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Lübbert M, Wijermans PW, Kicinski M, Chantepie S, Van der Velden WJFM, Noppeney R, Griškevičius L, Neubauer A, Crysandt M, Vrhovac R, Luppi M, Fuhrmann S, Audisio E, Candoni A, Legrand O, Foà R, Gaidano G, van Lammeren-Venema D, Posthuma EFM, Hoogendoorn M, Giraut A, Stevens-Kroef M, Jansen JH, de Graaf AO, Efficace F, Ammatuna E, Vilque JP, Wäsch R, Becker H, Blijlevens N, Dührsen U, Baron F, Suciu S, Amadori S, Venditti A, Huls G. 10-day decitabine versus 3 + 7 chemotherapy followed by allografting in older patients with acute myeloid leukaemia: an open-label, randomised, controlled, phase 3 trial. Lancet Haematol 2023; 10:e879-e889. [PMID: 37914482 DOI: 10.1016/s2352-3026(23)00273-9] [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: 04/06/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Many older patients with acute myeloid leukaemia die or cannot undergo allogeneic haematopoietic stem-cell transplantation (HSCT) due to toxicity caused by intensive chemotherapy. We hypothesised that replacing intensive chemotherapy with decitabine monotherapy could improve outcomes. METHODS This open-label, randomised, controlled, phase 3 trial was conducted at 54 hospitals in nine European countries. Patients aged 60 years and older who were newly diagnosed with acute myeloid leukaemia and had not yet been treated were enrolled if they had an Eastern Cooperative Oncology Group performance status of 2 or less and were eligible for intensive chemotherapy. Patients were randomly assigned (1:1) to receive decitabine or standard chemotherapy (known as 3 + 7). For the decitabine group, decitabine (20 mg/m2) was administered for the first 10 days in the first 28-day cycle, followed by 28-day cycles consisting of 5 days or 10 days of decitabine. For the 3 + 7 group, daunorubicin (60 mg/m2) was administered over the first 3 days and cytarabine (200 mg/m2) over the first 7 days, followed by 1-3 additional chemotherapy cycles. Allogeneic HSCT was strongly encouraged. Overall survival in the intention-to-treat population was the primary endpoint. Safety was assessed in all patients who received the allocated treatment. This trial is registered at ClinicalTrials.gov, NCT02172872, and is closed to new participants. FINDINGS Between Dec 1, 2014, and Aug 20, 2019, 606 patients were randomly assigned to the decitabine (n=303) or 3 + 7 (n=303) group. Following an interim analysis which showed futility, the IDMC recommended on May 22, 2019, that the study continued as planned considering the risks and benefits for the patients participating in the study. The cutoff date for the final analysis presented here was June 30, 2021. At a median follow-up of 4·0 years (IQR 2·9-4·8), 4-year overall survival was 26% (95% CI 21-32) in the decitabine group versus 30% (24-35) in the 3 + 7 group (hazard ratio for death 1·04 [95% CI 0·86-1·26]; p=0·68). Rates of on-protocol allogeneic HSCT were similar between groups (122 [40%] of 303 patients for decitabine and 118 [39%] of 303 patients for 3+7). Rates of grade 3-5 adverse events were 254 (84%) of 302 patients in the decitabine group and 279 (94%) of 298 patients in the 3 + 7 group. The rates of grade 3-5 infections (41% [125 of 302] vs 53% [158 of 298]), oral mucositis (2% [seven of 302] vs 10% [31 of 298]) and diarrhoea (1% [three of 302] vs 8% [24 of 298]) were lower in the decitabine group than in the 3 + 7 group. Treatment-related deaths were reported for 12% (35 of 302) of patients in the decitabine group and 14% (41 of 298) in the 3 + 7 group. INTERPRETATION 10-day decitabine did not improve overall survival but showed a better safety profile compared with 3 + 7 chemotherapy in older patients with acute myeloid leukaemia eligible for intensive chemotherapy. Decitabine could be considered a better-tolerated and sufficiently efficacious alternative to 3 + 7 induction in fit older patients with acute myeloid leukaemia without favourable genetics. FUNDING Janssen Pharmaceuticals.
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Affiliation(s)
- Michael Lübbert
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany.
| | - Pierre W Wijermans
- Department of Hematology, Haga Teaching Hospital, The Hague, Netherlands
| | - Michal Kicinski
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Sylvain Chantepie
- Department of Hematology, Centre Hospitalo-Universitaire de Caen, Caen, France
| | | | - Richard Noppeney
- Klinik für Hämatologie und Stammzelltransplantation, University Hospital Essen, Essen, Germany
| | - Laimonas Griškevičius
- Department of Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santaros Klinikos, Vilnius University, Vilnius, Lithuania
| | - Andreas Neubauer
- Department of Internal Medicine, Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Gießen and Marburg, Campus Marburg, Marburg, Germany
| | - Martina Crysandt
- Department of Hematology, Oncology, Hemostasiology and Stem Cell Transplantation, Medical Clinic IV, University Hospital RWTH Aachen, Aachen, Germany
| | - Radovan Vrhovac
- Department of Haematology, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Mario Luppi
- Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell'Adulto, University of Modena and Reggio Emilia, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Stephan Fuhrmann
- Department of Hematology and Oncology, Helios Hospital Berlin-Buch, Kiel, Germany
| | - Ernesta Audisio
- Department of Haematology, Azienda Ospedaliera Città della Salute e della Scienza di Torino-Ospedale Molinette, Torino, Italy
| | - Anna Candoni
- Clinica Ematologica Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Olivier Legrand
- Service d'Hématologie Clinique et de Thérapie cellulaire, Hôpital Saint Antoine, APHP, Paris, France
| | - Robin Foà
- Ematologia, Dipartimento di Medicina Traslazionale e di Precisione, Sapienza Università di Roma, Rome, Italy
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale and Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | | | | | - Mels Hoogendoorn
- Department of Hematology, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Anne Giraut
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Marian Stevens-Kroef
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joop H Jansen
- Laboratory Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Aniek O de Graaf
- Laboratory Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Fabio Efficace
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | | | - Jean-Pierre Vilque
- Department of Hematology, Centre Hospitalo-Universitaire de Caen, Caen, France
| | - Ralph Wäsch
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Heiko Becker
- Department of Hematology, Oncology and Stem Cell Transplantation, Faculty of Medicine, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | | | - Ulrich Dührsen
- Klinik für Hämatologie und Stammzelltransplantation, University Hospital Essen, Essen, Germany
| | - Frédéric Baron
- GIGA-I3 and Centre Hospitalier Universitaire, University of Liège, Liège, Belgium
| | - Stefan Suciu
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Sergio Amadori
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Adriano Venditti
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Gerwin Huls
- University Medical Center Groningen, Groningen, Netherlands.
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De Kort EA, Buil JB, Schalekamp S, Schaefer-Prokop C, Verweij PE, Schaap NPM, Blijlevens NMA, Van der Velden WJFM. Invasive Fungal Disease in Patients with Myeloid Malignancies: A Retrospective Cohort Study of a Diagnostic-Driven Care Pathway Withholding Mould-Active Prophylaxis. J Fungi (Basel) 2022; 8:jof8090925. [PMID: 36135650 PMCID: PMC9504036 DOI: 10.3390/jof8090925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 07/13/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022] Open
Abstract
Objectives: Patients receiving remission induction therapy for acute myeloid leukaemia (AML) are at high risk of developing invasive fungal disease (IFD). Newer therapies with targeted antileukemic agents and the emergence of azole resistance pose a challenge to the strategy of primary antifungal prophylaxis. We report the experience of a diagnostic-driven care pathway (DCP) for the management of IFD in these patients, using only culture-directed mould inactive prophylaxis. Methods: Retrospectively, we used a single-centre study of consecutive patients receiving intensive chemotherapy for myeloid malignancies between 2014 and 2021. DCP consisted of serial cultures and serum galactomannan (sGM) screening, CT imaging, and bronchoscopy to direct targeted antifungal treatment. IFD was classified according to the 2020 EORTC/MSGERC criteria. Results: A total of 192 patients with myeloid malignancies received 300 courses of intensive chemotherapy. There were 14 cases of invasive yeast infections and 18 of probable/proven invasive mould disease (IMD). The incidence of probable/proven IMD during the first cycle of remission-induction chemotherapy was 4.6% (n = 9). sGM remained negative in all cases of invasive aspergillosis (IA), with positive mycology findings in bronchoalveolar lavage. All-cause mortality was 9.4% (n = 18) 100 days after starting chemotherapy and was comparable between patients with or without IFD. The fungal-related mortality was 1% (n = 2). Conclusion: Diagnostic-driven based management without universal mould active prophylaxis is a feasible strategy in the management of IFD and limits unnecessary antimould treatment during intensive chemotherapy. The poor performance of serial serum galactomannan screening in detecting IA warrants further investigation.
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Affiliation(s)
- Elizabeth A. De Kort
- Department of Haematology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
- Correspondence:
| | - Jochem B. Buil
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 GA Nijmegen, The Netherlands
| | - Steven Schalekamp
- Department of Radiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Cornelia Schaefer-Prokop
- Department of Radiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Department of Radiology, Meander Medisch Centrum, 3813 TZ Amersfoort, The Netherlands
| | - Paul E. Verweij
- Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
- Center of Expertise in Mycology Radboudumc/CWZ, 6525 GA Nijmegen, The Netherlands
| | - Nicolaas P. M. Schaap
- Department of Haematology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Nicole M. A. Blijlevens
- Department of Haematology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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