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Kota V, Brümmendorf TH, Gambacorti-Passerini C, Lipton JH, Kim DW, An F, Leip E, Crescenzo RJ, Ferdinand R, Cortes JE. Efficacy and safety following bosutinib dose reduction in patients with Philadelphia chromosome‒positive leukemias. Leuk Res 2021; 111:106690. [PMID: 34673442 DOI: 10.1016/j.leukres.2021.106690] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/13/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Abstract
The recommended starting dose of bosutinib is 500 mg/day for chronic-phase (CP) or accelerated-/blast-phase Philadelphia chromosome-positive (Ph+) chronic myeloid leukemia (CML) resistant/intolerant to prior therapy. However, some patients may require dose reductions to manage the occurrences of adverse events (AEs). Bosutinib efficacy and safety were evaluated following dose reductions in a phase I/II study of Ph+ patients with CP CML resistant/intolerant to imatinib or imatinib plus dasatinib and/or nilotinib, and those with accelerated-/blast-phase CML or acute lymphoblastic leukemia after at least imatinib treatment. In all, 570 patients with ≥4 years' follow-up were included in this analysis. Among 144 patients who dose-reduced to bosutinib 400 mg/day (without reduction to 300 mg/day), 22 (15 %) had complete cytogenetic response (CCyR) before and after reduction, 40 (28 %) initially achieved CCyR after reduction, and 4 (3 %) only had CCyR before reduction. Among 95 patients who dose-reduced to bosutinib 300 mg/day, 23 (24 %) had CCyR before and after reduction, 13 (14 %) initially achieved CCyR after reduction, and 3 (3 %) only had CCyR before reduction. Results were similar to matched controls who remained on 500 mg/day, indicating dose reductions had not substantially affected efficacy. The incidence of treatment-emergent AEs was lower after dose reductions, particularly for gastrointestinal events. The incidence of hematologic toxicities generally was similar before and after dose reduction. The management of AEs with bosutinib through dose reduction can lead to improved/maintained efficacy and better tolerability; still, approximately half of patients on treatment at year 4 maintained a dose of ≥500 mg/day. ClinicalTrials.gov: NCT00261846.
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Affiliation(s)
- Vamsi Kota
- Georgia Cancer Center at Augusta University, Augusta, GA, USA.
| | - Tim H Brümmendorf
- Universitätsklinikum Aachen, RWTH Aachen, Germany; Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jeff H Lipton
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Dong-Wook Kim
- Seoul St. Mary's Hospital, Leukemia Research Institute, The Catholic University of Korea, Seoul, Republic of Korea
| | | | | | | | | | - Jorge E Cortes
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Kennedy JA, Hobbs G. Tyrosine Kinase Inhibitors in the Treatment of Chronic-Phase CML: Strategies for Frontline Decision-making. Curr Hematol Malig Rep 2018; 13:202-211. [PMID: 29687320 DOI: 10.1007/s11899-018-0449-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE OF REVIEW Over the past two decades, the introduction of tyrosine kinase inhibitors (TKIs) has transformed the treatment of chronic myeloid leukemia (CML). With four agents currently approved for frontline use in chronic-phase (CP) disease, it follows that treatment decision-making has been rendered more challenging. Here we will review recent advances that help inform the selection of a first-line TKI. RECENT FINDINGS Extended follow-up of the seminal CML trials has demonstrated the long-term efficacy of TKIs, while also highlighting significant differences in their respective toxicity profiles and potency. Dasatinib and nilotinib generate deeper molecular responses than imatinib, particularly among patients with higher risk disease, but this has not translated into a significant survival advantage. Similar results have been obtained at 1 year with bosutinib; its efficacy and toxicity were well balanced at a dose of 400 mg daily, prompting its recent approval for this indication. Lastly, multiple studies have demonstrated that TKIs can be safely discontinued in select individuals who have maintained deep responses for extended periods, establishing treatment-free remission as a novel goal in CP CML. The careful consideration of parameters such as disease risk, the potency, and toxicity profile of each TKI, as well as each patient's unique comorbidities and preferences, enables truly individualized therapeutic decision-making in CP CML, with the goal of ensuring that a high quality of life accompanies the survival advantage conferred by these agents.
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Affiliation(s)
- James A Kennedy
- Division of Hematology, Brigham and Women's Hospital, 77 Avenue Louis Pasteur - HIM 770, Boston, MA, 02115, USA.,Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 700 University Ave., Toronto, ON, M5G1Z5, Canada
| | - Gabriela Hobbs
- Massachusetts General Hospital, 100 Blossom Street, Cox-1, Boston, MA, 02114, USA.
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Heiblig M, Rea D, Chrétien ML, Charbonnier A, Rousselot P, Coiteux V, Escoffre-Barbe M, Dubruille V, Huguet F, Cayssials E, Hermet E, Guerci-Bresler A, Amé S, Sackmann-Sala L, Roy L, Sobh M, Morisset S, Etienne G, Nicolini FE. Ponatinib evaluation and safety in real-life chronic myelogenous leukemia patients failing more than two tyrosine kinase inhibitors: the PEARL observational study. Exp Hematol 2018; 67:41-48. [PMID: 30195076 DOI: 10.1016/j.exphem.2018.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 01/07/2023]
Abstract
Ponatinib represents a remarkable progress in the treatment of heavily pretreated chronic myelogenous leukemia (CML) and de novo Philadelphia chromosome-positive ALL patients despite significant toxicity in clinical trials. To date, "real-life" data remain few and the use of ponatinib in this setting and its consequences remain mostly unknown. We report, within a national observational study, the use of ponatinib in unselected CML patients who had previously failed ≥2 lines of tyrosine kinase inhibitor (TKI) therapy (or one line if an Abelson (ABL)T315I mutation was identified), in real-life conditions (2013-2014) in a compassionate program. Our analysis has been focused on 48 chronic phase CML patients recorded. With a median follow-up of 26.5 months since ponatinib initiation, the overall survival (OS) rates (80.5% at 3 years) and cumulative incidence of major molecular response (81.8% at 18 months) were similar to those of the phase II study, with no influence of BCR-ABL mutations nor the reason of ponatinib prescription. A specific subanalysis of the preexisting cardiovascular risk factors and events occurring on ponatinib is described. These events occurred after a median time on ponatinib of 5.8 months (excluding hypertension) and were observed in 29/48 patients (47%), even in those already on anti-aggregants/coagulants. The majority were not severe and resolved, but two cases were fatal. Other hematological or nonhematological nonvascular adverse events were similar to those previously described in trials. This observational study reports similar rates of survival, molecular responses, and a slight increase in the cardiovascular toxicity of ponatinib in real-life conditions, prompting improved control of cardiovascular risk factors and selection of patients.
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Affiliation(s)
- Maël Heiblig
- Hematology Department, Centre Léon Bérard, Lyon, France; INSERM U1170, Normal and Pathologic Hematopoiesis, Institut Gustave Roussy, Créteil, France
| | - Delphine Rea
- Hematology Department, Hôpital Saint Louis, Paris, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | | | - Aude Charbonnier
- Hematology Department, Institut Paoli Calmettes, Marseilles, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Philippe Rousselot
- Hematology Department, Hôpital A. Mignot, Le Chesnay, University Paris Saclay EA4340, Fontenay aux Roses, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Valérie Coiteux
- Hematology Department, Hôpital Claude Huriez, Lille, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Martine Escoffre-Barbe
- Hematology Department, Hôpital Pontchaillou, Rennes, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Viviane Dubruille
- Hematology Department, Hotel Dieu, Nantes, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Françoise Huguet
- Hematology Department, Institut Universitaire du Cancer, Toulouse, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Emilie Cayssials
- Hematology Department, Centre Hospitalier Universitaire de Poitiers, Poitiers, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Eric Hermet
- Hematology Department, Centre Hospitalier Universitaire Estaing, Clermont-Ferrand, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Agnès Guerci-Bresler
- Hematology Department, Hôpital de Brabois, Vandoeuvre-lès-Nancy, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Shanti Amé
- Hematology Department, Hôpital Civil, Strasbourg, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | | | - Lydia Roy
- Hematology Department, Hôpital Henri Mondor, Créteil, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Mohamad Sobh
- Hematology Department, Centre Léon Bérard, Lyon, France
| | | | - Gabriel Etienne
- Hematology Department, Institut Bergonié, Bordeaux, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France
| | - Franck E Nicolini
- Hematology Department, Centre Léon Bérard, Lyon, France; INSERM U1052, CRCL, Lyon, France; French Group of CML (Fi-LMC), Institut Bergonié, Bordeaux, France.
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Jabbour E, Kantarjian H. Chronic myeloid leukemia: 2018 update on diagnosis, therapy and monitoring. Am J Hematol 2018; 93:442-459. [PMID: 29411417 DOI: 10.1002/ajh.25011] [Citation(s) in RCA: 234] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 12/17/2017] [Indexed: 12/11/2022]
Abstract
DISEASE OVERVIEW Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm with an incidence of 1-2 cases per 100 000 adults. It accounts for approximately 15% of newly diagnosed cases of leukemia in adults. DIAGNOSIS CML is characterized by a balanced genetic translocation, t(9;22)(q34;q11.2), involving a fusion of the Abelson gene (ABL1) from chromosome 9q34 with the breakpoint cluster region (BCR) gene on chromosome 22q11.2. This rearrangement is known as the Philadelphia chromosome. The molecular consequence of this translocation is the generation of a BCR-ABL1 fusion oncogene, which in turn translates into a BCR-ABL1 oncoprotein. Frontline therapy: Four tyrosine kinase inhibitors (TKIs), imatinib, nilotinib, dasatinib, and bosutinib are approved by the United States Food and Drug Administration for first-line treatment of patients with newly diagnosed CML in chronic phase (CML-CP). Clinical trials with second generation TKIs reported significantly deeper and faster responses; this has not translated into improved long-term survival, because of the availability of effective salvage therapies. Salvage therapy: For patients who fail frontline therapy, second-line options include second and third generation TKIs. Second and third generation TKIs, although potent and selective, exhibit unique pharmacological profiles and response patterns relative to different patient and disease characteristics, such as patients' comorbidities, disease stage, and BCR-ABL1 mutational status. Patients who develop the T315I "gatekeeper" mutation display resistance to all currently available TKIs except ponatinib. Allogeneic stem cell transplantation remains an important therapeutic option for patients with CML-CP who have failed at least 2 TKIs, and for all patients in CML advanced phases.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia; The University of Texas M. D. Anderson Cancer Center; Houston Texas
| | - Hagop Kantarjian
- Department of Leukemia; The University of Texas M. D. Anderson Cancer Center; Houston Texas
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