1
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Garcia-Manero G, McCloskey J, Griffiths EA, Yee KWL, Zeidan AM, Al-Kali A, Deeg HJ, Patel PA, Sabloff M, Keating MM, Zhu N, Gabrail NY, Fazal S, Maly J, Odenike O, Kantarjian H, DeZern AE, O'Connell CL, Roboz GJ, Busque L, Buckstein R, Amin H, Randhawa J, Leber B, Shastri A, Dao KH, Oganesian A, Hao Y, Keer HN, Azab M, Savona MR. Oral decitabine-cedazuridine versus intravenous decitabine for myelodysplastic syndromes and chronic myelomonocytic leukaemia (ASCERTAIN): a registrational, randomised, crossover, pharmacokinetics, phase 3 study. Lancet Haematol 2024; 11:e15-e26. [PMID: 38135371 DOI: 10.1016/s2352-3026(23)00338-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND The DNA methyltransferase inhibitors azacitidine and decitabine for individuals with myelodysplastic syndromes or chronic myelomonocytic leukaemia are available in parenteral form. Oral therapy with similar exposure for these diseases would offer potential treatment benefits. We aimed to compare the safety and pharmacokinetics of oral decitabine plus the cytidine deaminase inhibitor cedazuridine versus intravenous decitabine. METHODS We did a registrational, multicentre, open-label, crossover, phase 3 trial of individuals with myelodysplastic syndromes or chronic myelomonocytic leukaemia and individuals with acute myeloid leukaemia, enrolled as separate cohorts; results for only participants with myelodysplastic syndromes or chronic myelomonocytic leukaemia are reported here. In 37 academic and community-based clinics in Canada and the USA, we enrolled individuals aged 18 years or older who were candidates to receive intravenous decitabine, with Eastern Cooperative Oncology Group performance status 0 or 1 and a life expectancy of at least 3 months. Participants were randomly assigned (1:1) to receive 5 days of oral decitabine-cedazuridine (one tablet once daily containing 35 mg decitabine and 100 mg cedazuridine as a fixed-dose combination) or intravenous decitabine (20 mg/m2 per day by continuous 1-h intravenous infusion) in a 28-day treatment cycle, followed by 5 days of the other formulation in the next treatment cycle. Thereafter, all participants received oral decitabine-cedazuridine from the third cycle on until treatment discontinuation. The primary endpoint was total decitabine exposure over 5 days with oral decitabine-cedazuridine versus intravenous decitabine for cycles 1 and 2, measured as area under the curve in participants who received the full treatment dose in cycles 1 and 2 and had decitabine daily AUC0-24 for both oral decitabine-cedazuridine and intravenous decitabine (ie, paired cycles). On completion of the study, all patients were rolled over to a maintenance study. This study is registered with ClinicalTrials.gov, NCT03306264. FINDINGS Between Feb 8, 2018, and June 7, 2021, 173 individuals were screened, 138 (80%) participants were randomly assigned to a treatment sequence, and 133 (96%) participants (87 [65%] men and 46 [35%] women; 121 [91%] White, four [3%] Black or African-American, three [2%] Asian, and five [4%] not reported) received treatment. Median follow-up was 966 days (IQR 917-1050). Primary endpoint of total exposure of oral decitabine-cedazuridine versus intravenous decitabine was 98·93% (90% CI 92·66-105·60), indicating equivalent pharmacokinetic exposure on the basis of area under the curve. The safety profiles of oral decitabine-cedazuridine and intravenous decitabine were similar. The most frequent adverse events of grade 3 or worse were thrombocytopenia (81 [61%] of 133 participants), neutropenia (76 [57%] participants), and anaemia (67 [50%] participants). The incidence of serious adverse events in cycles 1-2 was 31% (40 of 130 participants) with oral decitabine-cedazuridine and 18% (24 of 132 participants) with intravenous decitabine. There were five treatment-related deaths; two deemed related to oral therapy (sepsis and pneumonia) and three to intravenous treatment (septic shock [n=2] and pneumonia [n=1]). INTERPRETATION Oral decitabine-cedazuridine was pharmacologically and pharmacodynamically equivalent to intravenous decitabine. The results support use of oral decitabine-cedazuridine as a safe and effective alternative to intravenous decitabine for treatment of individuals with myelodysplastic syndromes or chronic myelomonocytic leukaemia. FUNDING Astex Pharmaceuticals.
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Affiliation(s)
| | - James McCloskey
- John Thuerer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | | | - Karen W L Yee
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Amer M Zeidan
- Yale Cancer Center, Yale University, New Haven, CT, USA
| | | | | | - Prapti A Patel
- The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mitchell Sabloff
- University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Nancy Zhu
- University of Alberta, Edmonton, AB, Canada
| | | | - Salman Fazal
- Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Joseph Maly
- Norton Cancer Institute, Louisville, KY, USA
| | | | - Hagop Kantarjian
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy E DeZern
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Baltimore, MD, USA
| | | | - Gail J Roboz
- New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA
| | | | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Harshad Amin
- Boca Raton Clinical Research, Boca Raton, FL, USA
| | | | - Brian Leber
- Juravinski Cancer Centre, Hamilton, ON, Canada
| | | | | | | | - Yong Hao
- Astex Pharmaceuticals, Pleasanton, CA, USA
| | | | | | - Michael R Savona
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
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2
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Perusini MA, Novitzky-Basso I, Atenafu EG, Forrest D, Bence-Bruckler I, Savoie L, Keating MM, Busque L, Delage R, Xenocostas A, Liew E, Laneuville P, Paulson K, Stockley T, Lipton JH, Leber B, Kim DDH. Final report of TKI discontinuation trial with dasatinib for the second attempt of treatment-free remission after failing the first attempt with imatinib: Treatment-free Remission Accomplished by Dasatinib (TRAD) study. Br J Haematol 2023; 203:781-791. [PMID: 37697469 DOI: 10.1111/bjh.19058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/04/2023] [Accepted: 08/10/2023] [Indexed: 09/13/2023]
Abstract
Multiple studies have reported a significant treatment-free remission (TFR) rate of 50%-60% in patients with chronic myeloid leukaemia (CML) who discontinue tyrosine kinase inhibitor (TKI) therapy. However, the remaining half of these patients still require re-initiation of TKI therapy for leukaemia control. It remains unclear if TKI drugs should be switched for re-therapy in patients who failed the first TFR (TFR1) attempt. Our study attempted to determine whether dasatinib therapy after TFR1 failure post-imatinib discontinuation could improve the likelihood of TFR2. Of 59 patients who lost molecular response after imatinib discontinuation for TFR1, 55 patients (93.2%) were treated with dasatinib, of whom 49 (89.1%) regained MR4.5 or deeper response, with a median time of 1.85 months to achieve MR4.5. Dasatinib was discontinued in 35 patients for TFR2 attempt, of whom 26 patients (74.28%) lost MMR and 6 (17.14%) MR4. Risk factor analysis for the TFR2 after dasatinib discontinuation suggested three significant factors: (1) doubling time of BCR::ABL1 transcript following TFR1 attempt, (2) rapid regaining of molecular response following dasatinib therapy and (3) undetectable BCR::ABL1 transcript prior to TFR2 attempt. The present study showed that dasatinib does not increase the TFR2 rate in general, but a selected group of patients could benefit from this approach.
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Affiliation(s)
- Maria Agustina Perusini
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Igor Novitzky-Basso
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Hematology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Eshetu G Atenafu
- Biostatistic Department, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Donna Forrest
- Leukemia/BMT Program of British Columbia, Division of Hematology, Vancouver General Hospital, British Columbia Cancer Agency, and University of British Columbia, Vancouver, British Columbia, Canada
| | - Isabelle Bence-Bruckler
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lynn Savoie
- University of Calgary, Alberta Health Services, Calgary, Alberta, Canada
| | - Mary-Margaret Keating
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lambert Busque
- Hematopoiesis and Aging Research Unit, University of Montreal, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Robert Delage
- Centre Universitaire d'Hématologie et d'Oncologie de Québec, CHU de Québec, Hôpital de l'Enfant-Jésus, Quebec City, Quebec, Canada
| | - Anargyros Xenocostas
- Division of Hematology, Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Elena Liew
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Pierre Laneuville
- Division of Hematology, McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Tracy Stockley
- Department of Pathology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey H Lipton
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Hematology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brian Leber
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Dong Hwan Kim
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Hematology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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3
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Buckstein R, Chodirker L, Yee KWL, Geddes M, Leitch HA, Christou G, Banerji V, Leber B, Khalaf D, St-Hilaire E, Finn N, Nevill T, Keating MM, Storring J, Parmentier A, Thambipillai A, Tang D, Westcott C, Cameron C, Spin P. The burden of red blood cell transfusions in patients with lower-risk myelodysplastic syndromes and ring sideroblasts: an analysis of the prospective MDS-CAN registry. Leuk Lymphoma 2023; 64:651-661. [PMID: 36606533 DOI: 10.1080/10428194.2022.2156793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Many patients with lower-risk myelodysplastic syndromes (LR MDS) require long-term red blood cell (RBC) transfusions to manage anemia. The consequences of RBC transfusions in LR MDS with ring sideroblasts (LR MDS-RS) are not well known. We estimated the association between cumulative RBC dose density and clinical and patient-reported outcomes using data from the MDS-CAN registry for patients enrolled between January 2008 and December 2018. Outcomes included overall survival, hospitalization, and health-related quality of life (HRQoL). A total of 145 enrolled patients with LR MDS and RS ≥5% had a median follow-up time of 27.1 months; 45 had no transfusions during follow-up, 51 had <1 transfusion per month, and 49 had ≥1 transfusion per month. The cumulative density of RBC transfusions was associated with significantly greater mortality, hospitalization, and inferior HRQoL, suggesting that exposure to RBC transfusion may constitute a significant treatment burden in patients with LR MDS-RS.
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Affiliation(s)
- Rena Buckstein
- Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Lisa Chodirker
- Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Karen W L Yee
- Department of Medicine, University of Toronto, Toronto, Canada
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Michelle Geddes
- Department of Medicine, Tom Baker Cancer Centre, Calgary, Canada
| | - Heather A Leitch
- Division of Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
| | - Grace Christou
- Clinical epidemiology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | | | - Brian Leber
- Hematology Disease Site Team, Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, Canada
| | - Dina Khalaf
- Hematology Disease Site Team, Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, Canada
| | - Eve St-Hilaire
- Hematology Services, Centre Hospitalier Universitaire Dr. Georges-L.-Dumont, Moncton, Canada
| | - Nicholas Finn
- Hematology Services, Centre Hospitalier Universitaire Dr. Georges-L.-Dumont, Moncton, Canada
| | - Thomas Nevill
- Division of Hematology, Leukemia/Bone Marrow Transplant Program of BC, BC Cancer, University of British Columbia, Vancouver, Canada
| | | | - John Storring
- Hematology Division, McGill University Health Centre, Montréal, Canada
| | - Anne Parmentier
- Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Aksharh Thambipillai
- Division of Medical Oncology and Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Derek Tang
- Bristol Myers Squibb, Princeton, NJ, USA
| | | | - Chris Cameron
- Value and Evidence Division, Marketing and Market Access, EVERSANA™, Sydney, Canada
| | - Paul Spin
- Value and Evidence Division, Marketing and Market Access, EVERSANA™, Sydney, Canada
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4
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Peters A, Keating MM, Nikonova A, Doucette S, Prica A. Management of Marginal Zone Lymphoma: A Canadian Perspective. Curr Oncol 2023; 30:1745-1759. [PMID: 36826096 PMCID: PMC9955247 DOI: 10.3390/curroncol30020135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/25/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Marginal zone lymphomas (MZL) are a rare, heterogenous group of lymphomas, accounting for 5-17% of indolent non-Hodgkin lymphomas in the western world. They can be further divided into three subtypes: extranodal MZL, splenic MZL, and nodal MZL. These subtypes differ in clinical presentation and behavior, which influences how they are managed. There is currently no standard of care for the treatment of MZL, owing to the difficulty in conducting phase 3 randomized trials in MZL, and the fact that there are limited data on the efficacy of therapy in individual subtypes. Treatment practices are thus largely borrowed from other indolent lymphomas and are based on patient and disease characteristics, as well as access to therapy. This review summarizes the Canadian treatment landscape for MZL and how these therapies may be sequenced in practice.
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Affiliation(s)
- Anthea Peters
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB T6G 1Z2, Canada
- Correspondence:
| | - Mary-Margaret Keating
- Division of Hematology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS B3H 2Y9, Canada
| | - Anna Nikonova
- Division of Hematology, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | | | - Anca Prica
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada
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5
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Buckstein R, Chodirker L, Mozessohn L, Yee KWL, Geddes M, Zhu N, Shamy A, Leitch HA, Christou G, Banerji V, Brian L, Khalaf D, St-Hilaire E, Finn N, Nevill T, Keating MM, Storring J, Delage R, Parmentier A, Thambipillai A, Siddiqui M, Westcott C, Cameron C, Mamedov A, Spin P, Tang D. A natural history of lower-risk myelodysplastic syndromes with ring sideroblasts: an analysis of the MDS-CAN registry. Leuk Lymphoma 2022; 63:3165-3174. [PMID: 36095125 DOI: 10.1080/10428194.2022.2109154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Patients with lower-risk (LR) myelodysplastic syndromes (MDS) with ring sideroblasts (RS) have better prognosis than those without RS, but how they fare over time is not fully understood. This study's objective was to assess the natural history of LR MDS with RS ≥5% using MDS-CAN registry individual data. Kaplan-Meier estimates and generalized linear mixed models were used to describe time-to-event outcomes and continuous outcomes, respectively. One hundred and thirty-eight patients were enrolled; median times from diagnosis to enrollment and follow-up were 6.6 and 39.6 months, respectively. Within 5 years of enrollment, 65% of patients had ≥1 red blood cell transfusion dependence episode. Within 5 years of diagnosis, 59% developed iron overload, 38% received iron chelation therapy, 14% progressed to acute myeloid leukemia, and 42% died. Patients exhibited inferior health-related quality of life trends. These first real-world data in LR MDS-RS in Canada indicate a high level of morbidity and mortality over a 5-year period. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02537990.
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Affiliation(s)
- Rena Buckstein
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisa Chodirker
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lee Mozessohn
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karen W L Yee
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Nancy Zhu
- Division of Hematology, University of Alberta, Edmonton, AB, Canada
| | - April Shamy
- Jewish General Hospital, Montréal, QC, Canada
| | - Heather A Leitch
- St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Grace Christou
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | - Leber Brian
- Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Dina Khalaf
- Juravinski Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Eve St-Hilaire
- Centre Hospitalier Universitaire Dr. Georges-L.-Dumont, Moncton, NB, Canada
| | - Nicholas Finn
- Centre Hospitalier Universitaire Dr. Georges-L.-Dumont, Moncton, NB, Canada
| | - Thomas Nevill
- Division of Hematology, Leukemia/Bone Marrow Transplant Program of BC, BC Cancer, University of British Columbia, Vancouver, BC, Canada
| | | | - John Storring
- McGill University Health Centre, Montréal, QC, Canada
| | - Robert Delage
- CHU de Québec, Hôpital de l'Enfant-Jésus, Centre Universitaire d'Hématologie et d'Oncologie de Québec, Québec, QC, Canada
| | - Anne Parmentier
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Aksharh Thambipillai
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mohammed Siddiqui
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Chris Cameron
- Value and Evidence Division, Marketing & Market Access, EVERSANA™, Sydney, NS, Canada
| | - Alexandre Mamedov
- Division of Medical Oncology & Hematology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Paul Spin
- Value and Evidence Division, Marketing & Market Access, EVERSANA™, Sydney, NS, Canada
| | - Derek Tang
- Bristol Myers Squibb, Princeton, NJ, USA
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6
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Teichman J, Geddes M, Zhu N, Keating MM, Sabloff M, Christou G, Leber B, Khalaf D, St-Hilaire E, Finn N, Shamy A, Yee KW, Storring JM, Nevill TJ, Delage R, Elemary M, Banerji V, Houston B, Mozessohn L, Chodirker L, Zhang L, Siddiqui M, Parmentier A, Leitch HA, Buckstein RJ. High transferrin saturation predicts inferior clinical outcomes in patients with myelodysplastic syndromes. Haematologica 2022; 108:532-542. [PMID: 35979720 PMCID: PMC9890030 DOI: 10.3324/haematol.2022.280723] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Indexed: 02/03/2023] Open
Abstract
Iron overload (IO) reflected by elevated ferritin is associated with increased mortality in myelodysplastic syndromes (MDS), however, ferritin is an imperfect metric. Elevated labile plasma iron correlates with clinical outcomes and transferrin saturation (TSAT) >80%, but is not readily measurable. The trajectory of TSAT, and its association with clinical outcomes remain undefined. Canadian MDS registry patients were evaluated. Mean TSAT, mean ferritin and transfusion dose density (TDD) were determined. Survival was evaluated by TSAT and ferritin (<50%, 50-80%, >80%), (≤500 μg/L, 501-800 μg/L, >800 μg/L). In 718 patients, median age was 74 years; 12%, 31%, 29%, 15% and 13% were IPSS-R very low, low, intermediate, high and very high. TSAT and ferritin were moderately correlated (r=0.63, P<0.0001). TSAT increased over time in transfusion- dependent patients (P=0.006). Higher TSAT and ferritin were associated with inferior 5-year overall (OS), progression- free (PFS), and leukemia-free survival (LFS) (P≤0.008) and higher TDD with inferior 5-year OS. TSAT >80% trended with inferior cardiac death-free survival (P=0.053). In univariate analysis, age, IPSS-R, blast percentage by Eastern Cooperative Oncology Group Performance Status, frailty, Charlson Comorbidity Index, iron chelation (Y/N), TDD, TSAT and ferritin were significantly associated with inferior OS. By multivariable analysis, TSAT >80% (P=0.007) remained significant for OS (R2 30.3%). In MDS, TSAT >80% and ferritin >800 μg/L portended inferior OS, PFS and LFS. TSAT may indicate the presence of oxidative stress, and is readily measurable in a clinical setting. The relationship between TSAT and cardiac death-free survival warrants further study.
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Affiliation(s)
| | | | - Nancy Zhu
- University of Alberta, Edmonton, Alberta
| | | | | | | | | | | | - Eve St-Hilaire
- Dr. Georges-L-Dumont University Hospital Center, Moncton, New Brunswick
| | - Nicholas Finn
- Dr. Georges-L-Dumont University Hospital Center, Moncton, New Brunswick
| | | | | | | | | | | | | | - Versha Banerji
- Sunnybrook Health Sciences Center, Toronto, Ontario,QEII Health Sciences Centre, Halifax, Nova Scotia
| | | | | | | | - Liying Zhang
- Sunnybrook Health Sciences Center, Toronto, Ontario
| | | | | | - Heather A. Leitch
- St. Paul’s Hospital, Vancouver, British Columbia, Canada,HAL and RJB contributed equally as co-senior authors
| | - Rena J. Buckstein
- Sunnybrook Health Sciences Center, Toronto, Ontario,HAL and RJB contributed equally as co-senior authors
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7
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Kim DDH, Kim TS, Atenafu EG, Novitzky Basso I, Forrest D, Bence-Bruckler I, Savoie L, Busque L, Keating MM, Delage R, Xenocostas A, Liew E, Paulson K, Stockley T, Laneuville P, Lipton JH, Kamel-Reid S, Leber B. BCR-ABL1 transcript doubling time as a predictor for treatment-free remission failure after imatinib discontinuation in chronic myeloid leukaemia in chronic phase. Br J Haematol 2021; 196:136-145. [PMID: 34496035 DOI: 10.1111/bjh.17807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/06/2021] [Accepted: 08/16/2021] [Indexed: 11/28/2022]
Abstract
The doubling time (DT) of the BCR-ABL1 quantitative polymerase chain reaction (qPCR) transcript level reflects the re-growing fraction of leukaemic cells after discontinuation of tyrosine kinase inhibitor (TKI). The present study analyzed monthly DT within six months after imatinib discontinuation in 131 patients. Monthly DT was calculated as x = ln(2)/K, where x is the DT and K is the fold BCR-ABL1 change from the previous value divided by the number of days between each measurement. The optimal DT value was determined as 12·75 days at two months using a recursive partitioning method. The patients were stratified into three groups: the high-risk group (DT<12·75 days but >0, with rapidly proliferating chronic myeloid leukaemia (CML) cells; n = 26) showed the lowest molecular relapse-free survival (mRFS) of 7·7% at 12 months, compared to 53·6% in the intermediate-risk group (DT≥12·75 days, with slowly proliferating CML cells; n = 16) or 90·0% in the low-risk group (DT≤0, i.e., without proliferating CML cells; n = 71; P < 0·001). Monthly assessment of DT helps identify high-risk patients for treatment-free remission failure with an imminent risk of molecular recurrence, and to define low-risk patients who can be spared the frequent monitoring of monthly molecular tests.
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Affiliation(s)
- Dennis Dong Hwan Kim
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Taehyung Simon Kim
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Eshetu G Atenafu
- Department of Biostatstics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Igor Novitzky Basso
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Donna Forrest
- Leukemia/BMT Program of British Columbia, Division of Hematology, Vancouver General Hospital, British Columbia Cancer Agency, University of British Columbia, Vancouver, BC, Canada
| | | | - Lynn Savoie
- University of Calgary, Alberta Health Services, Calgary, AB, Canada
| | - Lambert Busque
- Hematopoiesis and Aging Research Unit, University of Montreal, Hôpital Maisonneuve-Rosemont, Montreal, QC, Canada
| | - Mary-Margaret Keating
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS, Canada
| | - Robert Delage
- Centre Universitaire d'Hématologie et d'Oncologie de Québec, CHU de Québec, Hôpital de l'Enfant-Jésus, Québec, QC, Canada
| | - Anargyros Xenocostas
- Department of Medicine, Division of Hematology, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Elena Liew
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | | | - Tracy Stockley
- Department of Pathology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Pierre Laneuville
- Division of Hematology, McGill University Health Centre, Montreal, QC, Canada
| | - Jeffrey H Lipton
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Suzanne Kamel-Reid
- Department of Pathology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Brian Leber
- Division of Hematology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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8
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Amitai I, Geddes M, Zhu N, Keating MM, Sabloff M, Christou G, Leber B, Khalaf D, Leitch HA, St-Hilaire E, Finn N, Shamy A, Yee K, Storring J, Nevill T, Delage R, Elemary M, Banerji V, Chodirker L, Mozessohn L, Parmentier A, Siddiqui M, Mamedov A, Zhang L, Buckstein R. Patient-reported fatigue refines prognosis in higher-risk myelodysplastic syndromes (MDS): a MDS-CAN study. Br J Haematol 2021; 194:319-324. [PMID: 34060069 DOI: 10.1111/bjh.17537] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/12/2021] [Indexed: 01/24/2023]
Abstract
The incorporation of patient-reported outcomes with traditional disease risk classification was found to strengthen survival prediction in patients with myelodysplastic syndromes (MDS). In the present Canadian MDS registry analysis, we validate a recently reported prognostic model, the Fatigue-International Prognostic Scoring System among higher-risk patients [FA-IPSS(h)], which incorporates patients' reported fatigue, assessed by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life-Core 30 (QLQ-C30), with a threshold of ≥45 points, in higher IPSS score, stratifying them into distinct subgroups with different survival outcomes. We further validated this concept, using the Revised IPSS >3·5 as cut-off for the definition of higher-risk MDS, and patients' reported fatigue according to Edmonton Symptom Self-Assessment Scale (ESAS) Global Fatigue Scale (GFS), a single-item fatigue rating scale, which is easier to deploy. This emphasises the power of self-reported fatigue at refining overall survival predictions in higher-risk MDS and further bolsters the importance of considering patient-related outcomes in global assessments.
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Affiliation(s)
- Irina Amitai
- Haematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Michelle Geddes
- Haematology/Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Nancy Zhu
- Haematology/Oncology, University of Alberta Hospital, Edmonton, AB, Canada
| | - Mary-Margaret Keating
- Haematology/Oncology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | - Grace Christou
- Haematology/Oncology, University of Ottawa, Ottawa, ON, Canada
| | - Brian Leber
- Haematology/Oncology, Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Dina Khalaf
- Haematology/Oncology, Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Heather A Leitch
- Haematology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Eve St-Hilaire
- Haematology/Oncology, Dr. Georges-L-Dumont University Centre, Moncton, NB, Canada
| | - Nicholas Finn
- Haematology/Oncology, Dr. Georges-L-Dumont University Centre, Moncton, NB, Canada
| | - April Shamy
- Haematology/Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - Karen Yee
- Haematology/Oncology, Princess Margaret Hospital, Toronto, ON, Canada
| | - John Storring
- Haematology/Oncology, McGill University Health Centre, Royal Victoria Hospital, Montreal, QC, Canada
| | - Thomas Nevill
- Haematology/Oncology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Robert Delage
- Haematology/Oncology, Centre de recherche du CHU de Quebec, Universite Laval, Quebec City, QC, Canada
| | | | - Versha Banerji
- Haematology/Oncology, Cancer Care Manitoba, Winnipeg, MB, Canada
| | - Lisa Chodirker
- Haematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lee Mozessohn
- Haematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Anne Parmentier
- Haematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mohammed Siddiqui
- Haematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexandre Mamedov
- Haematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Liying Zhang
- Haematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rena Buckstein
- Haematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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9
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Rummel MJ, Janssens A, MacDonald D, Keating MM, Zaucha JM, Davis J, Lasher J, Babanrao Pisal C, Izquierdo M, Friedberg JW. A phase 3, randomized study of ofatumumab combined with bendamustine in rituximab-refractory iNHL (COMPLEMENT A + B study). Br J Haematol 2021; 193:1123-1133. [PMID: 33973233 DOI: 10.1111/bjh.17420] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/28/2021] [Indexed: 01/22/2023]
Abstract
The standard of care for indolent non-Hodgkin lymphoma (iNHL) is rituximab, an anti-CD20 antibody, with/without chemotherapy. However, multiple relapses are common in these patients. This phase 3, randomized study compared outcomes of a combination of ofatumumab (a second-generation anti-CD20 antibody) and bendamustine, with bendamustine alone in patients unresponsive to prior rituximab-based treatment. Overall, 346 patients were randomized to receive either the combination or bendamustine alone. Bendamustine was given for ≤8 cycles and ofatumumab for ≤12 cycles. The primary end-point was progression-free survival (PFS) after 215 protocol-defined events assessed by independent review committee (IRC). Median IRC-assessed PFS was 16·7 and 13·8 months in the combination and monotherapy arms respectively [hazard ratio (HR) = 0·82; P = 0·1390]. Median overall survival (OS) was 58·2 and 51·8 months in the combination and monotherapy arms respectively (HR = 0·89, P = 0·4968). The safety profile was consistent with previous reports. Overall, 73% and 80% of patients in the combination and monotherapy arms, respectively, experienced a ≥grade 3 adverse event. The study did not meet its primary end-point. No significant improvement in PFS and OS was seen with the combination of ofatumumab and bendamustine as compared with bendamustine alone in rituximab-refractory iNHL (NCT01077518).
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Affiliation(s)
- Mathias J Rummel
- Department for Haematology, Clinic for Haematology and Medical Oncology, Justus-Liebig University-Hospital, Gießen, Germany
| | - Ann Janssens
- Department of Haematology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - David MacDonald
- Division of Haematology, Dalhousie University, Halifax, NS, Canada
| | | | - Jan M Zaucha
- Department of Haematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
| | | | | | | | | | - Jonathan W Friedberg
- Wilmot Cancer Institute, University of Rochester Medical Centre, Rochester, NY, USA
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10
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Kim DDH, Novitzky-Basso I, Kim TS, Atenafu EG, Forrest D, Savoie L, Bence-Bruckler I, Keating MM, Busque L, Delage R, Xenocostas A, Liew E, Paulson K, Stockley T, Laneuville P, Lipton JH, Kamel-Reid S, Leber B. Optimal duration of imatinib treatment/deep molecular response for treatment-free remission after imatinib discontinuation from a Canadian tyrosine kinase inhibitor discontinuation trial. Br J Haematol 2021; 193:779-791. [PMID: 33876423 DOI: 10.1111/bjh.17447] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/16/2021] [Accepted: 03/05/2021] [Indexed: 11/29/2022]
Abstract
Although total duration of tyrosine kinase inhibitor (TKI) therapy and of molecular response at 4 log reduction or deeper (MR4) correlates with treatment-free remission (TFR) success after TKI discontinuation, the optimal cut-off values of the duration remain unresolved. Thus, 131 patients were enrolled into the Canadian TKI discontinuation study. The molecular relapse-free survival (mRFS) was defined from imatinib discontinuation till molecular recurrence, that is, major molecular response (MMR) loss and/or MR4 loss. We evaluated mRFS at 12 months after imatinib discontinuation, analyzed it according to the imatinib treatment duration and MR4 duration, and calculated P value, positive (PPV) and negative predictive value (NPV) in the yearly cut-off period of time. The shortest cut-off was sought that met the joint criteria of a P value ≤ 0·05, PPV ≥ 60% and NPV ≥ 60%. We propose six years as the shortest imatinib duration cut-off with a P value 0·01, PPV 68% and NPV 62%: The patients treated with imatinib duration ≥ 6 years showed a superior mRFS rate (61·8%) compared to those with less treatment (36·0%). Also, 4·5 years MR4 duration as the shortest cut-off with a P value 0·003, PPV 63% and NPV 61%: those with MR4 duration ≥ 4·5 years showed a higher mRFS rate (64·2%) than those with a shorter MR4 duration (41·9%).
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Affiliation(s)
- Dennis D H Kim
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Igor Novitzky-Basso
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Taehyung S Kim
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada.,Department of Computer Science, Donnelly Centre, University of Toronto, Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Donna Forrest
- Leukemia/BMT Program of British Columbia, Division of Hematology, Vancouver General Hospital, British Columbia Cancer Agency, and University of British Columbia, Vancouver, Canada
| | - Lynn Savoie
- University of Calgary, Alberta Health Services, Calgary, Canada
| | | | | | - Lambert Busque
- Hematopoiesis and Aging Research Unit, University of Montreal, Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Robert Delage
- Centre Universitaire d'Hématologie et d'Oncologie de Québec, CHU de Québec, Hôpital de l'Enfant-Jésus, Québec, Canada
| | - Anargyros Xenocostas
- Department of Medicine, Division of Hematology, London Health Sciences Centre, University of Western Ontario, London, Canada
| | - Elena Liew
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Tracy Stockley
- Department of Pathology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Pierre Laneuville
- Division of Hematology, McGill University Health Centre, Montreal, Canada
| | - Jeffrey H Lipton
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Suzanne Kamel-Reid
- Department of Pathology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Brian Leber
- Department of Oncology, McMaster University, Hamilton, Canada
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11
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Starkman R, Alibhai S, Wells RA, Geddes M, Zhu N, Keating MM, Leber B, Chodirker L, Sabloff M, Christou G, Leitch HA, St-Hilaire E, Finn N, Shamy A, Yee K, Storring J, Nevill T, Delage R, Elemary M, Banerji V, Lenis M, Kirubananthaan A, Mamedov A, Zhang L, Rockwood K, Buckstein R. An MDS-specific frailty index based on cumulative deficits adds independent prognostic information to clinical prognostic scoring. Leukemia 2019; 34:1394-1406. [PMID: 31811236 DOI: 10.1038/s41375-019-0666-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/30/2019] [Accepted: 11/17/2019] [Indexed: 12/21/2022]
Abstract
The frailty index (FI) is based on the principle that the more deficits an individual has, the greater their risk of adverse outcomes. It is expressed as a ratio of the number of deficits present to the total number of deficits considered. We developed an MDS-specific FI using a prospective MDS registry and assessed its ability to add prognostic power to conventional prognostic scores in MDS. The 42 deficits included in this FI included measurements of physical performance, comorbidities, laboratory values, instrumental activities of daily living, quality of life and performance status. Of 644 patients, 440 were eligible for FI calculation. The median FI score was 0.25 (range 0.05-0.67), correlated with age and IPSS/IPSS-R risk scores and discriminated overall survival. With a follow-up of 20 months, survival was 27 months (95% CI 24-30.4). By multivariate analysis, age >70, FI, transfusion dependence, and IPSS were significant covariates associated with OS. The incremental discrimination improvement of the frailty index was 37%. We derived a prognostic score with five risk groups and distinct survivals ranging from 7.4 months to not yet reached. If externally validated, the MDS-FI could be used as a tool to refine the risk stratification of current clinical prognostication models.
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Affiliation(s)
- R Starkman
- Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - S Alibhai
- Geriatric Medicine/Oncology, University Health Network, Toronto, ON, Canada
| | - R A Wells
- Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - M Geddes
- Hematology/Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - N Zhu
- Hematology/Oncology, University of Alberta Hospital, Edmonton, AB, Canada
| | - M M Keating
- Hematology/Oncology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - B Leber
- Hematology/Oncology, Juravinski Cancer Center, Hamilton, ON, Canada
| | - L Chodirker
- Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - M Sabloff
- Hematology/Oncology, University of Ottawa, Ottawa, ON, Canada
| | - G Christou
- Hematology/Oncology, University of Ottawa, Ottawa, ON, Canada
| | - H A Leitch
- Hematology, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - E St-Hilaire
- Hematology/Oncology, Dr. Georges-L-Dumont University Centre, Moncton, NB, Canada
| | - N Finn
- Hematology/Oncology, Dr. Georges-L-Dumont University Centre, Moncton, NB, Canada
| | - A Shamy
- Hematology/Oncology, Jewish General Hospital, Montreal, QC, Canada
| | - K Yee
- Hematology/Oncology, Princess Margaret Hospital, Toronto, ON, Canada
| | - J Storring
- Hematology/Oncology, McGill University Health Centre-Royal Victoria Hospital, Montreal, QC, Canada
| | - T Nevill
- Hematology/Oncology, Vancouver General Hospital, Vancouver, BC, Canada
| | - R Delage
- Hematology/Oncology, Centre de recherche du CHU de Quebec-Universite Laval, Quebec City, QC, Canada
| | - M Elemary
- Hematology, Saskatoon Cancer Centre, Saskatoon, SK, Canada
| | - V Banerji
- Hematology/Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - M Lenis
- Hematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A Kirubananthaan
- Hematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - A Mamedov
- Hematology Clinical Trials, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - L Zhang
- Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - K Rockwood
- Geriatric Medicine, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - R Buckstein
- Hematology/Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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12
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Leitch HA, Buckstein R, Zhu N, Nevill TJ, Yee KWL, Leber B, Keating MM, St Hilaire E, Kumar R, Delage R, Geddes M, Storring JM, Shamy A, Elemary M, Wells RA. Iron overload in myelodysplastic syndromes: Evidence based guidelines from the Canadian consortium on MDS. Leuk Res 2018; 74:21-41. [PMID: 30286330 DOI: 10.1016/j.leukres.2018.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 08/08/2018] [Accepted: 09/15/2018] [Indexed: 01/19/2023]
Abstract
In 2008 the first evidence-based Canadian consensus guideline addressing the diagnosis, monitoring and management of transfusional iron overload in patients with myelodysplastic syndromes (MDS) was published. The Canadian Consortium on MDS, comprised of hematologists from across Canada with a clinical and academic interest in MDS, reconvened to update these guidelines. A literature search was updated in 2017; topics reviewed include mechanisms of iron overload induced cellular damage, evidence for clinical endpoints impacted by iron overload including organ dysfunction, infections, marrow failure, overall survival, acute myeloid leukemia progression, and endpoints around hematopoietic stem-cell transplant. Evidence for an impact of iron reduction on the same endpoints is discussed, guidelines are updated, and areas identified where evidence is suboptimal. The guidelines address common questions around the diagnosis, workup and management of iron overload in clinical practice, and take the approach of who, when, why and how to treat iron overload in MDS. Practical recommendations for treatment and monitoring are made. Evidence levels and grading of recommendations are provided for all clinical endpoints examined.
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Affiliation(s)
- Heather A Leitch
- Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada.
| | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nancy Zhu
- Hematology/Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas J Nevill
- Leukemia/BMT Program of British Columbia, Division of Hematology, Vancouver, BC, Canada
| | - Karen W L Yee
- Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Brian Leber
- McMaster University, Hamilton, Ontario, Canada
| | | | - Eve St Hilaire
- Centre d'Oncologie, Dr-Leon-Richard, Moncton, New Brunswick, Canada
| | - Rajat Kumar
- Hematology/Oncology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Robert Delage
- Hematology Department, Centre Hospitalier Universitaire, Laval University, Quebec, QC, Canada
| | - Michelle Geddes
- Department of Medicine/Hematology, Foothills Medical Centre, Calgary, Alberta, Canada
| | | | - April Shamy
- Sir Mortimer B Davis Hospital, McGill University, Montreal, Quebec, Canada
| | - Mohamed Elemary
- Saskatoon Cancer Center, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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13
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Leitch HA, Parmar A, Wells RA, Chodirker L, Zhu N, Nevill TJ, Yee KWL, Leber B, Keating MM, Sabloff M, St Hilaire E, Kumar R, Delage R, Geddes M, Storring JM, Kew A, Shamy A, Elemary M, Lenis M, Mamedov A, Ivo J, Francis J, Zhang L, Buckstein R. Overall survival in lower IPSS risk MDS by receipt of iron chelation therapy, adjusting for patient-related factors and measuring from time of first red blood cell transfusion dependence: an MDS-CAN analysis. Br J Haematol 2017; 179:83-97. [PMID: 28677895 DOI: 10.1111/bjh.14825] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 05/25/2017] [Indexed: 01/23/2023]
Abstract
Analyses suggest iron overload in red blood cell (RBC) transfusion-dependent (TD) patients with myleodysplastic syndrome (MDS) portends inferior overall survival (OS) that is attenuated by iron chelation therapy (ICT) but may be biassed by unbalanced patient-related factors. The Canadian MDS Registry prospectively measures frailty, comorbidity and disability. We analysed OS by receipt of ICT, adjusting for these patient-related factors. TD International Prognostic Scoring System (IPSS) low and intermediate-1 risk MDS, at RBC TD, were included. Predictive factors for OS were determined. A matched pair analysis considering age, revised IPSS, TD severity, time from MDS diagnosis to TD, and receipt of disease-modifying agents was conducted. Of 239 patients, 83 received ICT; frailty, comorbidity and disability did not differ from non-ICT patients. Median OS from TD was superior in ICT patients (5·2 vs. 2·1 years; P < 0·0001). By multivariate analysis, not receiving ICT independently predicted inferior OS, (hazard ratio for death 2·0, P = 0·03). In matched pair analysis, OS remained superior for ICT patients (P = 0·02). In this prospective, non-randomized analysis, receiving ICT was associated with superior OS in lower IPSS risk MDS, adjusting for age, frailty, comorbidity, disability, revised IPSS, TD severity, time to TD and receiving disease-modifying agents. This provides additional evidence that ICT may confer clinical benefit.
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Affiliation(s)
- Heather A Leitch
- Hematology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | | | - Richard A Wells
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lisa Chodirker
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Nancy Zhu
- Hematology/Oncology, University of Alberta, Edmonton, AB, Canada
| | - Thomas J Nevill
- Division of Hematology, Leukemia/BMT Program of British Columbia, Vancouver, BC, Canada
| | - Karen W L Yee
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | | | | | - Eve St Hilaire
- Centre d'Oncologie, Dr-Leon-Richard, Moncton, NB, Canada
| | - Rajat Kumar
- Hematology/Oncology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Robert Delage
- Hematology Department, Centre Hospitalier Universitaire, Laval University, Quebec, QC, Canada
| | - Michelle Geddes
- Department of Medicine/Hematology, Foothills Medical Centre, Calgary, AB, Canada
| | | | - Andrea Kew
- Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada
| | - April Shamy
- Sir Mortimer B Davis Hospital, McGill University, Montreal, QC, Canada
| | - Mohamed Elemary
- Saskatoon Cancer Center, University of Saskatchewan, Saskatoon, SK, Canada
| | - Martha Lenis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Alexandre Mamedov
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jessica Ivo
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Janika Francis
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Liying Zhang
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rena Buckstein
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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14
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Abstract
Conformational flexibility of acyl carrier protein (ACP) is important for its ability to interact with multiple enzymes in bacterial fatty acid metabolism. We have recently shown that, unlike the prototypical ACP from Escherichia coli, the more acidic Vibrio harveyi ACP is largely unfolded at physiological pH. Mutations D18K, A75H and A75H/D18K were made in recombinant V. harveyi ACP (rACP) to determine the importance of basic residues Lys-18 and His-75 in maintaining the native conformation of E. coli ACP. Both D18K and A75H ACPs were fatty acylated by acyl-ACP synthetase, showing that neither mutation grossly alters tertiary structure. Circular dichroism (CD) indicated that rACP refolded upon addition of MgCl(2) at 100-fold lower concentrations (<1 mM) than KCl, suggesting that divalent cations stabilize rACP by interaction at specific sites. Surprisingly, mutants A75H and A75H/D18K exhibited native-like conformation in the absence of MgCl(2), while the D18K mutant was comparable to rACP. Moreover, the alpha-helical content of A75H, A75H/D18K and E. coli ACPs was more sensitive than that of rACP or D18K ACP to modification by the histidine-selective reagent diethylpyrocarbonate. Together, these results suggest that the partial positive charge of His-75 may be important in maintaining the conformational stability of E. coli ACP at a neutral pH.
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Affiliation(s)
- Mary-Margaret Keating
- Atlantic Research Centre, Department of Pediatrics, Dalhousie University, Halifax, NS, Canada B3H 4H7
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15
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Abstract
Multiple sclerosis (MS), a chronic disease of the central nervous system, is characterized by a variable and unpredictable course. The most common pattern of the disease is the relapsing-remitting form in which clearly defined relapses (also called exacerbations) are followed by complete or incomplete recovery. Interferon beta-1b (Betaseron), a drug that affects the natural course of the disease, was developed for the treatment of relapsing-remitting MS. Multiple Sclerosis Pathways (MSP), a disease management program, was developed to provide comprehensive and personal support to MS patients taking interferon beta-1b and to serve as an information resource for all people with MS, their families, and healthcare professionals. The MSP program includes personal patient assistance, reimbursement services, a 24-hour nurse hotline, training program, educational resources, and injection supplies. The nurse hotline counselor (NHC) utilizes the nursing process in a unique telephone nursing practice in this program. The positive impact of education and support on adherence to therapy has been validated by training and nurse hotline data.
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Affiliation(s)
- M G Madonna
- Multiple Sclerosis Pathways, Phoenix, AZ 85072-2171, USA
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16
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Abstract
A teaching program (Betaseron Instruction) for patients beginning interferon beta-1b therapy was developed at St. John's Mercy Medical Center in St. Louis, Missouri according to Bandura's theory of self-efficacy. Then, a study was conducted to determine attitudes of patients with multiple sclerosis (MS) about interferon beta-1b (Betaseron) therapy and evaluate the effectiveness of the teaching program. In that program, teaching skills mastery and the use of modeling and persuasion were used in curriculum development. A survey questionnaire in which information about the patients' evaluation of interferon beta-1b therapy effects was mailed to 60 patients who had participated in the teaching program between December, 1993 and October 1994. Thirty surveys were completed and returned. The mean age of participants was 42 years; 22% were men and 78% were women. The mean duration of therapy for the study participants was 10.5 weeks. Qualitative content analysis and tabulation of the one scaled question from the 30 completed surveys were performed to obtain outcome measurements of cognitive goals and determine the level of self-management of therapy. Responses regarding feelings about therapy, the benefits of the teaching program, confidence in performing skills that resulted from the use of interferon beta-1b therapy, adverse effects produced by the medication and quality of life issues were evaluated. The effectiveness of the Betaseron Instruction program and the importance of access to support systems from peers and healthcare professionals were validated by patient responses. The role of the nurse in patient teaching and the provision of support were indicated to be essential to a positive outcome in all of the patient surveys submitted.
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Affiliation(s)
- M M Keating
- St. John's Mercy Medical Center, St. Louis, Missouri 63141, USA
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17
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Vellekoop L, Dicke KA, Zander AR, Spitzer G, Verma DS, Keating MM, McCredie KB. Repeated high-dose cyclophosphamide, BCNU and VP-16-213 and autologous bone marrow transplantation in adult acute lymphocytic leukemia in first remission. Eur J Cancer Clin Oncol 1984; 20:593-9. [PMID: 6376130 DOI: 10.1016/0277-5379(84)90003-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
In adult acute lymphocytic leukemia (ALL) cure is rare. The purpose of this study was to try to improve remission duration and survival by administration of two courses of high-dose chemotherapy, each followed by autologous bone marrow rescue, in first remission. Chemotherapy consisted of cyclophosphamide, BCNU and VP-16-213. Rescue bone marrow was fractionated over a discontinuous albumin gradient to minimize contamination with leukemic cells. Fourteen patients entered the study. Median total remission duration was 14 months. Three patients relapsed after one course of treatment. Five patients relapsed after the second course. Four patients died after the second course and two patients remain alive and well in unmaintained remission, with a total remission duration of 42+ and 47+ months. It is concluded that this regimen is toxic but, with careful selection of patients, may lead to long-term unmaintained remissions.
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