Treatment outcomes for older patients with relapsed/refractory aggressive lymphoma receiving salvage chemotherapy and autologous stem cell transplantation are similar to younger patients: a subgroup analysis from the phase III CCTG LY.12 trial

Background

High-dose therapy and autologous stem cell transplantation (ASCT) is often considered for older patients (age >60 years) with relapsed/refractory aggressive lymphomas. Although registry data support the safety and potential efficacy of this approach, there are no prospective trials evaluating outcomes of ASCT in older patients. We evaluated the result of second-line chemotherapy and ASCT in older versus younger patients in the CCTG randomized LY.12 trial.

Patients and methods

From August 2003 to November 2011, 619 patients with relapsed/refractory aggressive lymphoma were randomized to gemcitabine, dexamethasone, cisplatin (GDP) or dexamethasone, cytarabine, cisplatin (DHAP); 177 patients (28.6%) enrolled were >60.0 years of age (range, 60-74) and 442 were ≤60.0 years of age. After two to three cycles, responding patients proceeded to ASCT. Intention-to-treat analysis was used to compare response rate, transplantation rate, event-free survival (EFS) and overall survival (OS) between patients aged ≤60.0 and >60.0 years.

Results

Patient characteristics were comparable between the two cohorts, except a larger proportion of older patients had high International Prognostic Index risk scores. Response to salvage therapy was 48.6% for patients aged  >60.0 versus 43.0% for those aged  ≤60.0 (P = 0.21). Transplantation rates were also similar: 50.3% versus 49.8% (P = 0.87) for older versus younger patients. Rates of febrile neutropenia and adverse events requiring hospitalization were comparable for older and younger patients (30.5% versus 22.9% and 37.9% versus 32.1%, respectively). With a median follow-up of 53 months, there was no difference in 4-year OS (36% and 40% for patients aged >60.0 and ≤60.0 years, P = 0.42), or 4-year EFS (20% versus 28%, P = 0.43). Mortality from salvage therapy was 8/174 (4.60%) and 5/436 (1.15%), and 100-day mortality post-ASCT was 7/88 (8.06%) and 4/219 (1.85%).

Conclusion

This subgroup analysis suggests that older patients derive similar benefit from salvage therapy and ASCT to younger patients, with acceptable toxicity.

ClinicalTrials.gov Identifier

NCT00078949.

Treatment and outcomes for primary cutaneous extramedullary plasmacytoma: a case series

BACKGROUND

Primary cutaneous plasmacytoma (pcp) is a rare disease, with few studies to guide therapy. Our primary study objective was to define treatments used for pcp; a secondary objective was to describe outcomes of patients, including disease recurrence and death.

METHODS

An institutional cancer registry was used to identify cases for retrospective chart review. In a systematic review, treatments for, and outcomes of, all known cases of pcp were described.

RESULTS

Three eligible cases identified at our institution; each patient had a solitary pcp. The systematic review identified 66 patients. Radiotherapy was the most commonly used primary treatment modality (31% of all patients; 42% for patients with solitary lesions), followed by surgery (28% of all patients; 36% for patients with solitary lesions). Median survival for all patients was 10.4 years [95% ci: 4.3 years to not reached], with a trend toward a decreased risk of death with solitary lesions compared with multiple lesions (hazard ratio: 0.37; 95% ci: 0.13 to 1.08; p = 0.059). For patients with solitary lesions, the median and recurrence-free survivals were, respectively, 17.0 years (95% ci: 1.7 years to not reached) and 11.0 years (95% ci: 2 years to not reached); for patients with multiple lesions, they were 4.3 years (95% ci: 1.3 to not reached) and 1.4 years (95% ci: 0.6 years to not reached). Disease recurrence, including progression to multiple myeloma, was the most common cause of death.

CONCLUSIONS

Compared with patients having multiple pcp lesions, those presenting with a single pcp lesion might experience longer overall survival. Local therapy (radiation or surgery) is a reasonable curative treatment for a solitary pcp lesion.

CyBorD induction therapy in clinical practice

Cyclophosphamide, bortezomib and dexamethasone (CyBorD) is a highly active three-drug induction regimen for untreated transplant-eligible multiple myeloma patients. Although CyBorD has been evaluated only in the phase 2 setting in a limited number of patients, its high efficacy and ease of administration have led to its widespread use. Given that clinical trial efficacy can overestimate real-life effectiveness, we reviewed our institutional experience with 109 newly diagnosed patients who were treated with CyBorD in a non-clinical trial setting. After a median of four cycles, overall response rate (ORR) and very good partial response rate or better (⩾VGPR) were 95 and 66%, respectively, comparable to phase 2 studies of CyBorD and other three/four-drug induction regimens. All patients subsequently underwent successful stem cell collection and upgraded responses to ORR 98% and ⩾VGPR 79% post transplant. At a median follow-up of 19.8 months after diagnosis, the 2-year OS probability was 95.3% (95%CI: 89-98). The presence of concurrent plasmacytoma at diagnosis was the only prognostic factor predicting poorer survival (HR=5.56; 95%CI: 0.92-33.74; P=0.03). CyBorD was well-tolerated, with no severe peripheral neuropathy and minimal hematologic toxicity. Therefore, CyBorD is a convenient, well-tolerated, highly effective induction regimen in preparation for autologous SCT in real-life clinical practice.

Systemic Treatment Safety Symposium 2014: Oral Chemotherapy

The second Systemic Treatment Safety Symposium, which took place February 21, 2014, in Toronto, aimed to identify opportunities for improving the delivery of systemic cancer treatment in Ontario based on regional needs, while providing a venue for collaboration and knowledgesharing. The agenda included a series of panel sessions followed by discussions, presentations of regional improvement projects and results, and breakout sessions. Based on the discussion that took place at the symposium, a provincial goal of zero handwritten or verbal oral chemotherapy orders by June 30, 2015, has now been established, and regions will be provided with funding for safe prescribing initiatives to support achievement of that aim. Building on the lessons learned from the 2014 System Treatment Safety Symposium, a common measurement strategy will be identified, and Cancer Care Ontario (cco) will also support the work by identifying the recommended key elements of a safe oral chemotherapy prescription. Additionally, cco will identify areas for improving systemic treatment computerized prescriber order entry systems to better enable prescribing of oral agents within such systems. Among the most prominent of the lessons learned during the symposium was the importance of having a focused topic (such as oral chemotherapy) while maintaining a province-wide scope. Another significant takeaway was that attendees appreciate the opportunity to hear from colleagues across the province about the work underway in various regions. Future safety symposia will also explore opportunities for enhanced engagement with participants through greater use of technology.

Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto

Rapid Response Systems have been introduced in the last decade to increase patient safety and decrease the rate of cardiorespiratory arrest on the hospital wards and readmission to the intensive care units. In this article we share our experience at the Hospital for Sick Children in Toronto on implementation and evolution of a pediatric rapid response team; the process, barriers, and ongoing challenges.

Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use

BACKGROUND

Chemotherapy is an effective treatment in the fight against many cancers. Medication errors in oncology can be particularly serious given the narrow therapeutic window of antineoplastic drugs and their high toxicities. Computerized prescriber order entry (cpoe) has consistently been shown to reduce medication errors and adverse drug events in various settings, but its use in the oncology setting has not been well established. To gain a better understanding of the meaningful use of cpoe systems in the outpatient chemotherapy setting, we undertook a systematic review of systemic therapy cpoe.

METHODS

A province-wide expert panel consisting of clinical experts, health information professionals, and specialists in human factors design provided guidance in the development of the research questions, search terms, databases, and inclusion criteria. The systematic review was undertaken by a core team consisting of a medical oncologist, nurse, pharmacist, and methodologist. The medline, embase, cinahl, and compendex databases were searched for relevant evidence.

RESULTS

The database searches resulted in 5642 hits, of which 9 met the inclusion criteria and were retained. In the oncology setting, cpoe systems generally reduce chemotherapy medication errors; however, specific types of errors increase with the use of cpoe. These systems affect practice both positively and negatively with respect to time, workload, and productivity.

CONCLUSIONS

Despite the paucity of oncology-specific research, cpoe should be used in outpatient chemotherapy delivery to reduce chemotherapy-related medication errors. Adoption by clinicians will be enhanced by cpoe processes that complement current practice and workflow processes.

Toward successful migration to computerized physician order entry for chemotherapy

BACKGROUND

Computerized physician order entry (cpoe) systems allow for medical order management in a clinical setting. Use of a cpoe has been shown to significantly improve chemotherapy safety by reducing the number of prescribing errors. Usability of these systems has been identified as a critical factor in their successful adoption. However, there is a paucity of literature investigating the usability of cpoe for chemotherapy and describing the experiences of cancer care providers in implementing and using a cpoe system.

METHODS

A mixed-methods study, including a national survey and a workshop, was conducted to determine the current status of cpoe adoption in Canadian oncology institutions, to identify and prioritize knowledge gaps in cpoe usability and adoption, and to establish a research agenda to bridge those gaps. Survey respondents were representatives of cancer care providers from each Canadian province. The workshop participants were oncology clinicians, human factors engineers, patient safety researchers, policymakers, and hospital administrators from across Canada, with participation from the United States.

RESULTS

A variety of issues related to implementing and using a cpoe for chemotherapy were identified. The major issues concerned the need for better understanding of current practices of chemotherapy ordering, preparation, and administration; a lack of system selection and procurement guidance; a lack of implementation and maintenance guidance; poor cpoe usability and workflow support; and other cpoe system design issues. An additional three research themes for addressing the existing challenges and advancing successful adoption of cpoe for chemotherapy were identified: The need to investigate variances in workflows and practices in chemotherapy ordering and administrationThe need to develop best-practice cpoe procurement and implementation guidance specifically for chemotherapyThe need to measure the effects of cpoe implementation in medical oncology.

CONCLUSIONS

Addressing the existing challenges in cpoe usability and adoption for chemotherapy, and accelerating successful migration to cpoe by cancer care providers requires future research focusing on workflow variations, chemotherapy-specific cpoe procurement needs, and implementation guidance needs.

PX-171–004, a multicenter phase II study of carfilzomib (CFZ) in patients with relapsed myeloma: An efficacy update

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Background: Carfilzomib (CFZ) is a proteasome inhibitor, active against hematologic malignancies. Preclinically, CFZ overcomes bortezomib (BTZ) resistance in multiple tumors, including myeloma (MM). PX-171–004 is an ongoing Phase II study evaluating safety and efficacy of CFZ in MM patients with relapsed disease after 1–3 prior therapies. Overall Response Rate (ORR) of 35.5% for all subjects was previously reported (ASH 2008); updated data are now available. Methods: Patients were divided into two cohorts: BTZ-naïve and BTZ-exposed. CFZ 20 mg/m2 was administered Days 1, 2, 8, 9, 15 and 16 in a 28-day cycle, for up to 12 cycles. Dexamethasone 4 mg po was administered prior to each dose in Cycle 1. The primary endpoint was ORR, defined as Partial Response (PR) or better. Secondary endpoints included Duration Of Response (DOR) and Time To Progression (TTP). Results: 31 patients were enrolled; 14 (45%) BTZ-naïve and 17 (55%) BTZ-exposed. Of the BTZ-exposed cohort, 2 subjects received BTZ exclusively as a single agent, 6 had BTZ in a chemotherapy combination, and 9 received BTZ in a transplant regime. Overall, 23 (74%) subjects had > 1 prior therapy and 27 (87%) received transplant. In BTZ-naïve patients, CFZ achieved an ORR of 57%; median DOR of 8.6 mos (range >1.9 to >9.7 mos). To date, 7 patients (50%) remain progression free and 3 patients have completed 12 cycles. The median follow-up was 10 mos and the median TTP has not been reached. For the BTZ- exposed group, CFZ achieved an ORR of 18%; median DOR not yet reached (>8.5 mos) (range >1 d to >8.5 mos). 7 patients (41%) are progression free and 3 patients have completed 12 cycles. Median follow-up and TTP were 9.2 and 8.9 mos, respectively. Conclusions: These preliminary results demonstrate that single-agent CFZ is tolerable for at least 1 yr and achieves sustained responses in relapsed MM. Prior BTZ mono/combination therapy does not preclude durable response with CFZ. These data support continuing evaluation of CFZ in the treatment of relapsed MM.

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