Determinants of survival in patients with chronic myeloid leukaemia treated in the new era of oral therapy: findings from a UK population-based patient cohort

HIF2-α Expression in CML Patients Receiving Hydroxyurea Prior to Imatinib That Achieved Major Molecular Response (MMR) versus in Those Not Achieving MMR

Introduction

Currently, Imatinib (IM) which is a Tyrosine Kinase Inhibitor (TKI), is the main treatment for patients with chronic myeloid leukemia (CML). Major molecular response (MMR) is used as therapeutic response. Resistance to IM may be caused by hypoxia which is regulated by hypoxia inducible factor (HIF) 2-α. The role of HIF2-α is currently not researched extensively. This study aimed to analyse the differences in HIF-2α expression between chronic phase CML patients that achieved MMR and those that did not achieve MMR.

Methods

This study used a cross-sectional method which analysed secondary data from whole blood samples in chronic phase CML patients aged 18-60 years that received hydroxyurea (HU) before IM, aged 18-60 years, received IM therapy for more than 12 months, and were willing to participate in the study. The exclusion criteria for this study were patients who were receiving IM at a dose of more than 400 mg/day. HIF-2α protein expression was examined using the enzyme-linked immunosorbent assay (ELISA) method. Differences between HIF-2α protein expression in groups that achieved MMR versus not achieving MMR was analysed using the Mann-Whitney test.

Results

A total of 79 subjects were obtained. The median HIF-2α was 90.56 pg/mg protein (3.01-4628.74). There was no statistically significant difference in expression of HIF-2α in the group that reached MMR and did not reach MMR, namely 123.45 pg/mg protein and 89.25 pg/mg protein respectively (p 0.718).

Conclusion

This study found no statistically significant difference between HIF-2α expression level and MMR achievement of chronic phase CML patients who received HU before IM therapy.

Real-world Imatinib Mesylate Treatment in Patients with Chronic Myeloid Leukemia: The Importance of Molecular Monitoring and the Early Molecular Response

INTRODUCTION

Chronic myeloid leukemia (CML) is a clonal myeloproliferative disorder characterized by the Philadelphia (Ph) chromosome. After the introduction of imatinib mesylate (IM) in 2000, the natural history of the disease changed. Data on the treatment of CML with IM are from randomized clinical trials. Establishing whether these results can be reproduced or if caution is needed when extrapolating data to the general population with CML is essential.

OBJECTIVES

To evaluate the molecular response (MR) in patients with chronic-phase CML (CML-CP) not included in clinical studies and correlate them with the responses obtained in clinical trials.

METHODS

Between January 2007 and January 2017, 227 patients newly diagnosed with CML-CP treated with IM as first-line treatment were included. This study is an observational, retrospective, and single-center study.

RESULTS

At a median follow-up time of 7.3 years, 60.3% of the 227 patients who started IM were still on IM. Early molecular response (EMR) at 3 and 6 months was achieved by 74.2% and 65%, respectively. The median time to a MMR was nine months. The MR4.0 and MR4.5 were 67.2% and 51.1%, respectively. The overall survival (OS), progression-free survival (PFS), and event-free survival (EFS) of the patients who exclusively used IM were 91%, 91%, and 85.1%, respectively.

CONCLUSION

The results presented are similar to those described in prospective and randomized trials, demonstrating that the outcomes are reproducible in the real world. EMR at 3 and 6 months reflects better long-term responses, including higher rates of deeper molecular responses. Considering treatment costs, the absence of literature evidence of an impact on overall survival demonstrated by first-line second-generation tyrosine kinase inhibitors (TKIs), and the global OS of 85.8%, imatinib mesylate (IM) is still an excellent therapeutic option.

[Survey and analysis of the concerns of patients with chronic myeloid leukemia in China in 2021]

Objective: To investigate the concerns of adult patients with chronic myeloid leukemia (CML) in the chronic phase receiving tyrosine kinase inhibitor (TKI) therapy in China. Methods: A cross-sectional questionnaire including 23 issues of concern was filled by patients with CML nationwide from August to September 2021. The results were compared with those from 2015 to 2016. Results: Data from 952 questionnaires were analyzed. The five most concerned issues were "TKI-related adverse effects and management" (66%) , "stopping TKI therapy" (46%) , "CML risk assessment" (46%) , "TKI dose reduction" (42%) , and "restrictions in daily life activities" (41%) . Compared with the results from 2015 to 2016, patients paid more attention to "TKI-related adverse effects and management" , "monitoring" , and "interpretation of laboratory reports" (all P<0.01) . Concerns of "TKI reimbursement policies" , "price reduction of TKIs" , and issues related to generic TKIs decreased significantly (all P<0.01) . Multivariate analysis showed that female patients (OR=1.8, 95% CI 1.4-2.5, P<0.001) , elderly patients (OR=1.0, 95% CI 1.0-1.0, P<0.001) , or patients with bachelor's degree or higher (OR=1.8, 95% CI 1.3-2.4, P<0.001) were more concerned with "TKI dose reduction" than others. Patients with a bachelor's degree or higher (OR=1.6, 95% CI 1.2-2.2, P=0.002) paid more attention to "CML risk assessment" , whereas those currently receiving a second- or third-generation TKI therapy (OR=1.9, 95% CI 1.3-2.6, P<0.001) were more concerned about "TKI resistance" . Conclusion: Patients with CML paid the most attention to "TKI-related adverse effects and management" , "stopping TKI therapy" , "CML risk assessment" , "TKI dose reduction" , and "restrictions in daily life activities" . Patients' sociodemographic covariates and treatment status were associated with their concerns.

Clear Improvement in Real-World Chronic Myeloid Leukemia Survival: A Comparison With Randomized Controlled Trials

Tyrosine kinase inhibitors (TKIs) have been improving the prognosis of patients with chronic myeloid leukemia (CML), but there are still large differences in survival among European countries. This raises questions on the added value of results from population-based studies, which use real-world data, compared to results of randomized controlled trials (RCTs) involving patients with CML. There are also questions about the extent of the findings on RCTs effectiveness for patients in the general population. We compare survival data extracted from our previous systematic review and meta-analysis of CML RCTs with the latest updated population-based survival data of EUROCARE-6, the widest collaborative study on cancer survival in Europe. The EUROCARE-6 CML survival estimated in patients (15–64 years) diagnosed in 2000–2006 vs. 2007–2013 revealed that the prognostic improvement highlighted by RCTs was confirmed in real-world settings, too. The study shows, evaluating for the first time all European regions, that the optimal outcome figures obtained in controlled settings for CML are also achievable (and indeed achieved) in real-world settings with prompt introduction of TKIs in daily clinical practice. However, some differences still persist, particularly in Eastern European countries, where overall survival values are lower than elsewhere, probably due to a delayed introduction of TKIs. Our results suggest an insufficient adoption of adequate protocols in daily clinical practice in those countries where CML survival values remain lower in real life than the values obtained in RCTs. New high-resolution population-based studies may help to identify failures in the clinical pathways followed there.

[Combination of socio-demographic and clinical co-variates for predicting treatment responses and outcomes in patients with chronic myeloid leukemia in the chronic phase]

Objective: To explore the impacts of socio-demographic and clinical co-variates on treatment responses and outcomes in patients with chronic myeloid leukemia in the chronic phase (CML-CP) receiving tyrosine kinase inhibitor (TKI) and identified the predictive models for them. Methods: Data of newly diagnosed adult patients with CML-CP receiving first-line TKI and having complete socio-demographic data and clinical information were reviewed. Cox model was used to identify the independent variables associated with complete cytogenetic response (CCyR) , major molecular response (MMR) , molecular response 4 (MR(4)) and molecular response 4.5 (MR(4.5)) , as well as failure-free survival (FFS) , progression-free survival (PFS) , overall survival (OS) and CML-related OS. Results: A total of 1414 CML-CP patients treated with first-line imatinib (n=1176) , nilotinib (n=170) or dasatinib (n=68) were reviewed. Median age was 40 (18-83) years and 873 patients (61.7% ) were males. Result of the multivariate analysis showed that lower educational level (P<0.001-0.070) and EUTOS long-term survival intermediate or high-risk (P<0.001-0.009) were significantly associated with lower cumulative incidences of CCyR, MMR, MR(4) and MR(4.5), as well as the inferior FFS, PFS, OS and CML-related OS. In addition, those who were males, from rural households, had white blood cells (WBC) ≥120×10(9)/L, hemoglobin (HGB) <115 g/L and treated with first-line imatinib had significantly lower cumulative incidences of cytogenetic and/or molecular responses. Being single, divorced or widowed, having, rural household registration, WBC≥120×10(9)/L, HGB<15 g/L, and comorbidity (ies) was significantly associated with inferior FFS, PFS, OS, and/or CML-related OS. Thereafter, the patients were classified into several subgroups using the socio-demographic characteristics and clinical variables by cytogenetic and molecular responses, treatment failure and disease progression, as well as overall survival and CML-related OS, respectively. There were significant differences in treatment responses and outcomes among the subgroups (P<0.001) . Conclusion: Except for clinical co-variates, socio-demographic co-variates significantly correlated with TKI treatment responses and outcomes in CML-CP patients. Models established by the combination of independent socio-demographic and clinical co-variates could effectively predict the responses and outcome.

Potential to Improve Therapy of Chronic Myeloid Leukemia (CML), Especially for Patients with Older Age: Incidence, Mortality, and Survival Rates of Patients with CML in Switzerland from 1995 to 2017

BACKGROUND

Tyrosine kinase inhibitors (TKI) substantially improved chronic myeloid leukemia (CML) prognosis. We aimed to describe time period- and age-dependent outcomes by reporting real-world data of CML patients from Switzerland.

METHODS

Population-based incidence, mortality, and survival were assessed for four different study periods and age groups on the basis of aggregated data from Swiss Cantonal Cancer Registries.

RESULTS

A total of 1552 new CML cases were reported from 1995 to 2017. The age-standardized rate (ASR) for the incidence remained stable, while the ASR for mortality decreased by 50-80%, resulting in a five-year RS from 36% to 74% over all four age groups. Importantly, for patients <60 years (yrs), the five-year RS increased only in earlier time periods up to 92%, whereas for older patients (+80 yrs), the five-year RS continued to increase later, however, reaching only 53% until 2017.

CONCLUSIONS

This is the first population-based study of CML patients in Switzerland confirming similar data compared to other population-based registries in Europe. The RS increased significantly in all age groups over the last decades after the establishment of TKI therapy. Interestingly, we found a more prominent increase in RS of patients with older age at later observation periods (45%) compared to patients at younger age (10%), implicating a greater benefit from TKI treatment for elderly occurring with delay since the establishment of TKI therapy. Our findings suggest more potential to improve CML therapy, especially for older patients.

[Treatment status of tyrosine kinase inhibitors in Chinese patients with chronic myeloid leukemia in 2020]

目的

调查中国慢性髓性白血病（CML）患者的治疗现状。

方法

横断面研究，2020年4月末至5月中旬，以填写调研问卷的形式在全国范围内调研CML患者，分析酪氨酸激酶抑制剂（TKI）一线选择、目前用药、药物转换和获得主要分子学反应（MMR）的比例及其影响因素。

结果

2933份来自全国31个省市自治区CML受访者的问卷可供分析，男性1683例（57.4％），中位年龄38（16～87）岁。一线选择：伊马替尼2481例（84.6％），原创性新药（原研药）1803例（61.5％）。填写问卷时用药：伊马替尼1765例（60.2％），原研药1791例（61.1％）。共1185例（40.4％）受访者曾经历TKI药物转换。1944例初发慢性期受访者TKI中位治疗45（3～227）个月，1417例（72.9％）获得≥MMR的疗效。多因素分析显示，城镇户籍（OR＝0.6，95％CI 0.5～0.8，P<0.001）、≥大学学历（OR＝0.5，95％CI 0.4～0.7，P<0.001）和进展期（OR＝0.5，95％CI 0.3～0.8，P＝0.001）受访者更少首选仿制TKI，而来自中部地区受访者比东部地区更多首选国产仿制TKI（OR＝1.7，95％CI 1.4～2.0，P<0.001）。进展期受访者更多首选二代TKI（OR＝5.4，95％CI 3.6～8.2，P<0.001），≥60岁受访者更少首选二代TKI（OR＝0.4，95％CI 0.2～0.7，P＝0.002）。诊断时处于进展期（OR＝2.2，95％CI 1.6～3.2，P<0.001）、首选伊马替尼（OR＝2.0，95％CI 1.6～2.6，P<0.001）、首选国产仿制药（OR＝1.3，95％CI 1.1～1.6，P＝0.002）、诊断距开始TKI治疗的时间更长（OR＝1.2，95％CI 1.1～1.2，P<0.001）和服用TKI的时间更长（OR＝1.1，95％CI 1.0～1.1，P<0.001）与药物转换比例增高显著相关。城镇户籍（OR＝0.7，95％CI 0.6～0.8，P<0.001）、获≥MMR（OR＝0.6，95％CI 0.5～0.8，P<0.001）和疗效未知（OR＝0.7，95％CI 0.6～0.9，P＝0.003）与药物转换比例低显著相关。女性（OR＝1.4，95％CI 1.1～1.7，P＝0.003）、城镇户籍（OR＝1.6，95％CI 1.3～2.0，P<0.001）、初始服用伊马替尼（OR＝1.4，95％CI 1.1～1.9，P＝0.016）和TKI治疗时间更长（OR＝1.2，95％CI 1.2～1.3，P<0.001）与获得≥MMR显著相关，而年龄≥60岁（OR＝0.7，95％CI 0.4～1.0，P＝0.047）和药物转换（OR＝0.6，95％CI 0.5～0.7，P<0.001）与未获得MMR显著相关。

结论

截至2020年，中国CML患者中大多数首选并持续服用伊马替尼，半数以上服用原研药。社会人口学特征和疾病分期影响了患者的TKI选择、药物转换和治疗反应。

Impact of socio-demographic co-variates on prognosis, tyrosine kinase-inhibitor use and outcomes in persons with newly-diagnosed chronic myeloid leukaemia

PURPOSE

Define the impact of socio-demographic co-variates on outcomes of persons with newly-diagnosed chronic phase chronic myeloid leukaemia (CML).

METHODS

Data of 961 consecutive subjects with newly-diagnosed CML were integrated for these outcomes in multi-variable Cox regression analyses after adjusting for confounders and interactions.

RESULTS

Elder age was associated with less use of a 2nd generation TKI as initial therapy. Household registration, comorbidity(ies) and education level were associated with use of a generic rather than branded TKI as initial therapy. Subjects with lower education level were more likely to be diagnosed with CML because of leukaemia-related symptoms. Rural registration and lower education level were also associated with a greater likelihood of switching TKI-therapy. Lower education level was associated with lower likelihood of achieving MMR [HR = 0.8 (0.7, 0.9), p = 0.002], MR^4.5 [HR = 0.8 (0.7, 1.0), p = 0.055], and poor FFS [HR = 1.7 (1.3, 2.5); p < 0.001], PFS [HR = 2.0 (1.1, 5.0); p = 0.014], CML-related survival [HR = 2.5 (1.0, 10.0); p = 0.060] and survival [HR = 2.5 (1.0, 10.0); p = 0.043]. Males had lower rates of MMR and MR^4.5 and worse FFS, but not survival compared with females. Being married was associated with a higher rate of MR^4.5, fewer failures, progressions, and deaths.

CONCLUSION

Socio-demographic co-variates have a strong impact on therapy choice and responses in persons with newly-diagnosed CML, including circumstances of diagnosis, risk category and prognosis, use of initial TKI, switching TKIs, response to TKI-therapy, and outcomes.

Global, Regional, and National Burden of Chronic Myeloid Leukemia, 1990-2017: A Systematic Analysis for the Global Burden of Disease Study 2017

Background

With the advent of tyrosine kinase inhibitors (TKIs), the prognosis of chronic myeloid leukemia (CML) seems to have dramatically improved over the last two decades. Accurate information of the global burden of CML is critical for direct health policy and healthcare resource allocation in the era of high-cost TKI therapy.

Objective

This study aimed to evaluate the health burden of CML at global, regional, and national levels from 1990 to 2017.

Methods

We collected data of CML between 1990 and 2017 from the Global Burden of Disease (GBD) study 2017 including, annual incidence, disease-related mortality, and disability-adjusted life-years (DALY), and the corresponding age-standardized rates (ASRs). To summarize the results, countries were categorized by sociodemographic index (SDI) quintiles and 21 GBD regions.

Results

In 2017, an estimated 34,179 [95% Uncertainty Interval (UI), 31,516–36,714) incident cases of CML were recorded, and 24,054 (95%UI, 22,233–26,072) CML-related deaths were reported worldwide. Both, the age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) steadily decreased from 1990 to 2017, with estimated annual percentage changes (EAPCs) of −2.39 (95%UI, −8.13–3.71) and −2.74 (95%UI, −9.31–4.31), respectively. The global incidence and mortality of CML in males were higher than that in females. The ASRs varied substantially across regions, with the highest burden in Andean Latin America, Central Sub-Saharan Africa, and Southeast Asia. Besides, the ASRs decreased most obviously in the high-SDI regions compared to non-high-SDI regions. Moreover, the lower the SDI, the higher was the proportion of deaths in the younger age groups.

Conclusion

Despite the decreasing trends of ASRs of CML from 1990 to 2017, the health-related burden of CML remains a challenge for the low-SDI regions. These findings highlight that appropriate strategies should be adopted in low-SDI countries to reduce the ASRs of CML.

Pregnancy outcomes of women whom spouse fathered children after tyrosine kinase inhibitor therapy for chronic myeloid leukemia: A systematic review

INTRODUCTION

The introduction of tyrosine kinase inhibitors (TKIs) has revolutionized the therapy of chronic myeloid leukemia (CML). Although the efficacy of TKIs is beyond dispute, conception-related safety issues are still waiting to be explored, particularly in males. This systematic review aimed to summarize all available evidence on pregnancy outcomes of female spouses of male CML patients who fathered children after TKI treatment for CML.

METHODS

We performed a systematic search in seven electronic databases for studies that reported on male CML patients who did or did not discontinue TKI treatment before conceiving, and the pregnancy outcomes of their female spouse are available. The search centered on the TKI era (from 2001 onward) without any other language or study design restrictions.

RESULTS

Out of a total of 38 potentially eligible papers, 27 non-overlapping study cohorts were analyzed. All were descriptive studies (case or case series studies). Altogether, 428 pregnancies from 374 fathers conceived without treatment discontinuation, 400 of which (93.5%) ended up in a live birth. A total of ten offspring with a malformation (2.5%) were reported: six with imatinib (of 313 live births, 1.9%), two with nilotinib (of 26 live births, 7.7%), one with dasatinib (of 43 live births, 2.3%), and none with bosutinib (of 12 live births). Data on CML status were scarcely reported. Only nine pregnancies (from nine males) and no malformation were reported in males who discontinued TKI treatment before conception.

CONCLUSION

Malformations affected, on average 2.5% of live births from fathers who did not discontinue TKI treatment before conception, which is comparable with the rate of malformations in the general population. Large-scale studies with representative samples are awaited to confirm our results.

Ponatinib and other CML Tyrosine Kinase Inhibitors in Thrombosis

Abl1 kinase has important biological roles. The Bcr-Abl1 fusion protein creates undesired kinase activity and is pathogenic in 95% of chronic myeloid leukemia (CML) and 30% of acute lymphoblastic leukemia (ALL) patients. Targeted therapies to these diseases are tyrosine kinase inhibitors. The extent of a tyrosine kinase inhibitor’s targets determines the degree of biologic effects of the agent that may influence the well-being of the patient. This fact is especially true with tyrosine kinase inhibitor effects on the cardiovascular system. Thirty-one percent of ponatinib-treated patients, the tyrosine kinase inhibitor with the broadest inhibitory spectrum, have thrombosis associated with its use. Recent experimental investigations have indicated the mechanisms of ponatinib-associated thrombosis. Further, an antidote to ponatinib is in development by re-purposing an FDA-approved medication.

Epidemiology of the classical myeloproliferative neoplasms: The four corners of an expansive and complex map

The classical myeloproliferative neoplasms (MPNs), specifically chronic myeloid leukemia (CML), polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF), represent clonal myeloid disorders whose pathogenesis is driven by well-defined molecular abnormalities. In this comprehensive review, we summarize the epidemiological literature and present our own analysis of the most recent the Surveillance, Epidemiology, and End Results (SEER) program data through 2016. Older age and male gender are known risk factors for MPNs, but the potential etiological role of other variables is less established. The incidences of CML, PV, and ET are relatively similar at 1.0-2.0 per 100,000 person-years in the United States, while PMF is rarer with an incidence of 0.3 per 100,000 person-years. The availability of tyrosine kinase inhibitor therapy has dramatically improved CML patient outcomes and yield a life expectancy similar to the general population. Patients with PV or ET have better survival than PMF patients.

Experiences of living with chronic myeloid leukaemia and adhering to tyrosine kinase inhibitors: A thematic synthesis of qualitative studies

PURPOSE

To investigate the experiences of adults living with chronic myeloid leukaemia and treated with tyrosine kinase inhibitors, with particular reference to factors influencing adherence.

METHODS

A thematic synthesis of all published qualitative studies examining adults with chronic myeloid leukaemia, receiving tyrosine kinase inhibitors. Eligible publications were identified by searching five electronic databases using defined criteria. The synthesis involved complete coding of extracted data and inductive theme development.

RESULTS

Nine studies were included and three overarching themes defined. Overarching themes were: 1) Disease impacts whole life; 2) Disease management strategies; and 3) Valued aspects of care. Side-effects often required physical and psychological adaptation. Patients developed individual decision-making processes to promote adherence and manage side effects. Unintentional non-adherence occurred due to forgetfulness and system failures. Intentional omission also occurred, which together with side effects, was unlikely to be reported to healthcare professionals (HCPs). HCP reassurance about missed doses could reinforce non-adherence. Information needs varied over time and between individuals. Knowledge among patients about treatment was often lacking and could lead to misunderstandings. Patients valued psychological support from HCPs and suggested an individualised approach, facilitating discussion of symptoms, adherence and their perspectives about living with chronic myeloid leukaemia, would improve care.

CONCLUSIONS

Patients with chronic myeloid leukaemia experienced significant side-effects from treatment and changes to their psychological and physical well-being. They developed their own strategies to manage their disease and treatment. This should be recognised in interventions to improve education, support and the delivery of care that is compassionate and adequately resourced.

Comparable Efficacy and Safety of Generic Imatinib and Branded Imatinib in Patients With Newly Diagnosed Chronic Myeloid Leukemia With a Consideration of Socioeconomic Characteristics: A Retrospective Study From a Single Center

INTRODUCTION

To compare the efficacy and safety of generic and branded imatinib in adults with newly diagnosed chronic myeloid leukemia in the chronic phase (CML-CP), we retrospectively reviewed data from patients CML-CP who received generic or branded imatinib.

PATIENTS AND METHODS

A propensity score matching (PSM) study was performed. A Cox regression model was used to identify factors associated with responses and outcomes.

RESULTS

Four hundred forty-two adults receiving generic imatinib (n = 236) or Glivec (Novartis, Basel, Switzerland; n = 206) were included. There were more patients with rural household registration (P < .001), lower education level (P < .001), divorced or widowed status (P = .009), higher white blood cell counts (P = .019), splenomegaly (P < .001), and longer intervals from diagnosis to imatinib initiation (P = .033) in the generic cohort. During the follow-up, there was no significant difference between the 2 cohorts in the 4-year probabilities of achieving a complete cytogenetic response (97.0% vs. 97.3%; P = .736), major molecular response (87.8% vs. 90.1%; P = .113), and molecular response^4.5 (32.5% vs. 38.8%; P = .186), as well as failure-free survival (77.3% vs. 81.4%; P = .313), progression-free survival (94.4% vs. 95.8%; P = .489), and overall survival (96.8% vs. 98.3%; P = .088). Multivariate analyses showed that the drug type was not associated with responses and outcomes. After the PSM procedure, 177 pairs of patients with comparable baseline characteristics were reanalyzed. Multivariate analyses confirmed that generic or branded imatinib used as first-line therapy was not associated with either responses or outcomes.

CONCLUSION

Sociodemographic characteristics might influence the tyrosine kinase inhibitor that patients chose. Generic and branded imatinib as first-line therapy had comparable efficacy and safety in CML-CP patients.

[Comparison of the efficacy and safety of Chinese generic imatinib and branded imatinib in patients with chronic myeloid leukemia in consideration of demographic characteristics]

目的

比较国产和原研伊马替尼一线治疗慢性髓性白血病慢性期（CML-CP）患者的有效性和安全性；探索服用原研伊马替尼获得完全细胞遗传学反应（CCyR）后转换为国产伊马替尼的患者疾病的稳定性和不良反应的变化。

方法

①一线治疗组：回顾性收集和分析2013年10月至2018年8月期间，接受国产仿制伊马替尼（商品名昕维®）或进口原研伊马替尼（商品名格列卫®）作为一线治疗并定期随访、监测的CML-CP连续病例。②转换组：回顾性收集和分析2006年12月至2016年9月期间，接受原研伊马替尼至少获得CCyR后转换为国产仿制伊马替尼治疗的CML-CP连续病例。

结果

①一线治疗组：共409例（国产伊马替尼201例，原研伊马替尼208例）患者入组，中位年龄42（18~83）岁。国产和原研组患者人口学特征差异具有统计学意义：国产伊马替尼组患者中受教育水平更低（P<0.001）、离异或丧偶者比例更高（P=0.004）、农村户籍者比例更高（P<0.001）。两组年龄、性别、Sokal危险度评分、WBC和HGB水平的差异无统计学意义。中位随访25（3~62）个月，国产伊马替尼组和原研伊马替尼组的3年CCyR、主要分子学反应（MMR）、分子学反应4.0（MR4.0）和分子学反应4.5（MR4.5）的累积获得率差异均无统计学意义（97.5%对94.5%，P=0.592；84.3%对93.1%，P=0.208；42.7%对41.7%，P=0.277；25.4%对33.0%，P=0.306），3年无失败生存（FFS）率、无进展生存（PFS）率和总生存（OS）率差异亦无统计学意义（76.7%对81.0%，P=0.448；91.8%对96.3%，P=0.325；95.8%对98.5%，P=0.167）。多因素分析显示，TKI类型不影响患者的治疗反应（CCyR、MMR、MR4.0和MR4.5累积获得率）及结局（FFS、PFS和OS）。两组不良反应发生率也相似。②转换组：共39例患者入组，中位年龄42（23~80）岁，于原研伊马替尼中位治疗38（8~114）个月后换为国产伊马替尼，换药后中位随访39（6~63）个月，23例（58.9%）患者分子学反应维持原来水平，12例（30.8%）分子学反应改善。新发药物不良反应均可耐受。

结论

人口学特征影响CML-CP患者的用药选择。在规范的监测和管理下，国产与原研伊马替尼一线治疗CML-CP患者的有效性和安全性相当。对于接受原研伊马替尼后获得稳定治疗反应的患者，可有效、安全地转换为国产伊马替尼。

Cost Effectiveness of the Third-Generation Tyrosine Kinase Inhibitor (TKI) Ponatinib, vs. Second-Generation TKIs or Stem Cell Transplant, as Third-Line Treatment for Chronic-Phase Chronic Myeloid Leukemia

BACKGROUND AND OBJECTIVES

Third-line treatment options for patients with chronic-phase chronic myeloid leukemia include tyrosine kinase inhibitors and allogeneic hematopoietic stem cell transplantation (alloHSCT). The objective of this study was to develop a Markov model with a lifetime time horizon to assess the cost effectiveness of ponatinib for third-line chronic-phase chronic myeloid leukemia vs. second-generation tyrosine kinase inhibitors (dasatinib, nilotinib, bosutinib) or alloHSCT from the public healthcare system perspective in Germany, Sweden, and Canada.

METHODS

Clinical outcomes were derived from the literature, and from patient-level data (phase II PACE trial) for ponatinib. Resource use included drugs, alloHSCT, monitoring and follow-up, adverse events, and end-of-life care; costs were based on national tariffs. Quality-adjusted life-years (QALYs) were calculated using chronic myeloid leukemia health-state utilities from an international time-trade-off study. Costs and benefits were discounted at 3% per annum for Germany and Sweden, and 5% for Canada.

RESULTS

Ponatinib yielded more discounted QALYs than any second-generation tyrosine kinase inhibitor/alloHSCT in all three countries, mainly owing to better response rates and longer durations of response. Incremental cost-effectiveness ratios for ponatinib vs. second-generation tyrosine kinase inhibitors were US$21,543-37,755/QALY in Germany, $24,018-38,227/QALY in Sweden, and $43,001-58,515/QALY in Canada. Ponatinib was dominant over alloHSCT in Germany, while incremental cost-effectiveness ratios for ponatinib vs. alloHSCT in Sweden and Canada were $715/QALY and $31,534/QALY, respectively.

CONCLUSIONS

Ponatinib may improve outcomes (mainly because of higher response rates and longer response durations) at an acceptable cost level compared with other third-line treatment options for chronic-phase chronic myeloid leukemia in Germany, Sweden, and Canada; however, the lack of an indirect comparison is a limitation of our study.

Incidence and spatial distribution of Chronic Myeloid Leukemia by regions of economic development in the state of Pernambuco, Brazil

Background

The establishment of regional development poles in the State of Pernambuco, Brazil was characterized by industrial expansion and consequent concerns about the increase in the occurrence of diseases, specifically those having long latency periods, as is the case of Chronic Myeloid Leukemia.

Methods

The study included 367 patients diagnosed with Chronic Myeloid Leukemia over a ten-year period at a reference treatment center. Records of patient charts and the TerraView software were used, respectively, for data collection and geographic mapping of the cases from the twelve established State development regions.

Results

A total incidence of 3.4 cases per 100,000 inhabitants was found, with a predominance of the disease among males, a median age of 47 years, a mestizo ethnicity, with elementary schooling and residence in urban area. Microregional incidence varied, but there was no significant variation in numbers over the years, and no relevant socio-environmental determinants were identified.

Conclusion

The present study determined the incidence and characterized the spatial distribution of Chronic Myeloid Leukemia cases over a decade in a northeastern Brazilian state. The variation in the incidence rate by region of development is compatible with a homogeneous distribution of the cases. The work is a baseline study to be used for present and future analyses of the impact of the state economic development poles and the occurrence of this chronic malignant disease.

Tyrosine kinase inhibitor interruptions, discontinuations and switching in patients with chronic-phase chronic myeloid leukemia in routine clinical practice: SIMPLICITY

SIMPLICITY (NCT01244750) is an observational study exploring tyrosine kinase inhibitor (TKI) use and management patterns in patients with chronic phase-chronic myeloid leukemia in the US and Europe in routine clinical practice. Herein we describe interruptions, discontinuations and switching of TKI therapy during the initial 2 years of treatment among 1121 patients prospectively enrolled between October 1, 2010 and March 7, 2017. Patient characteristics were broadly similar between the imatinib (n = 370), dasatinib (n = 376), and nilotinib (n = 375) cohorts. Treatment interruptions occurred in 16.4% (year 1) and 4.0% (year 2) of patients, mainly attributed to hematologic intolerances. Treatment discontinuations occurred in 21.8% (year 1) and 10.2% (year 2) of patients, with the highest rate within the first 3 months for intolerance. Switching of TKI was seen in 17.8% (year 1) and 9.5% (year 2) of patients. Significant associations were found between TKI switching and female gender (year 1), age ≥65 years at diagnosis (year 2) and treatment with imatinib (year 2). Intolerance was the most common reason given for patients discontinuing and for switching TKI therapy; however resistance was also cited. Lack of response monitoring in routine clinical practice may have resulted in lower identification of resistance in this dataset. Data from SIMPLICITY suggest that, in routine clinical practice, intolerance and resistance to TKIs influence decisions to change treatment. Changes in TKI therapy are frequent, with nearly a third of patients discontinuing their first-line TKI.

Efficacy and Safety of Generic Dasatinib as a Second-line Treatment for Patients with Chronic Myeloid Leukemia: a Multicenter Retrospective Study in Hubei Province, China

Dasatinib is a second-generation tyrosine kinase inhibitor (TKI) and it could be used as a second-line treatment for patients with chronic myeloid leukemia (CML). Yinishu, a generic dasatinib made in China, was approved by the China Food and Drug Administration in 2013 and it costs much less than the patented dasatinib SPRYCEL. The present study aimed to examine the efficacy and safety of Yinishu as a second-line treatment for CML by comparing the baseline clinical characteristics, rates of adverse events and efficacy between Yinishu and SPRYCEL groups. The results showed that there were no significant differences in the rates of optimal response between Yinishu and SPRYCEL for patients who started second-line treatment because of treatment failure. For patients who started second-line treatment because of intolerance of first-line treatment, their levels of BCR-ABL1/ABL1 on the international scale (BCR-ABL^IS) was maintained very low throughout the course of Yinishu treatment. Drug-related adverse events occurred with the same frequency in these two groups. It was confirmed that Yinishu was effective and safe as a secondline treatment for CML patients. Yinishu may be more suitable for patients who are economically unable to pay for the patented dasatinib SPRYCEL.

The impact of introducing tyrosine kinase inhibitors on chronic myeloid leukemia survival: a population-based study

BACKGROUND

Chronic myeloid leukemia is associated with a BCR/ABL oncoprotein inhibited by imatinib mesylate, the first tyrosine kinase inhibitor. Although experimental studies have clearly demonstrated the efficacy of imatinib, up-to-date data on its effectiveness at the population level are limited. Our study aims to assess the change in disease-specific survival for chronic myeloid leukemia after introducing tyrosine kinase inhibitors in first-line treatment.

METHODS

This study analyzed data from two population-based cancer registries in Italy. Disease-specific survival for chronic myeloid leukemia cases diagnosed before and after the introduction of tyrosine kinase inhibitors (February 2002) were calculated up to 10 years. Hazard ratios were calculated using Cox regression models adjusted for sex, age at diagnosis and residency. An interrupted time series analysis was also performed.

RESULTS

Between 1996 and 2012, 357 new cases of chronic myeloid leukemia were diagnosed (standardized incidence rate of 1.2 per 100,000 residents), quite constant throughout the period. The interrupted time series analysis showed a gain of 40.4% in 5 years of disease-specific survival for chronic myeloid leukemia (from 47.3, 95%CI 38.5-55.5% to 80.8%, 95%CI 74.5-85.8%) after the introduction of tyrosine kinase inhibitors. The hazard ratio was 0.36 (95%CI 0.25-0.52) for cases diagnosed after tyrosine kinase inhibitor introduction, with differences per age at diagnosis: <65yo 0.17 (95%CI 0.08-0.39), >74yo 0.41 (95%CI 0.23-0.73). An improvement in survival (hazard ratio 0.66, 95%CI 0.36-1.20) was also observed in cases diagnosed before, and alive at, tyrosine kinase inhibitors introduction.

CONCLUSIONS

Tyrosine kinase inhibitors increased disease-specific survival both for new and prevalent chronic myeloid leukemia cases. The effectiveness was similar to that observed in trials only in patients ages 65 years or younger.

Socio-economic patterning in early mortality of patients aged 0-49 years diagnosed with primary bone cancer in Great Britain, 1985-2008

BACKGROUND

Studies have shown marked improvements in survival between 1981 and 2000 for Ewing sarcoma patients but not for osteosarcoma. This study aimed to explore socio-economic patterning in early mortality rates for both tumours.

PROCEDURE

The study analysed all 2432 osteosarcoma and 1619 Ewing sarcoma cases, aged 0-49 years, diagnosed in Great Britain 1985-2008 and followed to 31/12/2009. Logistic regression models were used to calculate risk of dying within three months, six months, one year, three years and five years after diagnosis. Associations with Townsend deprivation score and its components were examined at small-area level. Urban/rural status was studied at larger regional level.

RESULTS

For osteosarcoma, after age adjustment, mortality at three months, six months and one year was associated with higher area unemployment, OR = 1.05 (95% CI 1.00, 1.10), OR = 1.04 (95% CI 1.01, 1.08) and OR = 1.04 (95% CI 1.02, 1.06) respectively per 1% increase in unemployment. Mortality at six months was associated with greater household non-car ownership, OR = 1.02 (95% CI 1.00, 1.03). For Ewing sarcoma, there were no significant associations between mortality and overall Townsend score, nor its components for any time period. For both tumours increasing mortality was associated with less urban and more remote rural areas.

CONCLUSIONS

This study found that for osteosarcoma, early mortality was associated with residence at diagnosis in areas of higher unemployment, suggesting risk of early death may be socio-economically determined. For both tumours, distance from urban centres may lead to greater risk of early death.

Emergency admission and survival from aggressive non-Hodgkin lymphoma: A report from the UK's population-based Haematological Malignancy Research Network

Background

Non-Hodgkin lymphoma (NHL) is often diagnosed after emergency presentation, a route associated with poor survival and an indicator of diagnostic delay. Accounting for around half of all NHLs, diffuse large B-cell lymphoma (DLBCL) is of particular interest since although it is potentially curable with standardised chemotherapy it can be challenging to identify at an early stage in the primary care setting.

Patients and methods

Set within a socio-demographically representative United Kingdom population of around 4 million people, data are from an established patient cohort. This report includes all patients (≥18 years) diagnosed with DLBCL 2004–2011 (n = 1660). Emergency admissions were identified via linkage to Hospital Episode Statistics using standard methods, and survival was examined using proportional hazards regression.

Results

Two out of every five patients were diagnosed following an emergency admission, and this was associated with advanced disease and poor survival (p < 0.001). Among the 80% of patients treated with curative chemotherapy, survival discrepancies emerged at the point of diagnosis; the adjusted hazard ratio (emergency versus non-emergency) at one month being 4.0 (95% confidence interval 1.9–8.2). No lasting impact was evident in patients who survived for 12 months or more.

Conclusion

Emergency presentation impacts negatively on DLBCL survival; patients presenting via this route have significantly poorer outcomes than patients with similar clinical characteristics who present via other routes.

•

Emergency presentation has a marked impact on non-Hodgkin lymphoma (NHL) survival, not explained by disease stage or treatment.

•

Emergency presentation among patients with diffuse large B-cell lymphoma is 50% higher in the United Kingdom than national data on non-Hodgkin lymphomas suggest.

•

Survival benefits from earlier diagnosis of potentially curable NHLs could exceed that of new treatments.

A Multi-centric Bioequivalence Trial in Ph+ Chronic Myeloid Leukemia Patients to Assess Bioequivalence and Safety Evaluation of Generic Imatinib Mesylate 400 mg Tablets

PURPOSE

This study was designed to characterize the pharmacokinetic profile and to assess bioequivalence of the sponsor's test formulation (imatinib mesylate 400 mg tablets) with an innovator product (Gleevec 400 mg tablets, Novartis Pharmaceuticals) under fed conditions, in adult patients of Philadelphia chromosome positive chronic myeloid leukemia (Ph+ CML) stabilized on imatinib mesylate 400 mg. In addition, the aim of this study was to monitor the safety profile of investigational medicinal products (IMPs).

MATERIALS AND METHODS

A multicenter, randomized, open label, two-period, crossover, single dose bioequivalence study was designed for conduct under fed conditions in 42 adult Ph+ CML patients already stabilized on imatinib 400 mg tablets. Pharmacokinetic parameters Tmax, Cmax, and AUC0-24 were calculated using a non-compartmental model on validated WinNonlin software. Validated SAS software was used for statistical evaluation of data. The safety profile of investigational products was monitored during the course of study by applying a clinical process for recording observed untoward effects postadministration of investigational products.

RESULTS

The 90% confidence intervals for the test/reference mean ratios of the ln-transformed PK variables Cmax (99.0%) and AUC0-24 (99.2%) were within an acceptable range of 80%-125%, as per bioequivalence assumptions. Both formulations were well tolerated after oral administration of IMPs.

CONCLUSION

The test product was found to be bioequivalent and safe, and thus can be used interchangeably in clinical practice.

Estimating the prevalence of hematological malignancies and precursor conditions using data from Haematological Malignancy Research Network (HMRN)

Objective

Well-established cancer registries that routinely link to death registrations can estimate prevalence directly by counting patients alive at a particular point in time (observed prevalence). Such direct methods can only provide prevalence for the years over which the registry has been operational. Time-defined estimates, including 5- and 10-year prevalence, may however underestimate the total cancer burden, and compared with other cancers, there is a lack of accurate information on the total prevalence of hematological malignancy subtypes. Accordingly, we aimed to estimate prevalence (observed and total prevalence) of hematological malignancies and precursor conditions by clinically meaningful subtypes using data from the UK’s specialist population-based register, the Haematological Malignancy Research Network (www.hmrn.org).

Methods

Observed and total prevalences were estimated from 15,810 new diagnoses of hematological malignancies from 2004 to 2011 and followed up to the 31 August 2011 (index data). Observed prevalence was calculated by the counting method, and a method based on modelling incidence and survival was used to estimate total prevalence. Estimates were made according to current disease classification for the HMRN region and for the UK.

Results

The overall observed and total prevalence rates were 281.9 and 548.8 per 100,000, respectively; the total number of observed and total prevalent cases in the UK was estimated as 165,841 and 327,818 cases, as expected variation existed by disease subtype reflecting the heterogeneity in underlying disease incidence, survival and age distribution of hematological cancers.

Conclusions

This study demonstrates the importance of estimating ‘total’ prevalence rather than ‘observed’ prevalence by current disease classification (ICD-O-3), particularly for subtypes that have a more indolent nature and for those that are curable. Importantly, these analyses demonstrate that relying on observed prevalence alone would result in a significant underestimation of the relative burden of some subtypes. While many of these cases may be considered cured and no longer being actively treated, people in this survivorship phase may have long-term medical needs and accordingly, it is important to provide accurate counts to allow for healthcare planning.

Myeloid malignancies in the real-world: Occurrence, progression and survival in the UK's population-based Haematological Malignancy Research Network 2004-15

BACKGROUND

Population-based information on cancer incidence, prevalence and outcome are required to inform clinical practice and research; but contemporary data are lacking for many myeloid malignancy subtypes.

METHODS

Set within a socio-demographically representative UK population of ∼4 million, myeloid malignancy data (N=5231 diagnoses) are from an established patient cohort. Information on incidence, survival (relative & overall), transformation/progression, and prevalence is presented for >20 subtypes.

RESULTS

The median diagnostic age was 72.4years (InterQuartile Range 61.6-80.2), but there was considerable subtype heterogeneity, particularly among the acute myeloid leukaemias (AML) where medians ranged from 20.3 (IQR 13.9-43.8) for AML 11q23 through to 73.7 (IQR 57.3-79.1) for AML with no recurrent genetic changes. Five-year Relative Survival (RS) estimates varied hugely; from <5% for aggressive entities like therapy-related AML (2.6%, 95% Confidence Interval 0.4-9.0) to >85% for indolent/treatable conditions like chronic myeloid leukaemia (89.8%, 95% CI 84.0-93.6). With a couple of notable exceptions, males experienced higher rates and worse survival than females: the age-standardized incidence rates of several conditions was 2-4 higher in males than females, and the 5-year RS for all subtypes combined was 48.8% (95% CI 46.5-51.2) and 60.4% (95% CI 57.7-62.9) for males and females respectively. During follow-up (potential minimum 2 years and maximum 11years) myelodysplastic syndrome (MDS) progression to AML ranged from 25% for refractory anaemia with excess blasts through to 5% for refractory anaemia with ring sideroblasts: the median interval between MDS and AML diagnosis was 9.0 months (IQR 4.8-17.4months).

CONCLUSIONS

The marked incidence and outcome variations seen by subtype, sex and age, confirm the requirement for "real-world" longitudinal data to inform aetiological hypotheses, healthcare planning, and future monitoring of therapeutic change. Several challenges for routine cancer registration were identified, including the need to link more effectively to diagnostic and clinical data sources, and to review policies on the recording of progressions and transformations.

Improved survival boosts the prevalence of chronic myeloid leukemia: predictions from a population-based study

PURPOSE

Due to prolonged survival, there will be many more chronic myeloid leukemia (CML) patients alive in the future. The aims of this work were to estimate the current prevalence of CML by using routine data and to project future patient numbers in Germany.

METHODS

Data were available for about 10.5 million people in the statutory health insurance system in Bavaria for the years 2008-2013. Survival rates were adapted from two recent publications.

RESULTS

The mean estimated age-standardized (Old European Standard Population) incidence rates per 100,000 inhabitants were 1.300 and 1.768 for women and men. Based on the population data, we estimated a total number of about 9000 CML patients in Germany for 2012. We expect the number of CML patients to increase further until at least 2040-2050 with a maximum of more than 20,000 CML patients as the most probable scenario.

CONCLUSIONS

Using a restrictive definition for case patients, we do not think that there is much overestimation. As a consequence of this considerable increase of the prevalence of CML the burden for the health care system will increase with respect to costs and medical care needed. The procedure presented here allows to estimate the expected number of CML patients in other countries, too.

Chronic myeloid leukemia incidence, survival and accessibility of tyrosine kinase inhibitors: a report from population-based Lithuanian haematological disease registry 2000-2013

BACKGROUND

Currently available chronic myeloid leukaemia (CML) survival reports have originated from more affluent countries. Herein we report the entire country data on incidence and survival of CML, as well as penetrance of tyrosine kinase inhibitors (TKIs) in Lithuania.

METHODS

We analyzed all patients (N = 601) from the national haematological disease monitoring system who were diagnosed with CML between 2000 and 2013. Crude (CR) and age-standardized (weighted) (ASW(R)) incidence and mortality rates, as well as 1-, 5-, and 10-year relative survival rates (RSR) were calculated. Information on TKI penetration is also reported.

RESULTS

Throughout the entire 2000-2013 period the median age at diagnosis of CML patients was 62 years. The respective incidence and mortality CRs were 1.28 and 0.78, both characterized by decreasing trends over the observation period. A 5-year RSR increased from 0.33 [95 % CI, 0.27-0.40] in 2000-2004 to 0.55 [95 % CI, 0.47-0.63] in 2005-2009. However, the respective 5-year RSRs for patients aged 65-74 and ≥75 were only 0.33 [95 % CI, 0.24-0.42] and 0.18 [95 % CI 0.07-0.23] during the entire study period. TKI penetrance for CML patients grew from 1.5 % in 2000-2004 to 30.6 % in 2005-2009 and 69.1 % in 2010-2013. TKI penetrance was low in the older age groups (60 % for the 65-74 and 19 % for the ≥75 patient group, in 2010-2013).

CONCLUSION

Relative CML survival in Lithuania steadily improved and paralleled the increase in TKI treatment availability. Patients above 64 years rarely received TKIs and their relative survival remained low throughout the observation period. The latency of TKI availability may have influenced the survival trends.

Impact of age and socioeconomic status on treatment and survival from aggressive lymphoma: a UK population-based study of diffuse large B-cell lymphoma

AIM

To examine the influence of patient's age and socio-economic status on treatment and outcome in diffuse large B-cell lymphoma (DLBCL); an aggressive curable cancer, with an incidence rate that increases markedly with age but varies little with socio-economic status.

METHODS

Set within a representative UK population of around 4 million, data are from an established patient cohort. This report includes all patients (≥ 18 years) newly diagnosed with DLBCL 2004-2012, with follow-up to February 2015.

RESULTS

Of the 2137 patients (median age 70.2 years) diagnosed with denovo DLBCL, 1709 (80%) were treated curatively/intensively and 1161(54.3%) died during follow-up. Five-year overall and relative survival (RS) estimates were 46.2% (95% CI 44.0-48.4%) and 54.6% (52.1%-57.0%) respectively for all patients, and 58.5% (56.1-60.9%) and 67.0% (64.3-69.6%) for intensively treated patients. 96.3% of patients <55 years (366/380) and 96.4% of those with the best performance status (543/563) were treated curatively: 5-year RSs being 77.9% (73.1-82%) and 87.1% (82.5-90.6%) respectively. At the other end of the age/fitness spectrum, 33.3% of those ≥ 85 years (66/198) and 41.1% with the worst performance (94/225) were treated curatively: the corresponding 5-year RSs being 50.5% (27.1-69.0%) and 22.9% (14.0-33.2%). The proportion of patients whose cancer was fully staged fell with increasing age and worsening performance status. No socio-economic variations with treatment, stage at presentation or outcome were detected.

CONCLUSIONS

Performance status is more discriminatory of survival than chronological age, with fitter patients benefiting from treatment across all ages. Socio-economic factors are not predictive of outcome in patients with DLBCL in the UK.

Treatment Outcomes in CML Patients Treated With Tyrosine Kinase Inhibitors at a Tertiary Teaching Hospital in South Africa

BACKGROUND

Chronic myeloid leukemia (CML) has become one of the most treatable hematologic neoplasms since the advent of the tyrosine kinase inhibitors (TKIs), but it was not known if similar treatment outcomes could be achieved in a resource-limited country. We tested the hypothesis that, despite challenges to access to second-generation TKIs, excellent responses could be replicated in the setting of limited resources.

PATIENTS AND METHODS

Records of 58 patients with newly diagnosed CML in the chronic phase treated with TKIs at a tertiary teaching hospital in Cape Town, South Africa between 2003 and 2012 were reviewed and assessed according to European LeukemiaNet (ELN) criteria.

RESULTS

After a median follow-up of 60.5 months, progression-free survival at 60 and 96 months was 79.98% and 68.4%, respectively. Overall survival at 60 and 96 months was 92.9% and 83.6%, respectively. Progression to blast phase at 60 months was associated with poorer survival (P = .0002) but progression to accelerated phase was not (P = .1456). Attainment of a complete cytogenetic response at 12 months (P = .28) or major molecular response at 18 months (P = .268) did not have prognostic significance.

CONCLUSION

Despite delays in achievement of the target responses defined according to ELN criteria, the use of imatinib mesylate as a first-line treatment can still result in treatment outcomes comparable with those in developed countries. These data suggest opportunities for improvement and success might be even greater with uninterrupted access to second-generation or newer TKIs.

Low educational level but not low income impairs the achievement of cytogenetic remission in chronic myeloid leukemia patients treated with imatinib in Brazil

OBJECTIVES

In Brazil, imatinib mesylate is supplied as the first-line therapy for chronic myeloid leukemia in the chronic phase through the public universal healthcare program, Sistema Único de Saúde (SUS). We studied the socio-demographic factors that influenced therapy success in a population in the northeast region of Brazil.

METHODS

Patients with chronic myeloid leukemia from the state of Piauí were treated in only one reference center. Diagnosis was based on WHO 2008 criteria. Risk was assessed by Sokal, Hasford and EUTOS scores. Patients received 400 mg imatinib daily. We studied the influence of the following factors on the achievement of complete cytogenetic response within one year of treatment: age, clinical risk category, time interval between diagnosis and the start of imatinib treatment, geographic distance from the patient's home to the hospital, years of formal education and monthly income.

RESULTS

Among 103 patients studied, the median age was 42 years; 65% of the patients had 2-9 years of formal education, and the median monthly income was approximately 100 US$. Imatinib was started in the first year after diagnosis (early chronic phase) in 69 patients. After 12 months of treatment, 68 patients had a complete cytogenetic response. The Hasford score, delay to start imatinib and years of formal education influenced the attainment of a complete cytogenetic response, whereas income and the distance from the home to the healthcare facility did not.

CONCLUSION

Patients require additional healthcare information to better understand the importance of long-term oral anticancer treatment and to improve their compliance with the treatment.

Lymphoma incidence, survival and prevalence 2004-2014: sub-type analyses from the UK's Haematological Malignancy Research Network

BACKGROUND

Population-based information about cancer occurrence and survival are required to inform clinical practice and research; but for most lymphomas data are lacking.

METHODS

Set within a socio-demographically representative UK population of nearly 4 million, lymphoma data (N=5796) are from an established patient cohort.

RESULTS

Incidence, survival (overall and relative) and prevalence estimates for >20 subtypes are presented. With few exceptions, males tended to be diagnosed at younger ages and have significantly (P<0.05) higher incidence rates. Differences were greatest at younger ages: the <15 year male/female rate ratio for all subtypes combined being 2.2 (95% CI 1.3-3.4). These gender differences impacted on prevalence; most subtype estimates being significantly (P<0.05) higher in males than females. Outcome varied widely by subtype; survival of patients with nodular lymphocyte predominant Hodgkin lymphoma approached that of the general population, whereas less than a third of those with other B-cell (e.g., mantle cell) or T-cell (e.g., peripheral-T) lymphomas survived for ≥5 years. No males/female survival differences were detected.

CONCLUSIONS

Major strengths of our study include completeness of ascertainment, world-class diagnostics and generalisability. The marked variations demonstrated confirm the requirement for 'real-world' data to inform aetiological hypotheses, health-care planning and the future monitoring of therapeutic changes.

Immunology of chronic myeloid leukemia: current concepts and future goals

Although chronic myeloid leukemia is a rare malignancy, it has developed into a model system for the study of a variety of aspects of cancer biology and immunology. The introduction of tyrosine kinase inhibitors has resulted in a significant prolongation of the survival rates of chronic myeloid leukemia patients but has not resulted in a cure. There is a growing conviction that this aim can be achieved through immunotherapy. For this concept to be successful, a considerable increase in the present understanding of chronic myeloid leukemia immunology is required. The authors attempt to review and evaluate the current findings that demonstrate a number of immunological aberrations in patients prior to the start of any therapy and their normalization after achieving remission. They also discuss the recent clinical trials with experimental therapeutic vaccines and then present their own strategy on how to address the problem.

The role of observational studies in optimizing the clinical management of chronic myeloid leukemia

Survival has increased dramatically for patients with chronic phase chronic myeloid leukemia (CP-CML) using BCR-ABL targeted tyrosine kinase inhibitors, such that life expectancy is expected to approximate that of patients without CP-CML. Randomized controlled trials (RCTs) and observational studies provide valuable insights into the management of chronic diseases such as CP-CML. RCTs are undoubtedly the backbone of clinical research, and the 'gold standard' for evaluating the efficacy and safety of new therapies. However, many questions surrounding the optimal management of patients with CML remain unanswered, and it is widely accepted that these questions will be best answered by evaluating the use of available therapies in clinical practice. Observational studies can extend the knowledge base beyond the clinical trial setting and thus capture a more accurate picture of everyday clinical practice, particularly patients' experiences of long-term CML treatment. There is therefore growing interest in and appreciation of the value of observational research. This review article will examine the relative merits of RCTs and observational studies in the setting of CML, highlighting those factors - such as the advancing age of the CML patient population and growing importance of patient-reported outcomes - that mean that observational studies should play an important role in shaping clinical practice. This article also provides an overview of what observational studies have told us thus far about the optimal management of patients with CML, outlines some of the key remaining unanswered clinical questions in CML, and summarizes ongoing observational studies designed to provide answers to these key questions.