the collection of multiple biopsies before surgery can help researchers determine how the cancer is responding to treatment and can predict for long-term outcomes. However biopsies can be uncomfortable, and sometimes clinicians and research teams in hospitals may be reluctant to offer clinical trials requiring several biopsies to patients who have been recently diagnosed with breast cancer. The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU) oversees a large number of breast cancer clinical trials where multiple biopsies are required. ICR-CTSU recognises that patient advocates (patients who have previously had, or cared for someone with, cancer) are key members of the trial design group and should be involved in the clinical trial throughout its lifespan. Patient advocates can provide reassurance regarding the acceptability of trial designs involving multiple biopsies from a patient perspective. This paper summarises patient advocate involvement in ICR-CTSU breast cancer trials activity and how this has benefited our research. ABSTRACT The importance of collecting tissue samples in breast cancer has become increasingly recognised, as the diversity of the disease has become better known. It has been documented in recent research that tumours may change in response to treatment prior to surgery (the neoadjuvant treatment setting). The collection of sequential biopsies over time can identify changes within tumours and potentially predict how the tumour may respond to certain treatments. However, the acceptability of multiple biopsies amongst patients, clinicians and other research staff in hospitals is variable and recruitment into clinical trials requiring multiple biopsies may be challenging.The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU) is responsible for a portfolio of breast cancer trials where multiple biopsies are key to the trial design. Patient advocate involvement has been essential in helping us to design and deliver complex and innovative cancer trials which require multiple invasive tissue biopsies, often without any direct benefit to the trial participants. The views expressed by patient advocates involved in ICR-CTSU trials supports the published evidence that patients are willing to donate additional tissue for research and that clinicians' concerns about approaching patients for trials involving multiple biopsies are often unfounded.Patient advocate involvement in ICR-CTSU trials activity takes various forms, from membership on protocol development groups and trial management groups, attendance at focus groups and forums, and presentations at trial development and launch meetings. This involvement has provided reassurance to research teams within the NHS and research ethics committees of the importance and acceptability of our trials from a patient perspective. Patient advocate involvement throughout the lifetime of our trials ensures that the patient remains central to our research considerations.
Collapse
Affiliation(s)
- Leona M. Batten
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit, Sir Richard Doll Building, 15 Cotswold Road, Sutton, London, SM2 5NG UK
| | - Indrani Subarna Bhattacharya
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit, Sir Richard Doll Building, 15 Cotswold Road, Sutton, London, SM2 5NG UK
| | - Laura Moretti
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit, Sir Richard Doll Building, 15 Cotswold Road, Sutton, London, SM2 5NG UK
| | - Joanne S. Haviland
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit, Sir Richard Doll Building, 15 Cotswold Road, Sutton, London, SM2 5NG UK
| | - Marie A. Emson
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit, Sir Richard Doll Building, 15 Cotswold Road, Sutton, London, SM2 5NG UK
| | - Sarah E. Miller
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit, Sir Richard Doll Building, 15 Cotswold Road, Sutton, London, SM2 5NG UK
| | - Monica Jefford
- National Cancer Research Institute, Angel Building, 407, St John Street, Clerkenwell, London, EC1V 4AD UK
| | - Mairead MacKenzie
- Independent Cancer Patients Voice, 17 Woodbridge St, Clerkenwell, London, EC1R 0LL UK
| | - Maggie Wilcox
- Independent Cancer Patients Voice, 17 Woodbridge St, Clerkenwell, London, EC1R 0LL UK
| | - Marie Hyslop
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit, Sir Richard Doll Building, 15 Cotswold Road, Sutton, London, SM2 5NG UK
| | - Rachel Todd
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit, Sir Richard Doll Building, 15 Cotswold Road, Sutton, London, SM2 5NG UK
| | - Claire F. Snowdon
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit, Sir Richard Doll Building, 15 Cotswold Road, Sutton, London, SM2 5NG UK
| | - Judith M. Bliss
- Division of Clinical Studies, The Institute of Cancer Research Clinical Trials and Statistics Unit, Sir Richard Doll Building, 15 Cotswold Road, Sutton, London, SM2 5NG UK
| |
Collapse
|