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Cuneo A, Ghia P. Ibrutinib in CLL: benefit for all? Blood 2024; 143:1558-1559. [PMID: 38635254 DOI: 10.1182/blood.2023023758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Affiliation(s)
| | - Paolo Ghia
- Università Vita-Salute San Raffaele
- Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele
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2
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Urso A, Cavazzini F, Ballardini MP, Gambara S, Consolo S, Rigolin GM, Cuneo A. First-Line Treatment of Older Patients with CLL: A New Approach in the Chemo-Free Era. Cancers (Basel) 2023; 15:3859. [PMID: 37568676 PMCID: PMC10417156 DOI: 10.3390/cancers15153859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Bruton tyrosine kinase inhibitors (BTKi) and the BCL2 inhibitor venetoclax, with or without the anti-CD20 monoclonal antibody Obinutuzumab, represent the preferred options for the first-line therapy of CLL because they are more effective and may improve quality of life. However, patient inclusion criteria are heterogeneous across trials designed for older patients, and the identification of CLL-specific parameters identifying unfit patients at risk of developing drug-specific adverse events is required to guide treatment choice. Due to inclusion/exclusion criteria in trials, higher discontinuation rates with BTKi were reported in real-world studies, and registry analyses provided useful information on factors predicting earlier discontinuation in a real-world setting. Though targeted agents were shown to be cost-effective treatments in high-income countries, the out-of-pocket expenses may limit accessibility to these drugs, and the overall expenditure for new drugs in CLL is projected to increase substantially, posing an issue for sustainability. This being said, the choice of a finite-duration treatment based on venetoclax-containing regimens or treatment until progression with BTKi is today possible in high-income countries, and the therapy choice drivers are represented by coexisting medical conditions rather than age, patient expectations, logistics, and sustainability.
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Affiliation(s)
| | | | | | | | | | | | - Antonio Cuneo
- Hematology Unit, University of Ferrara, 44121 Ferrara, Italy (F.C.); (M.P.B.); (S.C.)
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3
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Relative dose intensity of obinutuzumab-chlorambucil in chronic lymphocytic leukemia: a multicenter Italian study. Blood Adv 2022; 6:3875-3878. [PMID: 35789375 PMCID: PMC9278285 DOI: 10.1182/bloodadvances.2022006964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/21/2022] [Indexed: 11/25/2022] Open
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4
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Ferrarini I, Gandini F, Zapparoli E, Rigo A. Two Distinct Clinical Patterns of Ibrutinib-to-Venetoclax Transition in Relapsed Chronic Lymphocytic Leukemia Patients. Curr Oncol 2022; 29:2792-2797. [PMID: 35448201 PMCID: PMC9028984 DOI: 10.3390/curroncol29040227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/16/2022] Open
Abstract
Patients with chronic lymphocytic leukemia (CLL) relapsing on ibrutinib are often treated with the Bcl-2 inhibitor venetoclax. However, the transition from one agent to another poses some clinical challenges due to disease flares sometimes occurring right after ibrutinib interruption. Here, we describe three clinical vignettes highlighting two distinct patterns of ibrutinib-to-venetoclax transition. While patients following the favorable pattern transited to venetoclax without experiencing disease flare, the one patient who took the unfavorable path showed rapid disease rebound, with large-cell transformation occurring one week after ibrutinib interruption. A high burden of BTK and PLCG2 mutations was found only in patients with the favorable transition pattern, suggesting that removing BTK inhibition might be particularly harmful if CLL cells are progressing through mechanisms external to the BTK axis.
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Affiliation(s)
- Isacco Ferrarini
- Section of Hematology, Department of Medicine, University of Verona, 37134 Verona, Italy;
- Correspondence: ; Tel.: +39-0458126877
| | - Francesca Gandini
- B-Cell Neoplasia Unit, Division of Experimental Oncology, Università Vita-Salute San Raffaele, 20132 Milan, Italy;
| | - Ettore Zapparoli
- Centre for Omics Sciences, IRCCS Ospedale San Raffaele, 20132 Milan, Italy;
| | - Antonella Rigo
- Section of Hematology, Department of Medicine, University of Verona, 37134 Verona, Italy;
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5
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Marchetti M, Vitale C, Rigolin GM, Vasile A, Visentin A, Scarfò L, Coscia M, Cuneo A. Old and New Drugs for Chronic Lymphocytic Leukemia: Lights and Shadows of Real-World Evidence. J Clin Med 2022; 11:jcm11082076. [PMID: 35456167 PMCID: PMC9028394 DOI: 10.3390/jcm11082076] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/16/2022] Open
Abstract
Several novel treatments for chronic lymphocytic leukemia (CLL) have been recently approved based on the results of randomized clinical trials. However, real-world evidence (RWE) is also requested before and after drug authorization in order to confirm safety and to provide data for health technology assessments. We conducted a scoping review of the available RWE for targeted treatments of CLL, namely ibrutinib, acalabrutinib, idelalisib, and venetoclax, as well as for chemoimmunotherapy (CIT). In particular, we searched studies published since 1 January 2010 and reported outcomes of the above treatments based on health databases, registries, or phase IV studies, including named-patient programs. We included both full papers and abstracts of studies presented at major meetings. Overall, 110 studies were selected and analyzed: 28,880 patients were treated with ibrutinib, 1424 with idelalisib, 751 with venetoclax, 496 with acalabrutinib, and 14,896 with CIT. Reported discontinuation rates were higher than in clinical trials, while effectiveness could not be indirectly compared with clinical trials since a detailed case mix, including cytogenetic risk factors, was partially available and propensity scores rarely applied. RWE on CLL can help to set realistic outcomes with novel treatments, however, real-world studies should be fostered, and available data shared.
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Affiliation(s)
- Monia Marchetti
- Haematology and Transplant Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
- Correspondence:
| | - Candida Vitale
- Hematology Unit, Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (C.V.); (M.C.)
| | - Gian Matteo Rigolin
- Haematology Unit, Azienda Ospedaliera Universitaria di Ferrara, 44121 Ferrara, Italy; (G.M.R.); (A.C.)
- Haematology and Rheumatology Section, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
| | - Alessandra Vasile
- Department of Public Health, University of Eastern Pedemont, 28100 Novara, Italy;
| | - Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, 35128 Padua, Italy;
| | - Lydia Scarfò
- Division of Experimental Oncology, Department of Onco-Hematology, IRCCS San Raffaele Hospital, 20132 Milan, Italy;
| | - Marta Coscia
- Hematology Unit, Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy; (C.V.); (M.C.)
| | - Antonio Cuneo
- Haematology Unit, Azienda Ospedaliera Universitaria di Ferrara, 44121 Ferrara, Italy; (G.M.R.); (A.C.)
- Haematology and Rheumatology Section, Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy
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6
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Clinical Efficacy of Bendamustine Plus Rituximab (BR) for B-cell Relevant Indolent Non-Hodgkin’s Lymphoma and Role of β2-MG in Predicting the Efficacy of BR Regimen: A Real-World Retrospective Study in China. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:1080879. [PMID: 35096126 PMCID: PMC8794694 DOI: 10.1155/2022/1080879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/14/2021] [Indexed: 11/18/2022]
Abstract
Background. Domestic bendamustine has been approved for appearing on the market in China in the past two years. The report on bendamustine plus rituximab (BR) in the treatment of Chinese B-cell-associated indolent non-Hodgkin’s lymphoma (iNHL) has not yet been published. This study probed into clinical efficacy of the BR regimen for B-cell-associated iNHL in China as well as the value of β2-microglobulin (β2-MG) as a prognostic factor. Methods. We retrospectively analyzed clinical data of 73 B-cell-associated iNHL patients who received BR treatment in The First Affiliated Hospital, College of Medicine, Zhejiang University from January 2020 to January 2021, including clinical characteristics, therapies, therapeutic efficacy, and prognosis-related factors. Thirty-three patients (45.2%) did not receive any other treatment before the BR regimen, and other patients received CHOP, R-CHOP, and other regimens in the past. The cutoff date for follow-up was May 2021. Clinical characteristics of patients were analyzed. The clinical efficacy of the BR regimen was evaluated. Differences of β2-MG expression before and after treatment were analyzed between the CR+PR group and the SD+PD group. Main outcomes were progression-free survival (PFS) and overall survival (OS). A multivariate Cox regression model was taken to analyze prognostic factors relative to survival rate of patients, and adverse events (AEs) during treatment. Results. The objective response rate (ORR) of B-cell-associated iNHL patients who received BR regimen as first-/multiline treatment was 79.5%, with complete response (CR) of 37.0%, partial response (PR) of 42.5%, median PFS of 12.1 months (95% confidence interval (CI): 10.9-13.2), and median OS of 15.5 months (95% CI: 14.8-16.1). Before treatment, there was no statistical significance in the β2-MG level between the CR+PR group and the SD+PD group (
). After treatment, the β2-MG level in the CR group was noticeably lower than that in the SD+PD group (
). The β2-MG level in the CR+PR group decreased conspicuously after treatment (
). The β2-MG level in the SD+PD group after treatment was not notably different from that before treatment (
). According to the median expression level of β2-MG before treatment, patients were divided into two groups. The average PFS of the low expression group was
months, which was longer than the high expression group (
months), but the difference between the groups was not statistically significant (
). Multivariate Cox regression analysis showed that B-cell-associated iNHL subtype was the independent prognostic marker most likely to affect PFS of patients (
). Incidence of any grade of AEs in all patients was 32.9% (24/73). Conclusion. B-cell-associated iNHL patients who received BR regimen had favorable clinical efficacy and were tolerable to AEs. Though the β2-MG level in this study could not be used to predict clinical outcome, a lower level before treatment seemed to be implicated in better survival outcomes of patients. Our research also unraveled that B-cell-associated iNHL subtype may be a key factor to patient’s prognosis. Overall, this study offers some important insights into clinical application of the BR regimen for Chinese B-cell-associated iNHL patients.
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Treatment Options for Elderly/Unfit Patients with Chronic Lymphocytic Leukemia in the Era of Targeted Drugs: A Comprehensive Review. J Clin Med 2021; 10:jcm10215104. [PMID: 34768624 PMCID: PMC8584288 DOI: 10.3390/jcm10215104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 11/28/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL) incidence increases with age reaching 37.9/100,000 in patients over 85 years. Although there is no standardized geriatric tool specifically validated for CLL, a correct framing of the fitness status is of critical importance to individualize treatment strategies. Based on the evidence available to date, frontline chemoimmunotherapy has an increasingly narrowing application, being eligible for candidacy only in elderly fit patients without or with minimal geriatric syndromes. On the other hand, treatment with BCR inhibitors, monotherapy, or in combination with anti-CD20 antibodies (e.g., obinutuzumab), must be preferred both for frontline and relapsed CLL not only in unfit patients, but also in fit patients with unmutated IGHV or harboring del(17p) and/or TP53 mutations/deletions. Second-generation inhibitors (e.g., acalabrutinib, zanubrutinib, pirtobrutinib) are novel compounds that, due to their better safety profile and different specificity, will help physicians overcome some of the safety issues and treatment resistances. In the era of targeted therapies, treatment decisions in elderly and/or unfit patients with CLL must be a balance between efficacy and safety, carefully evaluating comorbidities and geriatric syndromes to ensure the best approach to improve both quality of life and life expectancy.
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Abstract
ABSTRACT In this article, we carry out an overview on the management options available for chronic lymphocytic leukemia (CLL) patients and discuss possible treatment decisions, taking into account the issue of sustainability and availability. Targeted agents have shown to be superior compared with chemoimmunotherapy (CIT) in terms of progression-free survival in high-risk CLL. In the majority of studies, however, continuous treatment was compared with fixed-duration CIT and no overall survival or progression-free survival-2 (time from randomization to second progression or death) advantage could be documented. Meanwhile, a substantial financial burden on both patients and payers has raised issues about affordability and adherence to treatment. Therefore, value-based pricing of new drugs has been used to set up price negotiation policies in several countries, and fixed-duration therapy has shown to be less costly than continuous treatment. Thus, CIT continues to have a role in the treatment of CLL patients with a favorable genetic profile, that is, with a mutated IGHV gene profile and a wild-type TP53. Targeted treatment represents the preferred choice in patients with an unmutated IGHV gene configuration and/or a TP53 disruption, provided that adherence to treatment is guaranteed and bearing in mind that should costly drugs not be available for frontline treatment, new agents can be very effective as first salvage treatment.
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9
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Ronconi G, Dondi L, Calabria S, Piccinni C, Pedrini A, Esposito I, Martini N. Real-world Prescription Pattern, Discontinuation and Costs of Ibrutinib-Naïve Patients with Chronic Lymphocytic Leukemia: An Italian Healthcare Administrative Database Analysis. Clin Drug Investig 2021; 41:595-604. [PMID: 34032988 DOI: 10.1007/s40261-021-01044-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVE In order to integrate the existing and inconsistent information from clinical trials and real-world practice on chronic lymphocytic leukemia (CLL) treated with ibrutinib, this analysis aimed to describe the prescription pattern of new users of ibrutinib affected by CLL, focusing on discontinuation, severe adverse events (AEs) and change of treatment, and to assess the integrated healthcare expenditure from the Italian National Health System (INHS) perspective. METHODS Starting from the ReS database, adults with at least a supply of ibrutinib (ATC code L01XE27) were selected from 01/01/2016 to 12/31/2017. Those without any ibrutinib supply in the year before the index prescription were considered new users. Out of them, only patients with at least a primary or secondary in-hospital diagnosis of CLL (ICD-9-CM code 204.1*) from 01/01/2013 to 12/31/2018 were further broken down according to the ibrutinib's line treatment (first line-FL; second or later line-SLL) and analysed. They were characterized by sex and age in the selection period. Mean annual consumption (defined daily doses [DDD]), treatment discontinuation, changes of therapy, interruptions and healthcare costs in charge of the INHS were assessed during two follow-up years. RESULTS Out of more than 5 million inhabitants of the ReS database, 69 new ibrutinib users and diagnosed with CLL in 2016 (incidence: 1.6 × 100,000) and 41 in 2017 (incidence: 0.9 × 100,000) were selected. Of these, 21 (19.1%) were FL ibrutinib users and 89 (80.9%) were SLL ones, mostly males and with mean ages (±SD) of 65 ± 14 and 70 ± 10, respectively. The mean annual consumption among FL users decreased from 222.2 DDD per patient treated to 216.0 DDD, while increased among SLL patients from 238.6 DDD to 260.1 DDD, in the first and second follow-up year, respectively. The discontinuation rate was about 40% in the first year, similarly among FL and SLL users. SLL patients discontinued more frequently (52.8% vs 20.0%) in the second year. Very few AEs were recorded. The 62.5% of FL and 55.6% of SLL users discontinuing ibrutinib in 1-year follow-up, while one SLL patient (5.3%) in the second year changed therapy. The 20.0% and 15.9% of all new users in first and second year interrupted ibrutinib. The total integrated cost of FL patients was €55,732 reducing by about €15,000, while it was €58,716 for SLL ones decreasing by €6,000, respectively, in the first and in the second year. Pharmaceuticals were the key cost driver (ibrutinib accounted for more than 77%). CONCLUSIONS This analysis on Italian administrative data provided results about prescription patterns of ibrutinib FL and SLL new users with CLL, focusing on discontinuation, treatment change and healthcare costs over 2-year follow-up, and contributed to improve the knowledge on this hard-to-treat disease.
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Affiliation(s)
- Giulia Ronconi
- Fondazione ReS (Ricerca e Salute) - Health and Research Foundation, Via Magnanelli 6/3, 40033, Casalecchio di Reno (Bologna), Italy
| | - Letizia Dondi
- Fondazione ReS (Ricerca e Salute) - Health and Research Foundation, Via Magnanelli 6/3, 40033, Casalecchio di Reno (Bologna), Italy
| | - Silvia Calabria
- Fondazione ReS (Ricerca e Salute) - Health and Research Foundation, Via Magnanelli 6/3, 40033, Casalecchio di Reno (Bologna), Italy.
| | - Carlo Piccinni
- Fondazione ReS (Ricerca e Salute) - Health and Research Foundation, Via Magnanelli 6/3, 40033, Casalecchio di Reno (Bologna), Italy
| | - Antonella Pedrini
- Fondazione ReS (Ricerca e Salute) - Health and Research Foundation, Via Magnanelli 6/3, 40033, Casalecchio di Reno (Bologna), Italy
| | | | - Nello Martini
- Fondazione ReS (Ricerca e Salute) - Health and Research Foundation, Via Magnanelli 6/3, 40033, Casalecchio di Reno (Bologna), Italy
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Dogliotti I, Ragaini S, Vassallo F, Boccellato E, De Luca G, Perutelli F, Boccomini C, Clerico M, Botto B, Grimaldi D, Orsucci L, Ferrero S, Vitale C, Ferrero D, Coscia M, Cavallo F. Real Life Use of Bendamustine in Elderly Patients with Lymphoid Neoplasia. J Pers Med 2021; 11:jpm11040249. [PMID: 33808164 PMCID: PMC8066290 DOI: 10.3390/jpm11040249] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Bendamustine is a cytotoxic alkylating drug with a broad range of indications as a single agent or in combination therapy in lymphoid neoplasia patients. However, its tolerability in elderly patients is still debated. METHODS An observational, retrospective study was carried out; patients with chronic lymphocytic leukemia (CLL) or lymphoma, aged ≥ 65 years old, treated with bendamustine-based regimens in first or subsequent lines between 2010 and 2020 were considered eligible. RESULTS Overall, 179 patients aged ≥ 65 years were enrolled, 53% between 71 and 79 years old. Cumulative Illness Rating Scale (CIRS) comorbidity score was ≥6 in 54% patients. Overall survival (OS) at 12 months was 95% (95% confidence interval [CI]: 90-97%); after a median follow up of 50 months, median OS was 84 months. The overall response rate was 87%, with 56% complete responses; the median time to progression (TTP) was 61 months. The baseline factors affecting OS by multivariable analysis were sex, histological diagnosis, renal function, and planned bendamustine dose, while only type of lymphoma and bendamustine dose impacted on TTP. Main adverse events were neutropenia (grade ≥ 3: 43%) and infections (any grade: 36%), with 17% of patients requiring hospital admission. CONCLUSIONS The responses to bendamustine, as well as survival, are relevant even in advanced age patients, with a manageable incidence of acute toxicity.
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Affiliation(s)
- Irene Dogliotti
- Stem Cell Transplant Unit, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy;
| | - Simone Ragaini
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
| | - Francesco Vassallo
- Division of Hematology, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (F.V.); (C.B.); (B.B.); (L.O.)
| | - Elia Boccellato
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
| | - Gabriele De Luca
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
| | - Francesca Perutelli
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
| | - Carola Boccomini
- Division of Hematology, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (F.V.); (C.B.); (B.B.); (L.O.)
| | - Michele Clerico
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
| | - Barbara Botto
- Division of Hematology, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (F.V.); (C.B.); (B.B.); (L.O.)
| | - Daniele Grimaldi
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
| | - Lorella Orsucci
- Division of Hematology, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (F.V.); (C.B.); (B.B.); (L.O.)
| | - Simone Ferrero
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
| | - Candida Vitale
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
| | - Dario Ferrero
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
| | - Marta Coscia
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
| | - Federica Cavallo
- Division of Hematology, Department of Molecular Biotechnology and Health Sciences, University of Torino, A.O.U., Città della Salute e della Scienza di Torino, 10126 Turin, Italy; (S.R.); (E.B.); (G.D.L.); (F.P.); (M.C.); (D.G.); (S.F.); (C.V.); (D.F.); (M.C.)
- Correspondence: ; Tel.: +39-01-1633-4556; Fax: +39-01-1633-6507
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11
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Rigolin GM, Cavazzini F, Piciocchi A, Arena V, Visentin A, Reda G, Zamprogna G, Cibien F, Vitagliano O, Coscia M, Farina L, Gaidano G, Murru R, Varettoni M, Paolini R, Sportoletti P, Pietrasanta D, Molinari AL, Quaglia FM, Laurenti L, Marasca R, Marchetti M, Mauro FR, Crea E, Vignetti M, Gentile M, Montillo M, Foà R, Cuneo A. Efficacy of idelalisib and rituximab in relapsed/refractory chronic lymphocytic leukemia treated outside of clinical trials. A report of the Gimema Working Group. Hematol Oncol 2021; 39:326-335. [PMID: 33739461 PMCID: PMC8451799 DOI: 10.1002/hon.2861] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/23/2021] [Accepted: 03/06/2021] [Indexed: 12/16/2022]
Abstract
Because the efficacy of new drugs reported in trials may not translate into similar results when used in the real‐life, we analyzed the efficacy of idelalisib and rituximab (IR) in 149 patients with relapsed/refractory chronic lymphocytic leukemia treated at 34 GIMEMA centers. Median progression‐free survival (PFS) and overall survival were 22.9 and 44.5 months, respectively; performance status (PS) ≥2 and ≥3 previous lines of therapy were associated with shorter PFS and overall survival (OS). 48% of patients were on treatment at 12 months; the experience of the centers (≥5 treated patients) and PS 0–1 were associated with a significantly longer treatment duration (p = 0.015 and p = 0.002, respectively). TP53 disruption had no prognostic significance. The overall response rate to subsequent treatment was 49.2%, with median OS of 15.5 months and not reached in patients who discontinued, respectively, for progression and for toxicity (p < 0.01). Treatment breaks ≥14 days were recorded in 96% of patients and adverse events mirrored those reported in trials. In conclusion, this real‐life analysis showed that IR treatment duration was longer at experienced centers, that the ECOG PS and ≥3 lines of previous therapy are strong prognostic factor and that the overall outcome with this regimen was superimposable to that reported in a randomized trial.
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Affiliation(s)
- Gian Matteo Rigolin
- Department of Medical Sciences, Hematology Section, University of Ferrara, Cona - Ferrara, Italy
| | - Francesco Cavazzini
- Department of Medical Sciences, Hematology Section, University of Ferrara, Cona - Ferrara, Italy
| | | | | | - Andrea Visentin
- Department of Medicine, Hematology and Clinical Immunology Unit, University of Padua, Padua, Italy
| | - Gianluigi Reda
- Ematologia, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Giulia Zamprogna
- Hematology, Niguarda Cancer Centre, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | | | - Marta Coscia
- Department of Molecular Biotechnology and Health Sciences, University of Torino, Turin, Italy.,Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy
| | - Lucia Farina
- Division of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Milano, Italy
| | - Gianluca Gaidano
- Department of Translational Medicine, Division of Hematology, Università del Piemonte Orientale, Novara, Italy
| | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale Oncologico A. Businco, ARNAS "G. Brotzu", Cagliari, Italy
| | - Marzia Varettoni
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Paolo Sportoletti
- Department of Medicine and Surgery, Institute of Hematology and Centre for Hemato-Oncological Research, Ospedale S. Maria della Misericordia, Perugia, Italy
| | - Daniela Pietrasanta
- Hematology Division, Dipartimento Internistico Struttura Complessa di Ematologia Ospedale civile SS Antonio e Biagio, Alessandria, Italy
| | | | - Francesca M Quaglia
- Department of Medicine, Section of Hematology, University of Verona, Verona, Italy
| | - Luca Laurenti
- Fondazione Policlinico Universitario A Gemelli. Roma IRCCS, Rome, Italy
| | - Roberto Marasca
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Francesca R Mauro
- Department of Translational and Precision Medicine, Hematology, 'Sapienza' University, Rome, Italy
| | | | | | - Massimo Gentile
- Department of Onco-Hematology, Hematology Unit, A.O. of Cosenza, Cosenza, Italy
| | - Marco Montillo
- Hematology, Niguarda Cancer Centre, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Robin Foà
- Department of Translational and Precision Medicine, Hematology, 'Sapienza' University, Rome, Italy
| | - Antonio Cuneo
- Department of Medical Sciences, Hematology Section, University of Ferrara, Cona - Ferrara, Italy
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12
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Smolej L, Brychtová Y, Cmunt E, Doubek M, Špaček M, Belada D, Šimkovič M, Stejskal L, Zygulová I, Urbanová R, Brejcha M, Zuchnická J, Móciková H, Kozák T. Low-dose fludarabine and cyclophosphamide combined with rituximab in the first-line treatment of elderly/comorbid patients with chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL): long-term results of project Q-lite by the Czech CLL Study Group. Br J Haematol 2021; 193:769-778. [PMID: 33618437 DOI: 10.1111/bjh.17373] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/29/2021] [Indexed: 12/29/2022]
Abstract
Therapeutic options used to be very limited for treatment-naïve elderly/comorbid patients with chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL) before the introduction of chemo-immunotherapy. Because dose-reduced fludarabine-based regimens yielded promising results, the Czech CLL Study Group initiated a prospective observational study to assess safety and efficacy of low-dose fludarabine and cyclophosphamide combined with rituximab (FCR) in elderly/comorbid patients. Between March 2009 and July 2012, we enrolled 107 patients considered ineligible for full-dose FCR (median age, 70 years; median Cumulative Illness Rating Scale score, 5; median creatinine clearance, 69 ml/min). Notably, 77% patients had unfavourable biological prognosis [unmutated immunoglobulin heavy-chain variable-region gene (IGHV), 74%; deletion 17p, 9%). Fludarabine was reduced to 12 mg/m2 intravenously (iv) or 20 mg/m2 orally on days 1-3 and cyclophosphamide to 150 mg/m2 iv/orally on days 1-3. Grade 3-4 neutropenia occurred in 56% of the patients, but there were serious infections in only 15%. The median progression-free survival was 29 months, but was markedly longer in patients with mutated IGHV (median 53 months), especially in absence of del 11q or 17p (median 74 months). Low-dose FCR is a well-tolerated and effective first-line regimen for selected elderly/comorbid patients with CLL/SLL with favourable biology. The study was registered at clinicaltrials.gov (NCT02156726).
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Affiliation(s)
- Lukáš Smolej
- 4th Department of Internal Medicine - Haematology, Faculty of Medicine, University Hospital, Hradec Králové, Czech Republic
| | - Yvona Brychtová
- Department of Internal Medicine - Haematology and Oncology, University Hospital, Brno, Czech Republic
| | - Eduard Cmunt
- First Department of Medicine - Haematology, General University Hospital, Prague, Czech Republic
| | - Michael Doubek
- Department of Internal Medicine - Haematology and Oncology, University Hospital, Brno, Czech Republic
| | - Martin Špaček
- First Department of Medicine - Haematology, General University Hospital, Prague, Czech Republic
| | - David Belada
- 4th Department of Internal Medicine - Haematology, Faculty of Medicine, University Hospital, Hradec Králové, Czech Republic
| | - Martin Šimkovič
- 4th Department of Internal Medicine - Haematology, Faculty of Medicine, University Hospital, Hradec Králové, Czech Republic
| | - Lukáš Stejskal
- Haematology/Tranfusiology Department, Silesian Hospital Opava, Opava, Czech Republic
| | - Irena Zygulová
- Haematology/Tranfusiology Department, Silesian Hospital Opava, Opava, Czech Republic
| | - Renata Urbanová
- Department of Haematology - Oncology, University Hospital, Olomouc, Czech Republic
| | | | - Jana Zuchnická
- Department of Haematology, University Hospital, Ostrava, Czech Republic
| | - Heidi Móciková
- Department of Haematology, University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Tomáš Kozák
- Department of Haematology, University Hospital Královské Vinohrady, Prague, Czech Republic
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13
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Cuneo A, Mato AR, Rigolin GM, Piciocchi A, Gentile M, Laurenti L, Allan JN, Pagel JM, Brander DM, Hill BT, Winter A, Lamanna N, Tam CS, Jacobs R, Lansigan F, Barr PM, Shadman M, Skarbnik AP, Pu JJ, Sehgal AR, Schuster SJ, Shah NN, Ujjani CS, Roeker L, Orlandi EM, Billio A, Trentin L, Spacek M, Marchetti M, Tedeschi A, Ilariucci F, Gaidano G, Doubek M, Farina L, Molica S, Di Raimondo F, Coscia M, Mauro FR, de la Serna J, Medina Perez A, Ferrarini I, Cimino G, Cavallari M, Cucci R, Vignetti M, Foà R, Ghia P. Efficacy of bendamustine and rituximab in unfit patients with previously untreated chronic lymphocytic leukemia. Indirect comparison with ibrutinib in a real-world setting. A GIMEMA-ERIC and US study. Cancer Med 2020; 9:8468-8479. [PMID: 32969597 PMCID: PMC7666748 DOI: 10.1002/cam4.3470] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 08/28/2020] [Accepted: 09/02/2020] [Indexed: 12/29/2022] Open
Abstract
Limited information is available on the efficacy of front‐line bendamustine and rituximab (BR) in chronic lymphocytic leukemia (CLL) with reduced renal function or coexisting conditions. We therefore analyzed a cohort of real‐world patients and performed a matched adjusted indirect comparison with a cohort of patients treated with ibrutinib. One hundred and fifty‐seven patients with creatinine clearance (CrCl) <70 mL/min and/or CIRS score >6 were treated with BR. The median age was 72 years; 69% of patients had ≥2 comorbidities and the median CrCl was 59.8 mL/min. 17.6% of patients carried TP53 disruption. The median progression‐free survival (PFS) was 45 months; TP53 disruption was associated with a shorter PFS (P = 0.05). The overall survival (OS) at 12, 24, and 36 months was 96.2%, 90.1%, and 79.5%, respectively. TP53 disruption was associated with an increased risk of death (P = 0.01). Data on 162 patients ≥65 years treated with ibrutinib were analyzed and compared with 165 patients ≥65 years treated with BR. Factors predicting for a longer PFS at multivariable analysis in the total patient population treated with BR and ibrutinib were age (HR 1.06, 95% CI 1.02‐1.10, P < 0.01) and treatment with ibrutinib (HR 0.55, 95% CI 0.33‐0.93, P = 0.03). In a post hoc analysis of patients in advanced stage, a significant PFS advantage was observed in patient who had received ibrutinib (P = 0.03), who showed a trend for OS advantage (P = 0.08). We arrived at the following conclusions: (a) BR is a relatively effective first‐line regimen in a real‐world population of unfit patients without TP53 disruption, (b) ibrutinib provided longer disease control than BR in patients with advanced disease stage.
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Affiliation(s)
- Antonio Cuneo
- Hematology, Department of Medical Sciences, St. Anna University Hospital, Ferrara, Italy
| | - Anthony R Mato
- Division of Hematological Oncology, CLL Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gian Matteo Rigolin
- Hematology, Department of Medical Sciences, St. Anna University Hospital, Ferrara, Italy
| | - Alfonso Piciocchi
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Massimo Gentile
- Department of Onco-Hematology, Hematology Unit, A.O. of Cosenza, Cosenza, Italy
| | - Luca Laurenti
- Department of Radiological, Radiotherapeutic and Hematological Sciences, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | | | - John M Pagel
- Center for Blood Disorders and Stem Cell Transplantation, Swedish Cancer Institute, Seattle, WA, USA
| | - Danielle M Brander
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC, USA
| | - Brian T Hill
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Allison Winter
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Constantine S Tam
- Peter McCallum Cancer Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Ryan Jacobs
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | | | - Paul M Barr
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Mazyar Shadman
- Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Alan P Skarbnik
- Lymphoproliferative Disorders Program, Novant Health Cancer Institute, Charlotte, NC, USA
| | - Jeffrey J Pu
- SUNY Upstate Medical University, SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Stephen J Schuster
- Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nirav N Shah
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chaitra S Ujjani
- Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Lindsey Roeker
- Division of Hematological Oncology, CLL Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Atto Billio
- Hematology and Transplant Unit, San Maurizio Hospital, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology, Department of Medicine, University of Padua, Padua, Italy
| | - Martin Spacek
- Department of Medicine, Department of Hematology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | | | - Alessandra Tedeschi
- Hematology, Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, University of eastern Piedmont, Novara, Italy
| | - Michael Doubek
- Department of Internal Medicine - Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lucia Farina
- Hematology Department, Fondazione IRCCS Istituto Nazionale Tumori, Milano, Italy
| | - Stefano Molica
- Hematology Unit, A. Pugliese Hospital, Azienda Ospedaliera Pugliese Ciaccio, Catanzaro, Italy
| | | | - Marta Coscia
- Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino and Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | | | | | - Isacco Ferrarini
- Hematology, Department of Cell Therapy and Hematology, University Hospital, Verona, Italy
| | - Giuseppe Cimino
- Department of Translational and Precision Medicine, University "La Sapienza", UOC di Ematologia con Trapianto, Ospedale S. Maria Goretti, Latina, Italy
| | - Maurizio Cavallari
- Hematology, Department of Medical Sciences, St. Anna University Hospital, Ferrara, Italy
| | - Rosalba Cucci
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Marco Vignetti
- Italian Group for Adult Hematologic Diseases (GIMEMA), Data Center and Health Outcomes Research Unit, Rome, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
| | - Paolo Ghia
- Strategic Research Program on CLL, Division of Experimental Oncology, IRCCS Ospedale San Raffaele, Università Vita-Salute San Raffaele, Milan, Italy
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