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Boccia R, Xiao H, von Wilamowitz-Moellendorff C, Raorane R, Deshpande S, Klijn SL, Yucel A. A Systematic Literature Review of Predictors of Erythropoiesis-Stimulating Agent Failure in Lower-Risk Myelodysplastic Syndromes. J Clin Med 2024; 13:2702. [PMID: 38731231 PMCID: PMC11084325 DOI: 10.3390/jcm13092702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/04/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Erythropoiesis-stimulating agents (ESAs) are the first-line treatment option for anemia in patients with lower-risk myelodysplastic syndromes (LR-MDS). A systematic literature review was conducted to identify evidence of the association between prognostic factors and ESA response/failure in LR-MDS. MEDLINE, Embase, and relevant conferences were searched systematically for studies assessing the association between prognostic factors and ESA response/failure in adult patients. Of 1566 citations identified, 38 were included. Patient risk status in studies published from 2000 onwards was commonly assessed using the International Prognostic Scoring System (IPSS) or revised IPSS. ESA response was generally assessed using the International Working Group MDS criteria. Among the included studies, statistically significant relationships were found, in both univariate and multivariate analyses, between ESA response and the following prognostic factors: higher hemoglobin levels, lower serum erythropoietin levels, and transfusion independence. Furthermore, other prognostic factors such as age, bone marrow blasts, serum ferritin level, IPSS risk status, and karyotype status did not demonstrate statistically significant relationships with ESA response. This systematic literature review has confirmed prognostic factors of ESA response/failure. Guidance to correctly identify patients with these characteristics could be helpful for clinicians to provide optimal treatment.
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Affiliation(s)
- Ralph Boccia
- The Center for Cancer and Blood Disorders, 6410 Rockledge Drive, Suite 660, Bethesda, MD 20817, USA
| | - Hong Xiao
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrence Township, NJ 08648, USA; (H.X.)
| | | | - Renuka Raorane
- Evidera, Ltd., UK Office, The Ark, 201 Talgarth Rd, London W6 8BJ, UK; (C.v.W.-M.); (R.R.)
| | - Sohan Deshpande
- Evidera, Ltd., UK Office, The Ark, 201 Talgarth Rd, London W6 8BJ, UK; (C.v.W.-M.); (R.R.)
| | - Sven L. Klijn
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrence Township, NJ 08648, USA; (H.X.)
| | - Aylin Yucel
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrence Township, NJ 08648, USA; (H.X.)
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2
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Mo A, Poynton M, Wood E, Shortt J, Brunskill SJ, Doree C, Sandercock J, Saadah N, Luk E, Stanworth SJ, McQuilten Z. Do anemia treatments improve quality of life and physical function in patients with myelodysplastic syndromes (MDS)? A systematic review. Blood Rev 2023; 61:101114. [PMID: 37479599 DOI: 10.1016/j.blre.2023.101114] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
Anemia is common in Myelodysplastic Syndromes (MDS). Different anemia treatments have been tested in clinical studies, but the full impact on patients' health-related quality of life (HRQoL) and physical function is unknown. The main aim of this review was to assess whether improvements in anemia are associated with changes in HRQoL/physical function. Twenty-six full-text publications were identified, enrolling 2211 patients: nine randomized trials (RCTs), fourteen non-randomized studies of interventions and three cross-sectional studies. Interventions included: growth factors/erythropoiesis-stimulating agents (n = 14), red cell transfusion (n = 9), erythroid maturation agents (n = 1), or a combination (n = 2). Five RCTs reported no changes in HRQoL despite erythroid response to the intervention, raising the question of whether anemia treatment alone can effectively improve HRQoL. Many studies were considered at high risk of bias for assessing HRQoL. There is a pressing need for future clinical trials to better define the nature of the relationship between anemia and HRQoL/functional outcomes.
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Affiliation(s)
- Allison Mo
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia; Department of Haematology, Monash Health, Clayton, Australia; Austin Pathology & Department of Haematology, Heidelberg, Australia
| | - Matthew Poynton
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Erica Wood
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia; Department of Haematology, Monash Health, Clayton, Australia
| | - Jake Shortt
- Department of Haematology, Monash Health, Clayton, Australia; School of Clinical Sciences, Monash University, Australia
| | - Susan J Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, United Kingdom
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, United Kingdom
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, United Kingdom
| | - Nicholas Saadah
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
| | - Edwin Luk
- Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Melbourne, Australia
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; NHS Blood and Transplant, John Radcliffe Hospital, Oxford, United Kingdom; Radcliffe Department of Medicine, University of Oxford, United Kingdom
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia; Department of Haematology, Monash Health, Clayton, Australia.
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3
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Stempel JM, Xie Z, Bewersdorf JP, Stahl M, Zeidan AM. Evolution of Therapeutic Benefit Measurement Criteria in Myelodysplastic Syndromes/Neoplasms. Cancer J 2023; 29:203-211. [PMID: 37195777 DOI: 10.1097/ppo.0000000000000666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
ABSTRACT Myelodysplastic syndromes/neoplasms (MDS) are heterogeneous, clonal myeloid neoplasms characterized by ineffective hematopoiesis, progressive cytopenias, and an increased risk of progression to acute myeloid leukemia. The diversity in disease severity, morphology, and genetic landscape challenges not only novel drug development but also therapeutic response assessment. The MDS International Working Group (IWG) response criteria were first published in the year 2000 focusing on measures of blast burden reduction and hematologic recovery. Despite revision of the IWG criteria in 2006, correlation between IWG-defined responses and patient-focused outcomes, including long-term benefits, remains limited and has potentially contributed to failures of several phase III clinical trials. Several IWG 2006 criteria also lacked clear definitions leading to problems in practical applications and interobserver and intraobserver consistency of response reporting. Although the 2018 revision addressed lower-risk MDS, the most recent update in 2023 redefined responses for higher-risk MDS and has set out to provide clear definitions to enhance consistency while focusing on clinically meaningful outcomes and patient-centered responses. In this review, we analyze the evolution of the MDS response criteria, limitations, and areas of improvement.
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Affiliation(s)
- Jessica M Stempel
- From the Department of Internal Medicine, Hematology Section, Yale School of Medicine, New Haven, CT
| | - Zhuoer Xie
- Department of Hematology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Jan Philipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maximilian Stahl
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Harvard University, Boston, MA
| | - Amer M Zeidan
- From the Department of Internal Medicine, Hematology Section, Yale School of Medicine, New Haven, CT
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4
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Meunier M, Park S. Lower-risk myelodysplastic syndromes: Current treatment options for anemia. EJHAEM 2022; 3:1091-1099. [PMID: 36467818 PMCID: PMC9713208 DOI: 10.1002/jha2.523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/11/2022] [Accepted: 06/16/2022] [Indexed: 06/17/2023]
Abstract
Myelodysplastic syndromes (MDS) are a heterogeneous group of clonal hematological disorders. Treatment options are classified and defined by prognostic risk based on the International Prognostic Scoring System (IPSS) and, more recently, the revised IPSS (IPSS-R). The treatment goal for lower-risk MDS is to correct cytopenias or their consequences, with the goal of maintaining or improving quality of life. Erythropoiesis-stimulating agents (ESAs) play an important role in treating anemia. Individuals with MDS who have a 5q deletion are particularly sensitive to treatment with lenalidomide; however, this comprises the minority of patients with MDS. Luspatercept was recently approved in the United States and the European Union for the treatment of ESA-refractory MDS with ring sideroblasts. Research into new treatment options, especially after ESA failure, is needed. In this review, we will focus on the current therapeutic options for MDS-related anemia.
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Affiliation(s)
- Mathieu Meunier
- Department of HaematologyCHU Grenoble AlpesGrenobleFrance
- Institute for Advanced BioscienceUniversité Grenoble AlpesGrenobleFrance
| | - Sophie Park
- Department of HaematologyCHU Grenoble AlpesGrenobleFrance
- Institute for Advanced BioscienceUniversité Grenoble AlpesGrenobleFrance
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Health-Related Quality of Life Outcomes in Patients with Myelodysplastic Syndromes with Ring Sideroblasts Treated with Luspatercept in the MEDALIST Phase 3 Trial. J Clin Med 2021; 11:jcm11010027. [PMID: 35011768 PMCID: PMC8745777 DOI: 10.3390/jcm11010027] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/10/2021] [Accepted: 12/18/2021] [Indexed: 11/20/2022] Open
Abstract
Patients with myelodysplastic syndromes (MDS) often experience chronic anemia and long-term red blood cell transfusion dependence associated with significant burden on clinical and health-related quality of life (HRQoL) outcomes. In the MEDALIST trial (NCT02631070), luspatercept significantly reduced transfusion burden in patients with lower-risk MDS who had ring sideroblasts and were refractory to, intolerant to, or ineligible for prior treatment with erythropoiesis-stimulating agents. We evaluated the effect of luspatercept on HRQoL in patients enrolled in MEDALIST using the EORTC QLQ-C30 and the QOL-E questionnaire. Change in HRQoL was assessed every 6 weeks in patients receiving luspatercept with best supportive care (+ BSC) and placebo + BSC from baseline through week 25. No clinically meaningful within-group changes and between-group differences across all domains of the EORTC QLQ-C30 and QOL-E were observed. On one item of the QOL-E MDS-specific disturbances domain, patients treated with luspatercept reported marked improvements in their daily life owing to the reduced transfusion burden, relative to placebo. Taken together with previous reports of luspatercept + BSC reducing transfusion burden in patients from baseline through week 25 in MEDALIST, these results suggest luspatercept may offer a treatment option for patients that reduces transfusion burden while providing stability in HRQoL.
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Gonçalves AC, Alves R, Baldeiras I, Jorge J, Marques B, Paiva A, Oliveiros B, Cortesão E, Nascimento Costa JM, Sarmento-Ribeiro AB. Oxidative Stress Parameters Can Predict the Response to Erythropoiesis-Stimulating Agents in Myelodysplastic Syndrome Patients. Front Cell Dev Biol 2021; 9:701328. [PMID: 34164406 PMCID: PMC8215707 DOI: 10.3389/fcell.2021.701328] [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: 04/27/2021] [Accepted: 05/13/2021] [Indexed: 12/16/2022] Open
Abstract
Oxidative stress has been implicated in the development of several types of cancer, including myelodysplastic syndromes (MDS), as well as in the resistance to treatment. In this work, we assessed the potential of oxidative stress parameters to predict the response to erythropoiesis-stimulating agents (ESAs) in lower-risk MDS patients. To this end, we analyzed the systemic levels of reactive species (peroxides and NO), antioxidant defenses (uric acid, vitamin E, vitamin A, GSH, GSSG, TAS, as well as GPX and GR activities], and oxidative damage (8-OH-dG and MDA) in 66 MDS patients, from those 44 have been treated with ESA. We also calculated the peroxides/TAS and NO/TAS ratios and analyzed the gene expression of levels of the redox regulators, NFE2L2 and KEAP1. We found that patients that respond to ESA treatment showed lower levels of plasma peroxides (p < 0.001), cellular GSH (p < 0.001), and cellular GR activity (p = 0.001) when compared to patients who did not respond to ESA treatment. ESA responders also showed lower levels of peroxides/TAS ratio (p < 0.001) and higher levels of the expression of the NFE2L2 gene (p = 0.001) than those that did not respond to ESA treatment. The levels of plasmatic peroxides shown to be the most accurate biomarker of ESA response, with good sensitivity (80%) and specificity (100%) and is an independent biomarker associated with therapy response. Overall, the present study demonstrated a correlation between oxidative stress levels and the response to ESA treatment in lower-risk MDS patients, with the plasmatic peroxides levels a good predictive biomarker of drug (ESA) response.
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Affiliation(s)
- Ana Cristina Gonçalves
- University of Coimbra, Laboratory of Oncobiology and Hematology and University Clinic of Hematology, Faculty of Medicine (FMUC), Coimbra, Portugal.,University of Coimbra, Group of Environment, Genetics and Oncobiology (CIMAGO) - Institute for Clinical and Biomedical Research (iCBR), FMUC, Coimbra, Portugal.,University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal.,Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Raquel Alves
- University of Coimbra, Laboratory of Oncobiology and Hematology and University Clinic of Hematology, Faculty of Medicine (FMUC), Coimbra, Portugal.,University of Coimbra, Group of Environment, Genetics and Oncobiology (CIMAGO) - Institute for Clinical and Biomedical Research (iCBR), FMUC, Coimbra, Portugal.,University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal.,Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Inês Baldeiras
- University of Coimbra, FMUC, Coimbra, Portugal.,University of Coimbra, Center for Neuroscience and Cell Biology, Coimbra, Portugal
| | - Joana Jorge
- University of Coimbra, Laboratory of Oncobiology and Hematology and University Clinic of Hematology, Faculty of Medicine (FMUC), Coimbra, Portugal.,University of Coimbra, Group of Environment, Genetics and Oncobiology (CIMAGO) - Institute for Clinical and Biomedical Research (iCBR), FMUC, Coimbra, Portugal.,University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal.,Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Bárbara Marques
- University of Coimbra, Laboratory of Oncobiology and Hematology and University Clinic of Hematology, Faculty of Medicine (FMUC), Coimbra, Portugal.,Clinical Hematology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
| | - Artur Paiva
- University of Coimbra, Group of Environment, Genetics and Oncobiology (CIMAGO) - Institute for Clinical and Biomedical Research (iCBR), FMUC, Coimbra, Portugal.,University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal.,Centro Hospitalar e Universitário de Coimbra (CHUC), Unidade de Gestão Operacional em Citometria, Coimbra, Portugal
| | | | - Emília Cortesão
- University of Coimbra, Laboratory of Oncobiology and Hematology and University Clinic of Hematology, Faculty of Medicine (FMUC), Coimbra, Portugal.,University of Coimbra, Group of Environment, Genetics and Oncobiology (CIMAGO) - Institute for Clinical and Biomedical Research (iCBR), FMUC, Coimbra, Portugal.,University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal.,Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal.,Clinical Hematology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
| | - José Manuel Nascimento Costa
- University of Coimbra, Group of Environment, Genetics and Oncobiology (CIMAGO) - Institute for Clinical and Biomedical Research (iCBR), FMUC, Coimbra, Portugal.,University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal.,University of Coimbra, University Clinic of Oncology, FMUC, Coimbra, Portugal
| | - Ana Bela Sarmento-Ribeiro
- University of Coimbra, Laboratory of Oncobiology and Hematology and University Clinic of Hematology, Faculty of Medicine (FMUC), Coimbra, Portugal.,University of Coimbra, Group of Environment, Genetics and Oncobiology (CIMAGO) - Institute for Clinical and Biomedical Research (iCBR), FMUC, Coimbra, Portugal.,University of Coimbra, Center for Innovative Biomedicine and Biotechnology (CIBB), Coimbra, Portugal.,Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal.,Clinical Hematology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal
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Mo A, Stanworth SJ, Shortt J, Wood EM, McQuilten ZK. Red cell transfusions: Is less always best?: How confident are we that restrictive transfusion strategies should be the standard of care default transfusion practice? Transfusion 2021; 61:2195-2203. [PMID: 34075594 DOI: 10.1111/trf.16429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/19/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Allison Mo
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia.,Austin Pathology and Department of Haematology, Austin Health, Melbourne, Australia
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Jake Shortt
- Department of Haematology, Monash Health, Melbourne, Australia.,School of Clinical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
| | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
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8
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Oliva EN, Platzbecker U, Fenaux P, Garcia-Manero G, LeBlanc TW, Patel BJ, Kubasch AS, Sekeres MA. Targeting health-related quality of life in patients with myelodysplastic syndromes - Current knowledge and lessons to be learned. Blood Rev 2021; 50:100851. [PMID: 34088518 DOI: 10.1016/j.blre.2021.100851] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/10/2021] [Accepted: 05/13/2021] [Indexed: 12/12/2022]
Abstract
Using a range of health-related quality of life (HRQoL) instruments, most - but not all - studies of myelodysplastic syndromes (MDS) have reported that lower hemoglobin levels and red blood cell transfusion dependency are associated with worse HRQoL. In addition, some MDS treatments may significantly improve HRQoL, particularly among those patients who respond to therapy; however, the majority of these studies were underpowered for this secondary endpoint. Furthermore, decreased HRQoL has been associated with worse survival outcomes, and HRQoL scores can be used to refine classical prognostic systems. Despite the subjective nature of HRQoL, the importance and validity of measuring it in trials and clinical practice are increasingly being recognized, but properly validated MDS-specific instruments are required. We describe what is currently known about HRQoL in patients with MDS, and the limitations of measuring HRQoL, and we provide some recommendations to improve the measurement of this outcome in future trials.
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Affiliation(s)
- Esther N Oliva
- Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio Calabria, Italy.
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany.
| | - Pierre Fenaux
- Service d'Hématologie Séniors, Hôpital Saint-Louis, Université Paris 7, Paris, France.
| | | | | | | | - Anne Sophie Kubasch
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany.
| | - Mikkael A Sekeres
- Sylvester Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA.
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Stanworth SJ, Killick S, McQuilten ZK, Karakantza M, Weinkove R, Smethurst H, Pankhurst LA, Hodge RL, Hopkins V, Thomas HL, Deary AJ, Callum J, Lin Y, Wood EM, Buckstein R, Bowen D, Wallis L, Rabbi T, Serrano M, Williams R, Chacko J, Darlow J, Watson L, Earley K, Haas N, Woods L, Dimitriu C, Croft J, Carvalhosa A, Clarke C, Hickish T, Penny C, Sternberg A, Owen T, Parajes C, Meyer C, Dodge J, Meakin S, Lake D, Culligan D, Fletcher H, Forbes H, Johannesson N, Taylor G, Tomlinson J, Shaw A, Ratcliffe M, Lamacchia M, Vickers M, Duncan C, Untiveros P, Olaiya A, Tighe J, Preston G, Zaidi M, Lawrie A, Robertson C, Saadi H, Onyeakazi U, Radia R, Father T, Stainthorp K, Mc Connell S, Booth T, Langton C, Howcroft C, Saddiq I, Gupta ED, Byrne J, Lindsey‐Hill J, Badder D, Jones M, Pol R, Vyas P, Mead A, Peniket A, Bancroft R, Springett S, Yoganayagam S, Gray L, Friesen H, Wardle K, Murthy V, Pratt G, Kishore B, Mayer G, Nikolousis E, Smith N, Lovell R, Kartsios C, Ewing J, Lumley M, Khawaja J, Ali M, Sutton D, Murray D, Milligan D, Dhani S, O'Sullivan M, Whitehouse J, Schumacher A, Enstone R, Hardy A, Kelly M, Wallis J, Boal L, Davies M, Latter R, Wincup J, Ellis S, Poolan S, Birt M, Watts E, Charlton A, Forsyth H, Waring L, Twohig J, Marr H, Lennard A, Jones G, Menne T, Redding N, Jones S, Robinson K, Grand E, Cullis J, Collins F, Gamble L, Brown J, Tudgay S, Salisbury S, Mathew S, Tipler N, Parker T, Stobie E, Tribbeck M, Hebballi S, Millar C, Allotey D, Lala J, McGee N, Chmeil J, Hufton L, Dawson S, Weincove R, Smyth D, Buyck H, Hayden J, George A, Baluwala I, Wheeler M, Daysh L, Williams O, Millmow S, Miles R, Geller S, Blakemore M, Hargreaves A, Hayden G, Mo A, Van Dam M, Uhe M, Indran T, Wong J, Coughlin L, MacWhannell A, Beardsmore C, Lunn L, Pearson S, Shaw S, Parker J, Bowen A, Jones A, Player M. Red cell transfusion in outpatients with myelodysplastic syndromes: a feasibility and exploratory randomised trial. Br J Haematol 2020; 189:279-290. [PMID: 31960409 DOI: 10.1111/bjh.16347] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/06/2019] [Indexed: 01/05/2023]
Abstract
Optimal red cell transfusion support in myelodysplastic syndromes (MDS) has not been tested and established. The aim of this study was to demonstrate feasibility of recruitment and follow-up in an outpatient setting with an exploratory assessment of quality of life (QoL) outcomes (EORTC QLQ-C30 and EQ-5D-5L). We randomised MDS patients to standardised transfusion algorithms comparing current restrictive transfusion thresholds (80 g/l, to maintain haemoglobin 85-100 g/l) with liberal thresholds (105 g/l, maintaining 110-125 g/l). The primary outcomes were measures of compliance to transfusion thresholds. Altogether 38 patients were randomised (n = 20 restrictive; n = 18 liberal) from 12 participating sites in UK, Australia and New Zealand. The compliance proportion for the intention-to-treat population was 86% (95% confidence interval 75-94%) and 99% (95-100%) for restrictive and liberal arms respectively. Mean pre-transfusion haemoglobin concentrations for restrictive and liberal arms were 80 g/l (SD6) and 97 g/l (SD7). The total number of red cell units transfused on study was 82 in the restrictive and 192 in the liberal arm. In an exploratory analysis, the five main QoL domains were improved for participants in the liberal compared to restrictive arm. Our findings support the feasibility and need for a definitive trial to evaluate the effect of different red cell transfusion thresholds on patient-centred outcomes.
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Affiliation(s)
- Simon J. Stanworth
- Oxford University Oxford United Kingdom
- The John Radcliffe Hospital Oxford GBR
- NHSBT Oxford United Kingdom
| | - Sally Killick
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust Bournemouth United Kingdom
| | | | - Marina Karakantza
- Department of HaematologyLeeds Teaching Hospitals Leeds United Kingdom
| | - Robert Weinkove
- Wellington Blood & Cancer CentreCapital & Coast District Health Board Wellington New Zealand
- Malaghan Institute of Medical Research Wellington New Zealand
| | - Heather Smethurst
- NHS Blood and Transplant Clinical Trials Unit Cambridge United Kingdom
| | | | - Renate L. Hodge
- NHS Blood and Transplant Clinical Trials Unit Cambridge United Kingdom
| | - Valerie Hopkins
- NHS Blood and Transplant Clinical Trials Unit Cambridge United Kingdom
| | - Helen L. Thomas
- NHS Blood and Transplant Clinical Trials Unit Bristol United Kingdom
| | - Alison J. Deary
- NHS Blood and Transplant Clinical Trials Unit Cambridge United Kingdom
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular DiagnosticsSunnybrook Health Sciences Centre Toronto ON Canada
- Department of Laboratory Medicine and PathobiologyUniversity of Toronto Toronto ON Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular DiagnosticsSunnybrook Health Sciences Centre Toronto ON Canada
- Department of Laboratory Medicine and PathobiologyUniversity of Toronto Toronto ON Canada
| | - Erica M. Wood
- Transfusion Research UnitMonash University Melbourne Australia
| | - Rena Buckstein
- Odette Cancer CentreSunnybrook Health Sciences Centre Toronto ON Canada
| | - David Bowen
- Department of HaematologyLeeds Teaching Hospitals Leeds United Kingdom
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Park S, Kelaidi C, Meunier M, Casadevall N, Gerds AT, Platzbecker U. The prognostic value of serum erythropoietin in patients with lower-risk myelodysplastic syndromes: a review of the literature and expert opinion. Ann Hematol 2019; 99:7-19. [PMID: 31650290 PMCID: PMC6944671 DOI: 10.1007/s00277-019-03799-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 09/11/2019] [Indexed: 12/30/2022]
Abstract
Myelodysplastic syndromes (MDS) are hematopoietic stem cell malignancies associated with an erythroid maturation defect, resulting in anemia. Treatments for MDS include erythropoiesis-stimulating agents (ESAs). The identification of prognostic markers is important to help predict response and improve outcomes. Various scoring systems have been developed to help predict response to ESAs. Despite limitations in its assessment, serum erythropoietin (sEPO) level is an important predictor of hematologic response to ESAs in patients with lower-risk MDS. Numerous studies have reported significantly lower sEPO levels among responders versus non-responders. Furthermore, treatment response is significantly more likely among those with sEPO levels below versus those above various cutoffs. Other prognostic indicators for response to ESAs include lower transfusion requirement, fewer bone marrow blasts, higher hemoglobin, lower serum ferritin, lower-risk MDS, and more normal cytogenetics. Studies of other MDS therapies (e.g., lenalidomide and luspatercept) have also reported that lower sEPO levels are indicative of hematologic response. In addition, lower sEPO levels (up to 500 IU/L) have been included in treatment algorithms for patients with lower-risk MDS to define whether ESAs are indicated. Lower sEPO levels are predictive of hematologic response—particularly to ESAs. Further, clinical trials should use sEPO thresholds to ensure more homogeneous cohorts.
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Affiliation(s)
- Sophie Park
- CHU Grenoble, Université Grenoble Alpes, Institute for Advanced Biosciences, INSERM U1209, CNRS UMR 5309, CS 10217, 38043, Grenoble, France.
| | | | - Mathieu Meunier
- CHU Grenoble, Université Grenoble Alpes, Institute for Advanced Biosciences, INSERM U1209, CNRS UMR 5309, CS 10217, 38043, Grenoble, France
| | | | - Aaron T Gerds
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Uwe Platzbecker
- Medical Clinic and Policlinic 1, Hematology and Cellular Therapy, Leipzig University Hospital, Leipzig, Germany
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Park S, Greenberg P, Yucel A, Farmer C, O'Neill F, De Oliveira Brandao C, Fenaux P. Clinical effectiveness and safety of erythropoietin-stimulating agents for the treatment of low- and intermediate-1-risk myelodysplastic syndrome: a systematic literature review. Br J Haematol 2018; 184:134-160. [PMID: 30549002 DOI: 10.1111/bjh.15707] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Many patients with lower-risk myelodysplastic syndrome (MDS) experience anaemia, which has negative consequences. Erythropoiesis-stimulating agents (ESAs) and their biosimilars are used to treat anaemia in MDS and, currently, epoetin alfa and darbepoetin alfa are commonly used and recommended by clinical guidelines. To better understand the evidence available on the use of ESAs for anaemia in lower-risk MDS, we conducted a systematic literature review to identify randomized and nonrandomized prospective studies reporting on clinical efficacy/effectiveness, patient-reported quality of life (QoL), and safety. We extended our review to include retrospective studies for darbepoetin alfa specifically and to ascertain the feasibility of completing an indirect network meta-analysis comparing epoetin and darbepoetin alfa. Overall, 53 articles reporting on 35 studies were included. The studies indicated a clinical benefit of ESAs, with benefits observed across key clinical outcomes. ESAs showed consistent improvement in erythroid response rates (ESA-naïve, 45-73%; previous ESA exposure, 25-75%) and duration of response. Comparative studies demonstrated similar progression to acute myeloid leukaemia and several showed improved overall survival and QoL. Limited safety concerns were identified. This analysis confirmed ESA therapy should be the foremost first-line treatment of anaemia in most patients with lower-risk MDS who lack the 5q deletion.
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Affiliation(s)
- Sophie Park
- Clinique Universitaire d'Hématologie Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | | | | | | | | | | | - Pierre Fenaux
- Service d'Hématologie Clinique, Hôpital St. Louis and Paris 7 University, Paris, France
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Ikenoue T, Naito H, Kitamura T, Hattori H. Epoetin β pegol (continuous erythropoietin receptor activator, CERA) is another choice for the treatment of anemia in myelodysplastic syndrome: a case report. J Med Case Rep 2017; 11:296. [PMID: 29047386 PMCID: PMC5648440 DOI: 10.1186/s13256-017-1468-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/20/2017] [Indexed: 12/26/2022] Open
Abstract
Background In most patients, anemia is present when myelodysplastic syndrome is diagnosed. Although darbepoetin α is the first-choice supportive therapy for low-risk myelodysplastic syndrome, half of all patients develop a loss of response to darbepoetin α within 12 months. However, few reports have described supportive therapy after the loss of response to darbepoetin α. Case presentation We herein present a case involving a 65-year-old Japanese woman with low-risk myelodysplastic syndrome whose erythropoiesis-stimulating agent treatment was switched from darbepoetin α to epoetin β pegol (continuous erythropoietin receptor activator) to treat transfusion-dependent anemia. The frequent transfusions required to treat the anemia resulted in transfusion-associated circulatory overload. The transfusion-dependent anemia was initially treated with darbepoetin α, which negated the requirement for transfusion. However, after 12 months of darbepoetin α therapy, the hemoglobin concentration sharply declined. We switched her therapy from darbepoetin α to continuous erythropoietin receptor activator to avoid transfusion. After initiation of continuous erythropoietin receptor activator therapy, the hemoglobin concentration gradually increased and transfusion was not required. At the time of writing, no progression of the anemia had occurred. Conclusions Although darbepoetin α is the first-choice supportive therapy for low-risk myelodysplastic syndrome, continuous erythropoietin receptor activator might be considered the second-choice therapy.
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Affiliation(s)
- Tatsuyoshi Ikenoue
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan. .,Fujiidera Keijinkai Clinic, 1-2-3 Emisaka, Fujiidera, Osaka, Japan.
| | - Hiroshi Naito
- Fujiidera Keijinkai Clinic, 1-2-3 Emisaka, Fujiidera, Osaka, Japan
| | - Tetsuya Kitamura
- Fujiidera Keijinkai Clinic, 1-2-3 Emisaka, Fujiidera, Osaka, Japan
| | - Hideki Hattori
- Division of Hematology, Yao Municipal Hospital, 1-3-1 Ryugecho, Yao, Osaka, Japan
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Mies A, Platzbecker U. Increasing the effectiveness of hematopoiesis in myelodysplastic syndromes: erythropoiesis-stimulating agents and transforming growth factor-β superfamily inhibitors. Semin Hematol 2017; 54:141-146. [PMID: 28958287 DOI: 10.1053/j.seminhematol.2017.06.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 06/22/2017] [Indexed: 01/11/2023]
Abstract
Patients with lower-risk myelodysplastic syndromes (MDS) are mainly affected by chronic anemia and fatigue. Treatment strategies aim to improve anemia and quality of life, as well as iron overload due to red blood cell transfusion support. To promote proliferation and differentiation of erythropoiesis, erythropoiesis-stimulating agents (ESAs) such as erythropoietin (EPO) and mimetics are applied as first-line therapy in a large fraction of lower-risk MDS patients. In general, ESAs yield favorable responses in about half of the patients, although responses are often short-lived. In fact, many ESA-refractory patients harbor defects in late-stage erythropoiesis downstream of EPO action. Novel transforming growth factor (TGF)-β superfamily inhibitors sotatercept and luspatercept represent a promising approach to alleviate anemia by stimulating erythroid differentiation.
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Affiliation(s)
- Anna Mies
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany, German Cancer Consortium (DKTK), and German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Uwe Platzbecker
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany, German Cancer Consortium (DKTK), and German Cancer Research Center (DKFZ), Heidelberg, Germany
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15
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Platzbecker U, Symeonidis A, Oliva EN, Goede JS, Delforge M, Mayer J, Slama B, Badre S, Gasal E, Mehta B, Franklin J. A phase 3 randomized placebo-controlled trial of darbepoetin alfa in patients with anemia and lower-risk myelodysplastic syndromes. Leukemia 2017. [PMID: 28626220 PMCID: PMC5596208 DOI: 10.1038/leu.2017.192] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The use of darbepoetin alfa to treat anemia in patients with lower-risk myelodysplastic syndromes (MDS) was evaluated in a phase 3 trial. Eligible patients had low/intermediate-1 risk MDS, hemoglobin ⩽10 g/dl, low transfusion burden and serum erythropoietin (EPO) ⩽500 mU/ml. Patients were randomized 2:1 to receive 24 weeks of subcutaneous darbepoetin alfa 500 μg or placebo every 3 weeks (Q3W), followed by 48 weeks of open-label darbepoetin alfa. A total of 147 patients were randomized, with median hemoglobin of 9.3 (Q1:8.8, Q3:9.7) g/dl and median baseline serum EPO of 69 (Q1:36, Q3:158) mU/ml. Transfusion incidence from weeks 5–24 was significantly lower with darbepoetin alfa versus placebo (36.1% (35/97) versus 59.2% (29/49), P=0.008) and erythroid response rates increased significantly with darbepoetin alfa (14.7% (11/75 evaluable) versus 0% (0/35 evaluable), P=0.016). In the 48-week open-label period, dose frequency increased from Q3W to Q2W in 81% (102/126) of patients; this was associated with a higher hematologic improvement–erythroid response rate (34.7% (34/98)). Safety results were consistent with a previous darbepoetin alfa phase 2 MDS trial. In conclusion, 24 weeks of darbepoetin alfa Q3W significantly reduced transfusions and increased rates of erythroid response with no new safety signals in lower-risk MDS (registered as EudraCT#2009-016522-14 and NCT#01362140).
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Affiliation(s)
- U Platzbecker
- University Hospital Carl Gustav Carus Dresden, Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - A Symeonidis
- Division of Hematology, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - E N Oliva
- Division of Hematology, Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - J S Goede
- Division of Hematology, University Hospital and University of Zürich, Zürich, Switzerland
| | - M Delforge
- Department of Hematology &Chairman Leuven Cancer Institute, University Hospital Leuven, Leuven, Belgium
| | - J Mayer
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - B Slama
- Oncologie Médicale-Hématologie Clinique, Centre Hospitalier Departemental, Avignon, France
| | - S Badre
- Amgen Inc., Thousand Oaks, CA, USA
| | - E Gasal
- Amgen Inc., Thousand Oaks, CA, USA
| | - B Mehta
- Amgen Inc., Thousand Oaks, CA, USA
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The Value of Patient Reported Outcomes and Other Patient-Generated Health Data in Clinical Hematology. Curr Hematol Malig Rep 2016; 10:213-24. [PMID: 26040262 DOI: 10.1007/s11899-015-0261-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
With cures and long-term survival rates increasing in hematologic malignancies, increased focus has been placed on gaining a better understanding of the patient experience from disease and treatment effects. This has been the basis for the utilization of patient reported outcomes (PRO) and other patient-generated health data (PGHD) in efforts to improve long-term health-related quality of life (HRQOL). This review will summarize the impact PROs have had on the evolving standard of care for patients with hematologic malignant conditions and will conclude with a template for the integration of PRO and PGHD to enhance the patient experience, using stem cell transplantation as an example.
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17
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Park S, Fenaux P, Greenberg P, Mehta B, Callaghan F, Kim C, Tomita D, Xu H. Efficacy and safety of darbepoetin alpha in patients with myelodysplastic syndromes: a systematic review and meta-analysis. Br J Haematol 2016; 174:730-47. [PMID: 27214305 PMCID: PMC5089656 DOI: 10.1111/bjh.14116] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/15/2016] [Indexed: 01/22/2023]
Abstract
We conducted a systematic review and meta‐analysis to estimate the efficacy of darbepoetin alpha (DA) for treatment of myelodysplastic syndrome (MDS)‐related anaemia. Eligible studies were prospective, interventional, and reported World Health Organization, French‐American‐British, or International Prognostic Scoring System (IPSS) criteria. Outcomes included erythroid response rate (primary); haemoglobin response; change in haemoglobin, transfusion status, and quality‐of‐life (QoL); and safety. Ten studies (N = 647) were analysed. Erythroid response rate range was 38–72%; median response duration range was 12–51+ months. Patients with erythropoietin (EPO) <100 iu/l had 35% [95% confidence interval (CI): 22–48%; P < 0·001) better response than patients with EPO >100 iu/l. Erythropoesis‐stimulating agent (ESA)‐naïve patients had 17% (95% CI: 3–32%; P = 0·022) greater response rate than those previously treated with ESA. Nonetheless, previously treated patients had response rates of 25–75%. Higher baseline haemoglobin levels, higher dose, transfusion‐independence and low‐risk IPSS status were reported by several studies to be associated with better response. QoL, transfusion rates and haemoglobin levels improved with treatment. Hypertension, thromboembolism and progression to acute myeloid leukaemia were reported in 2%, 1% and 1% of patients, respectively. This meta‐analysis suggests that DA treatment can be useful for improving erythroid response in MDS patients with anaemia, even among patients previously treated with ESA.
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Affiliation(s)
- Sophie Park
- CHU de Grenoble, Clinique Universitaire d'Hématologie, Université Grenoble Alpes, Grenoble, France
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18
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Jang JH, Harada H, Shibayama H, Shimazaki R, Kim HJ, Sawada K, Mitani K. A randomized controlled trial comparing darbepoetin alfa doses in red blood cell transfusion-dependent patients with low- or intermediate-1 risk myelodysplastic syndromes. Int J Hematol 2015; 102:401-12. [PMID: 26323997 DOI: 10.1007/s12185-015-1862-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/16/2015] [Accepted: 08/25/2015] [Indexed: 11/28/2022]
Abstract
Darbepoetin alfa (DA) is a standard treatment for anemia in lower-risk MDS. However, to date there has been no comparative study to investigate the initial dosage. We, thus, conducted a randomized controlled trial to elucidate the optimal initial dosage of DA. International Prognostic Scoring System low or intermediate-1 risk MDS patients with hemoglobin levels ≤9.0 g/dL, serum erythropoietin levels ≤500 mIU/mL, and red blood cell transfusion dependency were enrolled. Patients were randomized to receive DA either at 60, 120, or 240 μg/week for 16 weeks followed by continuous administration with dose adjustment up to 48 weeks. Of 17, 18, and 15 patients in the 60, 120, and 240 μg DA groups included in the efficacy analysis, 64.7, 44.4, and 66.7 %, respectively, achieved the primary endpoint (major or minor erythroid response), while 17.6, 16.7, and 33.3 % achieved major erythroid responses in the initial 16-week period. No clinically significant safety concerns were identified. DA reduced the transfusion requirements effectively and safely in transfusion-dependent, lower-risk MDS patients. Given the highest achievement rate of the major erythroid response in the 240 μg group and the absence of dose-dependent adverse events, 240 μg weekly is the optimal initial dosage.
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Affiliation(s)
- Jun Ho Jang
- Department of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Hironori Harada
- Department of Hematology and Oncology, Hiroshima University Hospital, Hiroshima, Japan.,Department of Hematology, Juntendo University School of Medicine, Tokyo, Japan
| | - Hirohiko Shibayama
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Hyeoung-Joon Kim
- Department of Hematology/Oncology, Chonnam National University Hwasun Hospital, Hwasun, Jeollanam-do, Korea
| | | | - Kinuko Mitani
- Department of Hematology and Oncology, Dokkyo Medical University School of Medicine, 880, Kitakobayashi, Mibu-machi, Shimotsuga-gun, Tochigi, 321-0293, Japan.
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19
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Duong VH, Baer MR, Hendrick F, Weiss SR, Sato M, Zeidan AM, Gore SD, Davidoff AJ. Variations in erythropoiesis-stimulating agent administration in transfusion-dependent myelodysplastic syndromes impact response. Leuk Res 2015; 39:586-91. [PMID: 25869077 PMCID: PMC4441842 DOI: 10.1016/j.leukres.2015.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 03/04/2015] [Accepted: 03/15/2015] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Erythropoiesis-stimulating agents (ESAs) reduce red blood cell (RBC) transfusions in approximately 40% of patients with myelodysplastic syndrome (MDS) in clinical trials. We studied the association of timing of ESA initiation, agent (epoetin alfa, darbepoetin) and number of weeks of ESA use with response in MDS patients in routine practice. METHODS Patients diagnosed with MDS from 2001 to 2005 were identified in the Surveillance Epidemiology and End Results-Medicare linked database. The study cohort consisted of patients with new-onset transfusion dependence (TD). All patients received an ESA at least once during the study period, which began the week that criteria for TD were met and continued until transfusion independence (TI). Kaplan-Meier statistics and Cox Proportional Hazard models were used to assess relationships between time to ESA initiation, agent and number of weeks of ESA use and TI attainment. RESULTS Of 610 TD patients treated with ESAs, 210 (34.4%) achieved TI. Median time from ESA initiation to TI was 13 weeks. Shorter time from TD to ESA initiation and use of darbepoetin were associated with higher probability of achieving TI. The probability of achieving TI decreased beyond 8 weeks of treatment, and was very low beyond 16 weeks (8-15 weeks: HR=0.64, 16-31 weeks: HR=0.25, 32+ weeks HR=0.10). CONCLUSIONS In this observational, population-based study, variations in ESA administration impacted response in transfusion-dependent MDS patients, with higher response rates with early administration and use of darbepoetin, and low response likelihood in non-responders beyond 16 weeks of therapy.
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Affiliation(s)
- Vu H Duong
- University of Maryland Marlene and Stewart Greenebaum Cancer Center and Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Maria R Baer
- University of Maryland Marlene and Stewart Greenebaum Cancer Center and Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Franklin Hendrick
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Sheila R Weiss
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Masayo Sato
- Pharmaceutical Health Services Research Department, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Amer M Zeidan
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Steven D Gore
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Amy J Davidoff
- Agency for Healthcare Research and Quality, Rockville, MD, USA
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Abstract
The myelodysplastic syndromes are characterized by refractory cytopenias that lead to symptomatic anemia, bleeding, and increased risk for infections. For almost two decades, the use of darbepoetin and other erythropoietin stimulating agents to treat symptomatic anemia in lower-risk myelodysplastic syndromes has been a standard of care. This practice is supported by numerous Phase I/II studies and one Phase III study demonstrating the benefit of using erythropoietin stimulating agents alone, or in combination with granulocyte colony stimulating factor, for treatment of symptomatic anemia with the goal of decreasing red blood cell transfusion requirements. This review summarizes the published experience regarding the use of erythropoietin stimulating agents, with a special focus on darbepoetin, in patients with myelodysplastic syndrome and symptomatic anemia.
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Affiliation(s)
- David J Seastone
- Leukemia Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH USA
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21
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Duong VH, Komrokji RS, List AF. Update on the pharmacotherapy for myelodysplastic syndromes. Expert Opin Pharmacother 2014; 15:1811-25. [DOI: 10.1517/14656566.2014.937705] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Development and validation of QOL-E© instrument for the assessment of health-related quality of life in myelodysplastic syndromes. Open Med (Wars) 2013. [DOI: 10.2478/s11536-013-0196-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
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23
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Özcan MA, Ilhan O, Ozcebe OI, Nalcaci M, Gülbas Z. Review of therapeutic options and the management of patients with myelodysplastic syndromes. Expert Rev Hematol 2013; 6:165-89. [PMID: 23547866 DOI: 10.1586/ehm.13.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Myelodysplastic syndromes (MDS) are a poorly understood group of disorders caused by one or more genetic aberrations in the bone marrow-derived cell line responsible for hematopoiesis. Recent advances in genetic medicine have offered new insights into the epigenesis as well as the prognosis of MDS, but have not resulted in new or improved curative treatment options. Bone marrow transplantation, introduced before the advent of genetic medicine, is still the only potential cure. Advances in other medical and pharmaceutical areas have broadened the scope of supportive care and disease-modifying therapies, and treating physicians now have a broad range of disease management options depending on a patient's likely prognosis. There is now clear evidence that appropriate supportive care and therapeutic intervention can improve progression-free and overall survival of MDS patients.
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Affiliation(s)
- Mehmet A Özcan
- Department of Hematology, Dokuz Eylül University, Izmir, Turkey.
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24
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Diagnosis and treatment of primary myelodysplastic syndromes in adults: recommendations from the European LeukemiaNet. Blood 2013; 122:2943-64. [PMID: 23980065 DOI: 10.1182/blood-2013-03-492884] [Citation(s) in RCA: 472] [Impact Index Per Article: 42.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Within the myelodysplastic syndrome (MDS) work package of the European LeukemiaNet, an Expert Panel was selected according to the framework elements of the National Institutes of Health Consensus Development Program. A systematic review of the literature was performed that included indexed original papers, indexed reviews and educational papers, and abstracts of conference proceedings. Guidelines were developed on the basis of a list of patient- and therapy-oriented questions, and recommendations were formulated and ranked according to the supporting level of evidence. MDSs should be classified according to the 2008 World Health Organization criteria. An accurate risk assessment requires the evaluation of not only disease-related factors but also of those related to extrahematologic comorbidity. The assessment of individual risk enables the identification of fit patients with a poor prognosis who are candidates for up-front intensive treatments, primarily allogeneic stem cell transplantation. A high proportion of MDS patients are not eligible for potentially curative treatment because of advanced age and/or clinically relevant comorbidities and poor performance status. In these patients, the therapeutic intervention is aimed at preventing cytopenia-related morbidity and preserving quality of life. A number of new agents are being developed for which the available evidence is not sufficient to recommend routine use. The inclusion of patients into prospective clinical trials is strongly recommended.
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Santini V, Gozzini A, Bosi A. Treatment Options in Myelodysplastic Syndromes: A New Frontier. J Chemother 2013; 20:291-6. [DOI: 10.1179/joc.2008.20.3.291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Greenberg PL, Attar E, Bennett JM, Bloomfield CD, Borate U, De Castro CM, Deeg HJ, Frankfurt O, Gaensler K, Garcia-Manero G, Gore SD, Head D, Komrokji R, Maness LJ, Millenson M, O'Donnell MR, Shami PJ, Stein BL, Stone RM, Thompson JE, Westervelt P, Wheeler B, Shead DA, Naganuma M. Myelodysplastic syndromes: clinical practice guidelines in oncology. J Natl Compr Canc Netw 2013; 11:838-74. [PMID: 23847220 PMCID: PMC4000017 DOI: 10.6004/jnccn.2013.0104] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The myelodysplastic syndromes (MDS) represent a heterogeneous group of clonal hematopoietic disorders characterized by cytopenias, dysplasia in one or more myeloid lineages, and the potential for development of acute myeloid leukemia. These disorders primarily affect older adults. The NCCN Clinical Practice Guidelines in Oncology for MDS provide recommendations on the diagnostic evaluation and classification of MDS, risk evaluation according to established prognostic assessment tools (including the new revised International Prognostic Scoring System), treatment options according to risk categories, and management of related anemia.
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Thomas ML, Crisp N, Campbell K. The importance of quality of life for patients living with myelodysplastic syndromes. Clin J Oncol Nurs 2013; 16 Suppl:47-57. [PMID: 22641284 DOI: 10.1188/12.cjon.s1.47-57] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Myelodysplastic syndromes (MDS) are a group of myeloid stem cell clonal disorders characterized by a wide variation in illness trajectory and potential treatment. The physical, functional, emotional, social, and spiritual well-being of individuals with MDS can be affected by both disease and treatment-related factors. As a result, the quality of life (QOL) in patients with MDS may vary throughout the course of the illness. To date, most research exploring QOL in patients with MDS has been conducted as part of clinical trials evaluating the effectiveness of a therapeutic intervention. Although data from those studies are useful, they do not fully address the issues critical to maintaining or maximizing QOL. Oncology nurses are in a key position to assist patients with MDS to maintain their QOL. Findings from comprehensive QOL assessments will guide nurses in providing relevant interventions and evaluating their outcomes. In this manner, oncology nurses can assist their patients to maximize QOL while living with this challenging illness.
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Kelaidi C, Beyne-Rauzy O, Braun T, Sapena R, Cougoul P, Adès L, Pillard F, Lamberto C, Lambert C, Charniot JC, Guerci A, Choufi B, Stamatoullas A, Slama B, De Renzis B, Ame S, Damaj G, Boyer F, Chaury MP, Legros L, Cheze S, Testu A, Gyan E, Béné MC, Rose C, Dreyfus F, Fenaux P. High response rate and improved exercise capacity and quality of life with a new regimen of darbepoetin alfa with or without filgrastim in lower-risk myelodysplastic syndromes: a phase II study by the GFM. Ann Hematol 2013; 92:621-31. [PMID: 23358617 DOI: 10.1007/s00277-013-1686-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 01/17/2013] [Indexed: 11/24/2022]
Abstract
Darbepoetin (DAR), with or without granulocyte colony-stimulating factor (G-CSF), has proved effective in treating anemia in patients with lower-risk myelodysplastic syndrome (MDS), but its effects on quality of life (QoL) and exercise functioning are less well established. In this phase II study (no. NCT00443339), lower-risk MDS patients with anemia and endogenous erythropoietin (EPO) level <500 IU/L received DAR 500 μg once every 2 weeks for 12 weeks, with G-CSF added at week 12 in non-responders. Physical performance was assessed with the 6-min walking test and, for fit patients, maximal oxygen consumption (VO2max). QoL was evaluated using SF-36 and FACT-An tests. In 99 patients, erythroid response rate according to IWG 2006 criteria was 48 and 56 % at 12 and 24 weeks, respectively. Addition of G-CSF rescued 22 % of non-responders. In 48 % of the responders, interval between darbepoetin injections could be increased for maintenance treatment. Serum EPO level was the only independent predictive factor of response at 12 weeks, and its most discriminant cutoff value was 100 IU/L. QoL and VO2max showed improvement over time in responders, compared with non-responders. With a median follow-up of 52 months, median response duration was not reached, and 3-year cumulative incidence of acute myeloid leukemia and overall survival (OS) was 14.5 and 70 %, respectively. Baseline transfusion dependence, International Prognostic Score System (IPSS), and Revised IPSS accurately predicted OS from treatment onset. Tolerance of darbepoetin was good. In conclusion, this regimen of darbepoetin every 2 weeks yielded high response rates and prolonged response duration. Objective improvement in exercise testing and in patient-reported QoL confirms the clinical relevance of anemia correction with erythropoiesis-stimulating agents.
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Affiliation(s)
- C Kelaidi
- GFM Service d'Hématogie Clinique, Hôpital Avicenne, Assistance Publique des Hôpitaux de Paris, Université Paris 13, 125 rue de Stalingrad, Bobigny, France
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Health-related quality of life outcomes of lenalidomide in transfusion-dependent patients with Low- or Intermediate-1-risk myelodysplastic syndromes with a chromosome 5q deletion: results from a randomized clinical trial. Leuk Res 2012; 37:259-65. [PMID: 23273538 DOI: 10.1016/j.leukres.2012.11.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 11/16/2012] [Accepted: 11/26/2012] [Indexed: 01/23/2023]
Abstract
We report health-related quality of life (HRQL) outcomes assessed using the Functional Assessment of Cancer Therapy-Anemia (FACT-An) among 167 RBC transfusion-dependent patients with IPSS Low-/Intermediate-1-risk del5q31 MDS treated with lenalidomide versus placebo in a randomized phase 3 clinical trial, MDS-004. Mean baseline to 12 week changes in FACT-An Total scores improved following treatment with lenalidomide 5 and 10mg (+5.7 and +5.7, respectively) versus placebo (-2.8) (both p<0.05). Clinically important changes in HRQL from baseline were observed at weeks 12, 24, 36, and 48 among RBC-TI≥26 week responders in both treatment groups. Lenalidomide treatment may be effective in improving HRQL outcomes.
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Crisà E, Foli C, Passera R, Darbesio A, Garvey KB, Boccadoro M, Ferrero D. Long-term follow-up of myelodysplastic syndrome patients with moderate/severe anaemia receiving human recombinant erythropoietin + 13-cis-retinoic acid and dihydroxylated vitamin D3: independent positive impact of erythroid response on survival. Br J Haematol 2012; 158:99-107. [DOI: 10.1111/j.1365-2141.2012.09125.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 03/06/2012] [Indexed: 12/14/2022]
Affiliation(s)
- Elena Crisà
- Haematology Division; S. Giovanni Battista Hospital; University of Turin; Turin
| | | | - Roberto Passera
- Nuclear Medicine Service; S. Giovanni Battista Hospital; Turin
| | | | - Kimberly B. Garvey
- Haematology Division; S. Giovanni Battista Hospital; University of Turin; Turin
| | - Mario Boccadoro
- Haematology Division; S. Giovanni Battista Hospital; University of Turin; Turin
| | - Dario Ferrero
- Haematology Division; S. Giovanni Battista Hospital; University of Turin; Turin
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31
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The clinical, quality of life, and economic consequences of chronic anemia and transfusion support in patients with myelodysplastic syndromes. Leuk Res 2012; 36:525-36. [DOI: 10.1016/j.leukres.2012.01.006] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 12/28/2011] [Accepted: 01/09/2012] [Indexed: 12/17/2022]
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The Impact of Myelodysplastic Syndromes on Quality of Life: Lessons Learned from 70 Voices. ACTA ACUST UNITED AC 2012; 10:37-44. [DOI: 10.1016/j.suponc.2011.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 05/10/2011] [Accepted: 05/19/2011] [Indexed: 11/19/2022]
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33
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Al-Ameri A, Cherry M, Garcia-Manero G, Quintás-Cardama A. Standard therapy for patients with myelodysplastic syndromes. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2011; 11:303-13. [PMID: 21816368 DOI: 10.1016/j.clml.2011.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 01/06/2011] [Accepted: 01/28/2011] [Indexed: 02/03/2023]
Abstract
The myelodysplastic syndromes (MDS) are a group of clonal hematopoietic stem cell disorders characterized by cytopenias, dysplastic changes in the hematopoietic precursors, and an increased risk of evolving into acute leukemia. Treatment for patients with MDS ranges from supportive care with blood products and/or growth factors up to allogeneic stem cell transplantation. Over the past decade, several novel therapeutic agents have been approved for clinical use. In this article, the current approach for the management of patients with MDS according to their risk category is described and mainly focuses on approved novel agents.
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Affiliation(s)
- Ali Al-Ameri
- Department of Leukemia, MD Anderson Cancer Center, The University of Texas, Houston, TX 77030, USA
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35
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Villegas A, Arrizabalaga B, Fernández-Lago C, Castro M, Mayans JR, González-Porras JR, Duarte RF, Remacha AF, Luño E, Gasquet JA. Darbepoetin alfa for anemia in patients with low or intermediate-1 risk myelodysplastic syndromes and positive predictive factors of response. Curr Med Res Opin 2011; 27:951-60. [PMID: 21381892 DOI: 10.1185/03007995.2011.561834] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Current guidelines support the use of erythropoiesis-stimulating agents for the treatment of anemia associated with low-risk myelodysplastic syndromes (MDS). DESIGN AND METHODS Single-arm, open-label, multi-center, phase 2 trial that evaluated the efficacy and safety of darbepoetin alfa (DA) in patients with low or intermediate-risk MDS, hemoglobin <100 g/L, erythropoietin (EPO) levels <500 IU/L and transfusion requirements <2 units/month over the preceding 2 months. Erythroid response (major [MaR] or minor [MiR]) and fatigue (Functional Assessment of Cancer Therapy-Fatigue [FACT-F]) were evaluated at 8, 16 and 24 weeks. DA was initiated at 300 μg weekly. For patients who did not achieve MaR by 8 weeks, filgrastim 300 μg weekly was added. CLINICAL TRIAL REGISTRATION clinicaltrials.gov identifier: NCT01039350. RESULTS Forty-four patients (72.7% transfusion independent) were included. Median age was 76.0 years (range 41.3-92.4), 54.5% were male, and 90.9% presented ECOG Status (0-1). Eighteen patients received filgrastim. An erythroid response was achieved by 31 of 44 patients (70.5%) at week 8 (47.7% MaR, 22.7% MiR), 31 of 44 patients (70.5%) at week 16 (61.4% MaR, 9.1% MiR), and 32 of 44 patients (72.7%) at week 24 (61.3% MaR, 11.4% MiR). Mean (95% CI) change in FACT-F at week 24 was 3.61 (0.72 to 6.51). Baseline EPO levels <100 IU/L were a predictive factor of response. DA was well tolerated. Four mild (two iron deficiencies, flu syndrome and headache) and one fatal (thromboembolic event) adverse events were considered related to darbepoetin alfa. CONCLUSIONS A fixed dose of 300 μg of darbepoetin alfa weekly (with or without filgrastim) seems to be an effective and safe treatment for anemic patients with low or intermediate-risk MDS, low transfusion burden and EPO levels <500 IU/L. Results may not be extrapolable to unselected MDS patients.
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Affiliation(s)
- A Villegas
- Hematology Department, Hospital Clínico San Carlos Universidad Complutense, Madrid, Spain.
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36
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Caocci G, La Nasa G, Efficace F. Health-related quality of life and symptom assessment in patients with myelodysplastic syndromes. Expert Rev Hematol 2011; 2:69-80. [PMID: 21082996 DOI: 10.1586/17474086.2.1.69] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Health-related quality of life (HRQOL), symptom burden and other types of patient-reported outcomes have acquired an important role in clinical research, as they can provide precious information on the patient's perspective of disease symptoms and treatment-related effects. HRQOL in patients with myelodysplastic syndromes (MDSs) may be compromised for several reasons, including severe anemia, the frequent occurrence of infections and the need for blood transfusions. Many MDS patients are elderly patients who might present with comorbidities from the time of diagnosis. Our investigation started with a systematic search of the literature in which prospective studies were identified and evaluated according to a predefined coding scheme. Both HRQOL outcomes and traditional clinical reported outcomes were systematically analyzed. Overall, we found nine prospective studies, four of which evaluated HRQOL in a randomized controlled trial setting and, interestingly, all these studies were published after the year 2001, possibly reflecting a recent interest in HRQOL research in MDS patients. While methodological drawbacks were identified, mainly in terms of small sample size and amount of missing data, HROQL assessment has been shown to be feasible in MDS patients and there are excellent examples of how this approach can provide additional key outcomes. A good example is the important evidence emerging from two recent randomized controlled trials that HRQOL benefits are obtained with azacitidine and decitabine compared with supportive care. In view of the enormous potential of patient-reported outcome assessment in providing valuable outcomes in support of clinical decision-making, its implementation in future studies of MDS patients is strongly recommended.
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Affiliation(s)
- Giovanni Caocci
- Cattedra di Ematologia, Centro Trapianti Midollo Osseo, Ospedale R. Binaghi, Via Is Guadazzonis 3, Cagliari, Italy.
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37
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The hematopoietic growth factors in the myelodysplastic syndromes. Cancer Treat Res 2010. [PMID: 21052966 DOI: 10.1007/978-1-4419-7073-2_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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38
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Oliva EN, Nobile F, Alimena G, Specchia G, Danova M, Rovati B, Ronco F, Impera S, Risitano A, Alati C, Breccia M, Carmosino I, Vincelli I, Latagliata R. Darbepoetin alfa for the treatment of anemia associated with myelodysplastic syndromes: efficacy and quality of life. Leuk Lymphoma 2010; 51:1007-14. [PMID: 20367566 DOI: 10.3109/10428191003728610] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To evaluate efficacy, safety, changes in biological features, and quality of life (QoL) in low-risk anemic patients with MDS treated with darbepoetin alfa (DPO), 41 patients received DPO 150 microg weekly for 24 weeks. The dose was increased to 300 microg weekly in non-responsive patients. During treatment, 10/17 (59%) transfusion-dependent (TD) and 13/23 (56%) transfusion-free (TF) patients responded. In TF patients, Hb increased from 9.2 +/- 0.9 g/dL to 10.3 +/- 1.4 g/dL by 24 weeks (p = 0.004). The mean response duration was 22 weeks (95% CI: 19.7-24.0) in TF patients compared with 15.1 weeks (95% CI: 13.3-17.5) in TD patients. Response to treatment was associated with increases in QoL. Decreases in the percentage of apoptotic progenitor cells (p = 0.007) and CD34+ cells (p = 0.005) were observed. These results confirm previous studies demonstrating the safety and efficacy of DPO in anemic patients with MDS. Biological changes and improvement in QoL were associated with response. Adequate dosing is to be determined.
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Affiliation(s)
- Esther N Oliva
- Hematology Unit, Azienda Ospedaliera 'Bianchi-Melacrino-Morelli', Reggio Calabria, Italy.
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39
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McCormack SE, Warlick ED. Epigenetic approaches in the treatment of myelodysplastic syndromes: clinical utility of azacitidine. Onco Targets Ther 2010; 3:157-65. [PMID: 20856790 PMCID: PMC2939768 DOI: 10.2147/ott.s5852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Indexed: 11/23/2022] Open
Abstract
Myelodysplastic syndromes (MDS) are a varied group of diseases leading to significant morbidity and mortality. Therapy of MDS has been difficult, with supportive cares used to ameliorate symptoms, and hematopoietic stem cell transplantation the only curative option. Agents, such as the cytidine analog azacitidine, exert an effect on DNA methyltransferase leading to a reduction in DNA methylation, a process thought to be key to the pathogenesis of MDS. Recently, azacitidine has been shown to prolong survival and improve quality of life in patients with MDS, while maintaining a favorable adverse effect profile. This review highlights the scientific rationale for the use of azacitidine in addition to its application in current clinical practice for patients with MDS.
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Affiliation(s)
- Steven E McCormack
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
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40
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Bryan J, Jabbour E, Prescott H, Garcia-Manero G, Issa JP, Kantarjian H. Current and future management options for myelodysplastic syndromes. Drugs 2010; 70:1381-94. [PMID: 20614946 DOI: 10.2165/11537920-000000000-00000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The management of the myelodysplastic syndromes (MDS) requires insight into the complex biology of the disease. Despite this challenge, two recent developments have contributed significantly to advancements in the treatment of MDS: (i) improvements in classification systems and prognostic models; and (ii) the emergence of US FDA-approved agents such as lenalidomide, azacitidine and decitabine. Prior to these developments, supportive care measures consisting of blood and platelet transfusions, haematopoietic growth factors and antimicrobials remained standard of care for the treatment of MDS. As a result of these developments, clinicians are able to provide patient-tailored therapy for specific MDS subgroups. Clinical trials addressing combination therapies with multiple investigational agents as well as novel combination regimens are ongoing. This review focuses on supportive care modalities, the approved agents indicated for the treatment of MDS and future directions for the treatment of MDS, including agents under clinical investigation.
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Affiliation(s)
- Jeffrey Bryan
- Department of Leukemia, The University of Texas, M.D. Anderson Cancer Center, Houston, Texas 77030, USA
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41
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Abstract
The myelodysplastic syndromes (MDS) are a heterogeneous spectrum of disorders requiring selective therapy based on patients' specific clinical features, predominantly their prognostic subgroups, age and performance status. Guidelines for management of patients with MDS have been generated by a number of national panels. This review focuses on evidence-based data supporting therapeutic approaches, which have also been recommended by the US National Comprehensive Cancer Network MDS Panel, with discussion of accessibility of recommended drugs in the US and in other countries. For lower risk disease (International Prognostic Scoring System Low and Intermediate-1) therapy is aimed at haematological improvement whereas for higher risk disease (Intermediate-2 and High) treatment focuses on altering disease natural history. Recent information regarding additional clinical and biological features has provided useful parameters for assessing disease prognosis that aid risk-based management decisions. The rationale for use of low versus high intensity therapies with these agents, including allogeneic haematopoietic stem cell transplantation, is discussed in detail.
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Affiliation(s)
- Peter L Greenberg
- Hematology Division, Stanford University Cancer Center, Stanford, CA 94305-5821, USA.
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42
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Cuijpers MLH, Raymakers RAP, MacKenzie MA, de Witte TJM, Swinkels DW. Recent advances in the understanding of iron overload in sideroblastic myelodysplastic syndrome. Br J Haematol 2010; 149:322-33. [DOI: 10.1111/j.1365-2141.2009.08051.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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43
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Harvey RD. Myelodysplastic syndromes and the role of iron overload. Am J Health Syst Pharm 2010; 67:S3-9. [PMID: 20332503 DOI: 10.2146/ajhp090645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE The epidemiology of myelodysplastic syndromes (MDS) and iron overload, recent clinical findings that highlight the importance of actively managing iron overload, and recommendations for initiating and maintaining iron chelation therapy (ICT) are summarized. SUMMARY MDS are a variety of hematological disorders with differing time courses. Disease morbidities are primarily due to cytopenias and evolution to acute myeloid leukemia. Iron overload is a serious complication in patients with MDS due to the long-term use of red blood cell transfusions in patients with symptomatic anemia. Clinical consequences of iron overload include end-organ damage and dysfunction, an increased frequency of transplant-related complications, and reduced survival rates. To prevent these complications, recommendations for initiating and maintaining ICT should be followed by clinicians caring for patients with MDS and iron overload. CONCLUSION As current therapeutic options for patients with MDS do not always reduce the transfusion burden, many patients will still need long-term transfusion therapy. Strategies for the management of iron overload in MDS should be considered early in the disease course and in appropriate patients in order to prevent negative clinical outcomes associated with excessive iron accumulation.
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Affiliation(s)
- R Donald Harvey
- Department of Hematology/Medical Oncology, Emory University, Atlanta, GA 30322, USA.
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44
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Kelaidi C, Fenaux P. Darbepoetin alfa in anemia of myelodysplastic syndromes: present and beyond. Expert Opin Biol Ther 2010; 10:605-14. [DOI: 10.1517/14712591003709713] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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45
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Pinchon DJ, Stanworth SJ, Dorée C, Brunskill S, Norfolk DR. Quality of life and use of red cell transfusion in patients with myelodysplastic syndromes. A systematic review. Am J Hematol 2009; 84:671-7. [PMID: 19705430 DOI: 10.1002/ajh.21503] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The main treatment for many patients with Myelodysplastic Syndromes (MDS) remains red cell transfusion to attenuate the symptoms of chronic anemia. Fatigue can reduce a patient's health related quality of life (HRQoL), but there is little understanding of the optimal use of transfusions to improve this. A systematic review was performed to identify and appraise publications reporting the use of HRQoL instruments in patients with MDS. A total of 17 separate studies were identified that used 14 HRQoL instruments, but only one MDS disease specific HRQoL instrument (QOL-E) was reported. Two well established HRQoL instruments were most often used in MDS research (variants of the Functional Assessment of Cancer Therapy (FACT) and the European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (QLQ-C30)). Several common problems were identified in the published literature including a lack of power calculations to detect clinically relevant changes, small sample sizes and significant attrition rates for completion of HRQoL assessments, all of which limit the strength of any conclusions. There is no consensus on the optimal transfusion regimen to improve HRQoL in transfusion-dependent MDS. Future research into HRQoL within MDS is a pressing requirement. Studies should focus on the domains that are of most clinical importance to the patient as well as traditional quantitative changes of hemoglobin concentration.
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Anargyrou K, Vassilakopoulos TP, Angelopoulou MK, Terpos E. Incorporating novel agents in the treatment of myelodysplastic syndromes. Leuk Res 2009; 34:6-17. [PMID: 19656566 DOI: 10.1016/j.leukres.2009.07.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2009] [Revised: 07/11/2009] [Accepted: 07/13/2009] [Indexed: 01/19/2023]
Abstract
Myelodysplastic syndromes (MDS) are a group of heterogeneous clonal stem cell (SC) disorders that mainly affect the elderly population. They are characterized by ineffective hematopoiesis which results in quantitative and qualitative cellular defects and high incidence of leukemic transformation. Recent advances in MDS research have led to the development of novel agents which appears to improve remission rates and survival when compared to best supportive care. Currently azacitidine, decitabine, and lenalidomide are approved by the US FDA for the treatment of MDS, while the activity of other novel agents such as histone deacetylase inhibitors, farnesyl-transferase inhibitors, novel thrombopoietic agents, and anti-angiogenesis molecules is under evaluation. Erythropoietin-stimulating agents, iron chelating therapy and thrombopoietin receptor ligands may also improve quality of life and possibly prolong survival in MDS patients. The only treatment modality that can achieve long-term survival is the allogeneic SC transplantation which is given only in selected patients. Moreover the heterogeneity of MDS and the patient's advanced age and co-morbidity are significant factors besides cytogenetics, IPSS and WPSS that should be taken into account during the decision-making process. Therefore clinicians should treat patients with MDS on an individual basis aiming the increase of the response rates and the decrease of treatment-associated toxicities. This can only be achieved through the better understanding of the MDS subgroups. If we can better define MDS subgroups we will be able to identify patients who will benefit from the incorporation of the novel agents, as monotherapy or in combinations regimens along with supportive care.
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50
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Abstract
Optimal management of patients with myelodysplastic syndromes (MDS) requires an insight into the biology of the disease and the mechanisms of action of the available therapies. This review focuses on low-risk MDS, for which chronic anaemia and eventual progression to acute myeloid leukaemia are the main concerns. We cover the updated World Health Organization classification, the latest prognostic scoring system, and describe novel findings in the pathogenesis of 5q- syndrome. We perform in depth analyses of two of the most widely used treatments, erythropoietin and lenalidomide, discussing mechanisms of action, reasons for treatment failure and influence on survival.
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Affiliation(s)
- M Jädersten
- Division of Hematology and Center of Experimental Hematology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
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