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Chamseddine RS, Savenkov O, Rana S, Khalid M, Silver RT, Kucine N, Scandura JM, Abu-Zeinah G. Cytoreductive therapy in younger adults with polycythemia vera: a meta-analysis of safety and outcomes. Blood Adv 2024; 8:2520-2526. [PMID: 38507746 PMCID: PMC11131058 DOI: 10.1182/bloodadvances.2023012459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/09/2024] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Abstract
ABSTRACT Cytoreductive therapy is not routinely recommended for younger patients with polycythemia vera (PV) due to concern that treatment toxicity may outweigh therapeutic benefits. However, no systematic data support this approach. To support objective risk/benefit assessment of cytoreductive drugs in patients with PV aged <60 years (PV<60), this systematic review and meta-analysis was conducted to evaluate toxicity and disease-related complications in PV<60 treated with interferon alfa (rIFN-α) or hydroxyurea (HU). A search of PubMed, Scopus, Web of Science and Embase identified 693 unique studies with relevant keywords, of which 14 met inclusion criteria and were selected for analysis. The weighted average age of patients treated with rIFN-α was 48 years (n = 744 patients; 12 studies) and for HU was 56 years (n = 1397; 8 studies). The weighted average duration of treatment for either drug was 4.5 years. Using a Bayesian hierarchical model, the pooled annual rate of discontinuation due to toxicity was 5.2% for patients receiving rIFN-α (n = 587; 95% confidence interval [CI], 2.2-8.2) and 3.6% for HU (n = 1097; CI, 1-6.2). The average complete hematologic response for rIFN-α and HU was 62% and 52%, respectively. Patients experienced thrombotic events at a pooled annual rate of 0.79% and 1.26%; secondary myelofibrosis at 1.06% and 1.62%; acute myeloid leukemia at 0.14% and 0.26%; and death at 0.87% and 2.65%, respectively. No treatment-related deaths were reported. With acceptable rates of nonfatal toxicity, cytoreductive treatment, particularly with disease-modifying rIFN-α, may benefit PV<60. Future randomized trials prioritizing inclusion of PV<60 are needed to establish a long-term benefit of early cytoreductive treatment in these patients.
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Affiliation(s)
| | - Oleksandr Savenkov
- Division of Hematology and Medical Oncology, Richard T. Silver Myeloproliferative Neoplasms Center, Weill Cornell Medicine, New York, NY
| | | | | | - Richard T. Silver
- Division of Hematology and Medical Oncology, Richard T. Silver Myeloproliferative Neoplasms Center, Weill Cornell Medicine, New York, NY
| | - Nicole Kucine
- Division of Hematology and Oncology, Department of Pediatrics, Weill Cornell Medicine, New York, NY
| | - Joseph M. Scandura
- Division of Hematology and Medical Oncology, Richard T. Silver Myeloproliferative Neoplasms Center, Weill Cornell Medicine, New York, NY
| | - Ghaith Abu-Zeinah
- Division of Hematology and Medical Oncology, Richard T. Silver Myeloproliferative Neoplasms Center, Weill Cornell Medicine, New York, NY
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2
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Segura-Díaz A, Stuckey R, Florido Y, Sobas M, Álvarez-Larrán A, Ferrer-Marín F, Pérez-Encinas M, Carreño-Tarragona G, Fox ML, Tazón Vega B, Cuevas B, López Rodríguez JF, Sánchez-Farías N, González-Martín JM, Gómez-Casares MT, Bilbao-Sieyro C. DNMT3A/TET2/ASXL1 Mutations are an Age-independent Thrombotic Risk Factor in Polycythemia Vera Patients: An Observational Study. Thromb Haemost 2024. [PMID: 38190984 DOI: 10.1055/a-2239-9265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Polycythemia vera (PV) patients are classified as high or low thrombotic risk based on age and prior history of thrombosis. Despite adherence to treatment recommendations, vascular events remain frequent, leading us to question whether thrombotic risk stratification could be improved. We previously reported an association between thrombotic events and mutations in DTA genes (DNMT3A, TET2, and ASXL1). The objective of this study was to confirm this observation in a larger series of PV patients. METHODS PV patients with a minimum follow-up of 3 years were recruited from 8 European centers. Medical history was searched for thrombotic event recorded at any time and next-generation sequencing carried out with a myeloid panel. Multivariable logistic regression evaluated the impact of variables on thrombotic risk. Kaplan-Meier thrombosis-free survival curves were compared by the log rank test. Associations in the total cohort were confirmed in a case-control study to exclude selection bias. RESULTS Of the 136 patients recruited, 74 (56.1%) had a thrombotic event, with an incidence density of 2.83/100 person-years. In multivariable analysis, DTA mutation was a risk factor for thrombotic event, being predictive for shorter thrombosis-free survival in the whole cohort (p = 0.007), as well as in low-risk patients (p = 0.039) and older patients (p = 0.009), but not for patients with a prediagnostic event. A gender- and age-matched case-control study confirmed the increased risk of thrombotic event for PV patients with a DTA mutation. CONCLUSION Our results support the use of molecular testing at diagnosis to help predict which PV patients are at higher risk of developing thrombosis.
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Affiliation(s)
- Adrián Segura-Díaz
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Ruth Stuckey
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Yanira Florido
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Marta Sobas
- Department of Hematology and Bone Marrow Transplantation, Wrocław Medical University, Wrocław, Poland
| | | | - Francisca Ferrer-Marín
- Hematology Department, Hospital Morales Messeguer, Instituto Murciano de Investigación Biosanitaria, Centro de Investigación Biomédica en Red de Enfermedades Raras, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Manuel Pérez-Encinas
- Hematology Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - María L Fox
- Hematology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | | | - Beatriz Cuevas
- Hematology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - Juan F López Rodríguez
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Nuria Sánchez-Farías
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | | | - María T Gómez-Casares
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
- Department of Medical Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Cristina Bilbao-Sieyro
- Hematology Department, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
- Morphology Department, Universidad de Las Palmas de Gran Canaria, Las Palmas, Spain
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3
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Barbui T, Carobbio A, Vannucchi AM, De Stefano V. Are the available data sufficient to suggest cytoreductive agents for patients with CHIP and stroke? Blood Adv 2023; 7:7551-7553. [PMID: 37874911 PMCID: PMC10761349 DOI: 10.1182/bloodadvances.2023012007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/23/2023] [Indexed: 10/26/2023] Open
Affiliation(s)
- Tiziano Barbui
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Alessandro M. Vannucchi
- Department of Experimental and Clinical Medicine, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Valerio De Stefano
- Section of Hematology, Department of Radiological and Hematological Sciences, Catholic University, IRCCS Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
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Gill H, Leung GMK, Ooi MGM, Teo WZY, Wong CL, Choi CW, Wong GC, Lao Z, Rojnuckarin P, Castillo MRID, Xiao Z, Hou HA, Kuo MC, Shih LY, Gan GG, Lin CC, Chng WJ, Kwong YL. Management of classical Philadelphia chromosome-negative myeloproliferative neoplasms in Asia: consensus of the Asian Myeloid Working Group. Clin Exp Med 2023; 23:4199-4217. [PMID: 37747591 DOI: 10.1007/s10238-023-01189-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
Myeloproliferative neoplasms (MPN) are a heterogeneous group of clonal hematopoietic stem cell disorders characterized clinically by the proliferation of one or more hematopoietic lineage(s). The classical Philadelphia-chromosome (Ph)-negative MPNs include polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF). The Asian Myeloid Working Group (AMWG) comprises representatives from fifteen Asian centers experienced in the management of MPN. This consensus from the AMWG aims to review the current evidence in the risk stratification and treatment of Ph-negative MPN, to identify management gaps for future improvement, and to offer pragmatic approaches for treatment commensurate with different levels of resources, drug availabilities and reimbursement policies in its constituent regions. The management of MPN should be patient-specific and based on accurate diagnostic and prognostic tools. In patients with PV, ET and early/prefibrotic PMF, symptoms and risk stratification will guide the need for early cytoreduction. In younger patients requiring cytoreduction and in those experiencing resistance or intolerance to hydroxyurea, recombinant interferon-α preparations (pegylated interferon-α 2A or ropeginterferon-α 2b) should be considered. In myelofibrosis, continuous risk assessment and symptom burden assessment are essential in guiding treatment selection. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) in MF should always be based on accurate risk stratification for disease-risk and post-HSCT outcome. Management of classical Ph-negative MPN entails accurate diagnosis, cytogenetic and molecular evaluation, risk stratification, and treatment strategies that are outcome-oriented (curative, disease modification, improvement of quality-of-life).
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Affiliation(s)
- Harinder Gill
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China.
- Department of Medicine, Professorial Block, Queen Mary Hospital, Pokfulam Road, Pok Fu Lam, Hong Kong, China.
| | - Garret M K Leung
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China
| | - Melissa G M Ooi
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University, Singapore, Singapore
| | - Winnie Z Y Teo
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Fast and Chronic Program, Alexandra Hospital, Singapore, Singapore
| | - Chieh-Lee Wong
- Department of Medicine, Sunway Medical Centre, Shah Alam, Selangor, Malaysia
| | - Chul Won Choi
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gee-Chuan Wong
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Zhentang Lao
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Ponlapat Rojnuckarin
- King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | | | - Zhijian Xiao
- Blood Disease Hospital and Institute of Hematology, Chinese Academy of Medical Sciences Peking Union Medical College, Tianjin, China
| | - Hsin-An Hou
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chung Kuo
- Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Lee-Yung Shih
- Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Gin-Gin Gan
- University of Malaya, Kuala Lumpur, Malaysia
| | - Chien-Chin Lin
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wee-Joo Chng
- Department of Hematology-Oncology, National University Cancer Institute, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University, Singapore, Singapore
| | - Yok-Lam Kwong
- Department of Medicine, LKS Faculty of Medicine, School of Clinical Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong, China
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Gerds AT, Castro C, Snopek F, Flynn MM, Ellis AG, Manning M, Urbanski R. Cost-effectiveness of ropeginterferon alfa-2b-njft for the treatment of polycythemia vera. J Comp Eff Res 2023; 12:e230066. [PMID: 37531245 PMCID: PMC10690394 DOI: 10.57264/cer-2023-0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023] Open
Abstract
Aim: Patients with polycythemia vera (PV), a rare and chronic blood cancer, are at a higher risk for thromboembolic events, progression to myelofibrosis, and leukemic transformation. In 2021, ropeginterferon alfa-2b-njft (BESREMi®) was approved in the US to treat adults with PV. The purpose of this study is to estimate the cost-effectiveness of ropeginterferon alfa-2b-njft, used as a first- or second-line treatment, for the treatment of patients with PV in the US. Materials & methods: A Markov cohort model was developed from the healthcare system perspective in the United States. Model inputs were informed by the PROUD-PV and CONTINUATION-PV studies and published literature. The model population included both low-risk and high-risk patients with PV. The model compared ropeginterferon alfa-2b-njft used either as first- or second-line versus an alternative treatment pathway of first-line hydroxyurea followed by ruxolitinib. Results: Over the modeled lifetime, ropeginterferon alfa-2b-njft provided an additional 0.4 higher quality-adjusted life years (QALYs) and 0.4 life-years with an added cost of USD60,175, resulting in a cost per QALY of USD141,783. The model was sensitive to treatment costs, the percentage of patients who discontinue hydroxyurea, the percentage of ropeginterferon alfa-2b-njft users who switch to monthly dosing, the percentage of ropeginterferon alfa-2b-njft users as 2nd line treatment, and the treatment response rates. A younger patient age at baseline and a higher percentage of patients with low-risk disease improved the cost-effectiveness of ropeginterferon alfa-2b-njft. Conclusion: Ropeginterferon alfa-2b-njft is a cost-effective treatment option for a broad range of patients with PV, including both low- and high-risk patients and patients with and without prior cytoreductive treatment with hydroxyurea.
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Affiliation(s)
- Aaron T Gerds
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH 44106, USA
| | - Claudia Castro
- PharmaEssentia USA Corporation, Burlington, MA 01803, USA
| | - Frank Snopek
- PharmaEssentia USA Corporation, Burlington, MA 01803, USA
| | - Megan M Flynn
- PharmaEssentia USA Corporation, Burlington, MA 01803, USA
| | | | | | - Ray Urbanski
- PharmaEssentia USA Corporation, Burlington, MA 01803, USA
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Tefferi A, Barbui T. Polycythemia vera: 2024 update on diagnosis, risk-stratification, and management. Am J Hematol 2023; 98:1465-1487. [PMID: 37357958 DOI: 10.1002/ajh.27002] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 06/12/2023] [Indexed: 06/27/2023]
Abstract
DISEASE OVERVIEW Polycythemia vera (PV) is a JAK2-mutated myeloproliferative neoplasm characterized by clonal erythrocytosis; other features include leukocytosis, thrombocytosis, splenomegaly, pruritus, constitutional symptoms, microcirculatory disturbances, and increased risk of thrombosis and progression into myelofibrosis (post-PV MF) or acute myeloid leukemia (AML). DIAGNOSIS A working diagnosis is considered in the presence of a JAK2 mutation associated with hemoglobin/hematocrit levels of >16.5 g/dL/49% in men or 16 g/dL/48% in women; morphologic confirmation by bone marrow examination is advised but not mandated. CYTOGENETICS Abnormal karyotype is seen in 15%-20% of patients with the most frequent sole abnormalities being +9 (5%), loss of chromosome Y (4%), +8 (3%), and 20q- (3%). MUTATIONS Over 50% of patients harbor DNA sequence variants/mutations other than JAK2, with the most frequent being TET2 (18%) and ASXL1 (15%). Prognostically adverse mutations include SRSF2, IDH2, RUNX1, and U2AF1, with a combined incidence of 5%-10%. SURVIVAL AND PROGNOSIS Median survival is ⁓15 years but exceeds 35 years for patients aged ≤40 years. Risk factors for survival include older age, leukocytosis, abnormal karyotype, and the presence of adverse mutations. Twenty-year risk for thrombosis, post-PV MF, or AML are ⁓26%, 16% and 4%, respectively. RISK FACTORS FOR THROMBOSIS Two risk categories are considered: high (age >60 years or thrombosis history) and low (absence of both risk factors). Additional predictors for arterial thrombosis include cardiovascular risk factors and for venous thrombosis higher absolute neutrophil count and JAK2V617F allele burden. TREATMENT Current goal of therapy is to prevent thrombosis. Periodic phlebotomy, with a hematocrit target of <45%, combined with once- or twice-daily aspirin (81 mg) therapy, absent contraindications, is the backbone of treatment in all patients, regardless of risk category. Cytoreductive therapy is reserved for high-risk disease with first-line drugs of choice being hydroxyurea and pegylated interferon-α and second-line busulfan and ruxolitinib. In addition, systemic anticoagulation is advised in patients with venous thrombosis history. ADDITIONAL TREATMENT CONSIDERATIONS At the present time, we do not consider a drug-induced reduction in JAK2V617F allele burden, which is often incomplete and seen not only with peg-IFN but also with ruxolitinib and busulfan, as an indicator of disease-modifying activity, unless accompanied by cytogenetic and independently-verified morphologic remission. Accordingly, we do not use the specific parameter to influence treatment choices. The current review also includes specific treatment strategies in the context of pregnancy, splanchnic vein thrombosis, pruritus, perioperative care, and post-PV MF.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Verstovsek S, Krečak I, Heidel FH, De Stefano V, Bryan K, Zuurman MW, Zaiac M, Morelli M, Smyth A, Redondo S, Bigan E, Ruhl M, Meier C, Beffy M, Kiladjian JJ. Identifying Patients with Polycythemia Vera at Risk of Thrombosis after Hydroxyurea Initiation: The Polycythemia Vera-Advanced Integrated Models (PV-AIM) Project. Biomedicines 2023; 11:1925. [PMID: 37509564 PMCID: PMC10377437 DOI: 10.3390/biomedicines11071925] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 07/30/2023] Open
Abstract
Patients with polycythemia vera (PV) are at significant risk of thromboembolic events (TE). The PV-AIM study used the Optum® de-identified Electronic Health Record dataset and machine learning to identify markers of TE in a real-world population. Data for 82,960 patients with PV were extracted: 3852 patients were treated with hydroxyurea (HU) only, while 130 patients were treated with HU and then changed to ruxolitinib (HU-ruxolitinib). For HU-alone patients, the annualized incidence rates (IR; per 100 patients) decreased from 8.7 (before HU) to 5.6 (during HU) but increased markedly to 10.5 (continuing HU). Whereas for HU-ruxolitinib patients, the IR decreased from 10.8 (before HU) to 8.4 (during HU) and was maintained at 8.3 (after switching to ruxolitinib). To better understand markers associated with TE risk, we built a machine-learning model for HU-alone patients and validated it using an independent dataset. The model identified lymphocyte percentage (LYP), neutrophil percentage (NEP), and red cell distribution width (RDW) as key markers of TE risk, and optimal thresholds for these markers were established, from which a decision tree was derived. Using these widely used laboratory markers, the decision tree could be used to identify patients at high risk for TE, facilitate treatment decisions, and optimize patient management.
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Affiliation(s)
- Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ivan Krečak
- Department of Internal Medicine, General Hospital of Sibenik-Knin County, 22000 Sibenik, Croatia
- Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
| | - Florian H. Heidel
- Hematology, Oncology, Stem Cell Transplantation and Palliative Care, Internal Medicine C, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Valerio De Stefano
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica, Fondazione Policlinico A. Gemelli IRCCS, 00168 Roma, Italy
| | - Kenneth Bryan
- Novartis Ireland Limited, Dublin 4, D04 A9N6 Dublin, Ireland
| | | | | | | | - Aoife Smyth
- Novartis Pharma AG, CH-4056 Basel, Switzerland
- Novartis Pharmaceuticals UK Limited, London W12 7FQ, UK
| | | | - Erwan Bigan
- The Boston Consulting Group, Boston, MA 02210, USA
| | - Michael Ruhl
- The Boston Consulting Group, Boston, MA 02210, USA
| | | | - Magali Beffy
- The Boston Consulting Group, Boston, MA 02210, USA
| | - Jean-Jacques Kiladjian
- Centre d’Investigations Cliniques (INSERM CIC 1427), Université de Paris, Hôpital Saint-Louis, AP-HP, 75010 Paris, France
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8
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Barbui T, Vannucchi AM, De Stefano V, Carobbio A, Ghirardi A, Carioli G, Masciulli A, Rossi E, Ciceri F, Bonifacio M, Iurlo A, Palandri F, Benevolo G, Pane F, Ricco A, Carli G, Caramella M, Rapezzi D, Musolino C, Siragusa S, Rumi E, Patriarca A, Cascavilla N, Mora B, Cacciola E, Mannarelli C, Loscocco GG, Guglielmelli P, Gesullo F, Betti S, Lunghi F, Scaffidi L, Bucelli C, Vianelli N, Bellini M, Finazzi MC, Tognoni G, Rambaldi A. Ropeginterferon versus Standard Therapy for Low-Risk Patients with Polycythemia Vera. NEJM EVIDENCE 2023; 2:EVIDoa2200335. [PMID: 38320126 DOI: 10.1056/evidoa2200335] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Whether phlebotomy alone can adequately maintain target hematocrit in patients with low-risk polycythemia vera (PV) remains elusive. METHODS: In a phase 2 open-label randomized trial, we compared ropeginterferon alfa-2b (ropeg; 100 μg every 2 weeks) with phlebotomy only regarding maintenance of a median hematocrit level (≤45%) over 12 months in the absence of progressive disease (primary end point). In follow-up, crossover to the alternative treatment group was allowed if the primary end point was not met. RESULTS: In total, 127 patients were enrolled (ropeg: n=64; standard group: n=63). The primary end point was met in 81% and 51% in the ropeg and standard groups, respectively. Responders continued the assigned treatment until month 24 and maintained response in 83% and 59%, respectively (P=0.02). Ropeg responders less frequently experienced moderate/severe symptoms (33% vs. 67% in the standard group) and palpable splenomegaly (14% vs. 37%) and showed normalization of ferritin levels and blood counts. Nonresponders at 12 months crossed over to the standard (n=9) or ropeg (n=23) group; in patients switched to ropeg only, 7 of 23 met the response criteria in 12 months, and phlebotomy need was high (4.7 per patient per year). Discontinuation because of adverse events occurred in seven patients treated with ropeg. CONCLUSIONS: In this 24-month trial, ropeg was superior to phlebotomy alone in maintaining hematocrit on target. No dose-limiting side effects or toxicities were noted; 9.2% of patients on ropeg and no patients on standard treatment developed neutropenia. (Funded by AOP Health and others; ClinicalTrials.gov number, NCT03003325.)
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Affiliation(s)
- Tiziano Barbui
- Fondazione per la Ricerca Ospedale di Bergamo (FROM) Ente del Terzo Settore (ETS), Bergamo, Italy
| | - Alessandro Maria Vannucchi
- Centro di Ricerca ed Innovazione per le Malattie Mieloproliferative (CRIMM), Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, University of Florence, Florence, Italy
| | - Valerio De Stefano
- Dipartimento di Scienze Radiologiche ed Ematologiche, Sezione di Ematologia, Università Cattolica del Sacro Cuore - Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome
| | - Alessandra Carobbio
- Fondazione per la Ricerca Ospedale di Bergamo (FROM) Ente del Terzo Settore (ETS), Bergamo, Italy
| | - Arianna Ghirardi
- Fondazione per la Ricerca Ospedale di Bergamo (FROM) Ente del Terzo Settore (ETS), Bergamo, Italy
| | - Greta Carioli
- Fondazione per la Ricerca Ospedale di Bergamo (FROM) Ente del Terzo Settore (ETS), Bergamo, Italy
| | - Arianna Masciulli
- Fondazione per la Ricerca Ospedale di Bergamo (FROM) Ente del Terzo Settore (ETS), Bergamo, Italy
| | - Elena Rossi
- Dipartimento di Scienze Radiologiche ed Ematologiche, Sezione di Ematologia, Università Cattolica del Sacro Cuore - Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome
| | - Fabio Ciceri
- Unità Operativa di Ematologia e Trapianto Midollo Osseo, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan
| | - Massimiliano Bonifacio
- Department of Medicine, Section of Hematology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Alessandra Iurlo
- Unità Operativa Complessa di Ematologia, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda - Ospedale Maggiore Policlinico, Milan
| | - Francesca Palandri
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero Universitaria di Bologna, Istituto di Ematologia "L. & A. Seragnoli", Bologna, Italy
| | - Giulia Benevolo
- Struttura Complessa di Ematologia Universitaria, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Fabrizio Pane
- Unità Operativa Complessa di Ematologia e Trapianti di Midollo, Azienda Ospedaliera Universitaria Federico II di Napoli, Naples, Italy
- Dipartimento di Medicina Clinica e Chirurgia, Università di Napoli Federico II, Naples, Italy
| | - Alessandra Ricco
- Unità Operativa di Ematologia con Trapianto, Azienda Ospedaliera Universitaria "Consorziale Policlinico" di Bari, Bari, Italy
| | - Giuseppe Carli
- Unità Operativa Complessa di Ematologia, Azienda Unità Sanitaria Locale Socio Sanitaria (ULSS) 8 Berica, Ospedale San Bortolo di Vicenza, Vicenza, Italy
| | - Marianna Caramella
- Divisione di Ematologia, Azienda Socio Sanitaria Territoriale (ASST) Grande Ospedale Metropolitano Niguarda, Milan
| | - Davide Rapezzi
- Divisione di Ematologia, Azienda Ospedaliera S. Croce e Carle di Cuneo, Cuneo, Italy
| | - Caterina Musolino
- Unità Operativa Complessa di Ematologia, Azienda Ospedaliera Universitaria Policlinico "G. Martino", Messina, Italy
| | - Sergio Siragusa
- Divisione di Ematologia, Azienda Ospedaliera Universitaria Policlinico "P. Giaccone", Palermo, Italy
| | - Elisa Rumi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Divisione di Ematologia, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo di Pavia, Pavia, Italy
| | - Andrea Patriarca
- Struttura Complessa a Direzione Universitaria (SCDU) di Ematologia, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Nicola Cascavilla
- Unità Operativa di Ematologia, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Barbara Mora
- Unità Operativa di Ematologia, Azienda Socio Sanitaria Territoriale (ASST) Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Emma Cacciola
- Unità Operativa di Emostasi Centro Federato Federazione Centri per la Diagnosi della Trombosi e la Sorveglianza delle terapie Antitrombotiche (FCSA), Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie Avanzate "G. F. Ingrassia", Azienda Ospedaliera Universitaria Policlinico "G. Rodolico-San Marco", Catania, Italy
| | - Carmela Mannarelli
- Centro di Ricerca ed Innovazione per le Malattie Mieloproliferative (CRIMM), Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, University of Florence, Florence, Italy
| | - Giuseppe Gaetano Loscocco
- Centro di Ricerca ed Innovazione per le Malattie Mieloproliferative (CRIMM), Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, University of Florence, Florence, Italy
| | - Paola Guglielmelli
- Centro di Ricerca ed Innovazione per le Malattie Mieloproliferative (CRIMM), Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, University of Florence, Florence, Italy
| | - Francesca Gesullo
- Centro di Ricerca ed Innovazione per le Malattie Mieloproliferative (CRIMM), Azienda Ospedaliera Universitaria Careggi, Dipartimento di Medicina Sperimentale e Clinica, University of Florence, Florence, Italy
| | - Silvia Betti
- Dipartimento di Scienze Radiologiche ed Ematologiche, Sezione di Ematologia, Università Cattolica del Sacro Cuore - Policlinico Universitario Agostino Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome
| | - Francesca Lunghi
- Unità Operativa di Ematologia e Trapianto Midollo Osseo, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale San Raffaele, Milan
| | - Luigi Scaffidi
- Department of Medicine, Section of Hematology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Cristina Bucelli
- Unità Operativa Complessa di Ematologia, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda - Ospedale Maggiore Policlinico, Milan
| | - Nicola Vianelli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero Universitaria di Bologna, Istituto di Ematologia "L. & A. Seragnoli", Bologna, Italy
| | - Marta Bellini
- Struttura Complessa di Ematologia, Azienda Socio Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Chiara Finazzi
- Struttura Complessa di Ematologia, Azienda Socio Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
- Dipartimento di Oncologia ed Emato-Oncologia, Università degli Studi di Milano, Milan
| | - Gianni Tognoni
- Centro di Coordinamento Nazionale dei Comitati Etici, Agenzia Italiana del Farmaco (AIFA), Rome
| | - Alessandro Rambaldi
- Struttura Complessa di Ematologia, Azienda Socio Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
- Dipartimento di Oncologia ed Emato-Oncologia, Università degli Studi di Milano, Milan
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9
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Kuykendall AT. Treatment of hydroxyurea-resistant/intolerant polycythemia vera: a discussion of best practices. Ann Hematol 2023; 102:985-993. [PMID: 36944847 PMCID: PMC10113291 DOI: 10.1007/s00277-023-05172-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/09/2023] [Indexed: 03/23/2023]
Abstract
Polycythemia vera (PV) is a burdensome, chronic myeloproliferative neoplasm characterized by activating mutations in Janus kinase 2, erythrocytosis, and bone marrow hypercellularity. The goals of treatment are to achieve hematocrit and blood count control to ultimately reduce the risk of thrombohemorrhagic events and improve PV-related symptoms. Treatment is risk-stratified and typically includes cytoreduction with hydroxyurea or interferon formulations in first line for high-risk disease. However, inadequate response, resistance, or intolerance to first-line cytoreductive therapies may warrant introduction of second-line treatments, such as ruxolitinib. In this review, I detail preferred treatment and patient management approaches following inadequate response to or intolerance of first-line treatment for PV.
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Affiliation(s)
- Andrew T Kuykendall
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, FL, 33612, USA.
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10
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Mora B, Passamonti F. SOHO State of the Art Updates and Next Questions | Polycythemia Vera: Is It Time to Rethink Treatment? CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:79-85. [PMID: 36566109 DOI: 10.1016/j.clml.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/21/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
Polycythemia vera (PV) is a Philadelphia-negative myeloproliferative neoplasm characterized by excessive myeloid cells production, mostly secondary to mutations in the Janus kinase 2 (JAK2) gene. PV natural history might be burdened by thrombotic events (TEs) and evolution into post-PV myelofibrosis (PPV-MF) or blast phase (BP). To date, no treatment strategies have been shown to have disease modifying effects, so therapy is directed at preventing TEs. All patients require phlebotomies (PHLs) to keep hematocrit below 45% and once-daily low dose aspirin (if not contraindicated). Apart from patients at "high risk" because of age over 60 years or a thrombosis history, cytoreductive therapies (CT) should be given to patients with relevant signs of myeloproliferation or intolerance to PHLs. Approved choices both for first and second line CT are hydroxyurea (HU) and pegylated forms of interferon (peg-IFN), the latter probably being better for young patients, and subjects without critical and recent vascular events or massive splenomegaly. The JAK1/2 inhibitor ruxolitinib is the treatment of choice in case of resistance/intolerance to HU, with proved efficacy in terms of thrombotic prevention. Data are too preliminary to consider CT for "low risk" PV cases, but ropeg-IFN is being studied in this setting with a short follow-up. A careful monitoring for signs of evolution into PPV-MF is fundamental for optimizing patient management.
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Affiliation(s)
- Barbara Mora
- Department of Oncology, ASST Sette Laghi, Varese, Italy.
| | - Francesco Passamonti
- Department of Oncology, ASST Sette Laghi, Varese, Italy; Department of Medicine and Surgery, University of Insubria, Varese, Italy
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11
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Verstovsek S, Pemmaraju N, Reaven NL, Funk SE, Woody T, Valone F, Gupta S. Real-world treatments and thrombotic events in polycythemia vera patients in the USA. Ann Hematol 2023; 102:571-581. [PMID: 36637474 PMCID: PMC9977710 DOI: 10.1007/s00277-023-05089-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/29/2022] [Indexed: 01/14/2023]
Abstract
Polycythemia vera (PV) is a myeloproliferative neoplasm associated with increased risk of thrombotic events (TE) and death. Therapeutic interventions, phlebotomy and cytoreductive medications, are targeted to maintain hematocrit levels < 45% to prevent adverse outcomes. This retrospective observational study examined medical and pharmacy claims of 28,306 PV patients initiating treatment for PV in a data period inclusive of 2011 to 2019. Study inclusion required ≥ 2 PV diagnosis codes in the full data period, at least 1 year of PV treatment history, and ≥ 1 prescription claim and medical claim in both 2018 and 2019. Patients having ≥ 2 hematocrit (HCT) test results in linked outpatient laboratory data (2018-2019) were designated as the HCT subgroup (N = 4246). Patients were characterized as high- or low-risk at treatment initiation based on age and prior thrombotic history. The majority of patients in both risk groups (60% of high-risk and 83% of low-risk) initiated treatment with phlebotomy monotherapy, and during a median follow-up period of 808 days, the vast majority (81% low-risk, 74% high-risk) maintained their original therapy during the follow-up period. Hematocrit control was suboptimal in both risk groups; 54% of high-risk patients initiating with phlebotomy monotherapy sometimes/always had HCT levels > 50%; among low-risk patients, 64% sometimes/always had HCT levels above 50%. Overall, 16% of individuals experienced at least 1 TE subsequent to treatment initiation, 20% (n = 3920) among high-risk and 8% (n = 629) among low-risk patients. This real-world study suggests that currently available PV treatments may not be used to full advantage.
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12
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Alvarez-Larrán A, Garrote M, Ferrer-Marín F, Pérez-Encinas M, Mata-Vazquez MI, Bellosillo B, Arellano-Rodrigo E, Gómez M, García R, García-Gutiérrez V, Gasior M, Cuevas B, Angona A, Gómez-Casares MT, Martínez CM, Magro E, Ayala R, Del Orbe-Barreto R, Pérez-López R, Fox ML, Raya JM, Guerrero L, García-Hernández C, Caballero G, Murillo I, Xicoy B, Ramírez MJ, Carreño-Tarragona G, Hernández-Boluda JC, Pereira A. Real-world analysis of main clinical outcomes in patients with polycythemia vera treated with ruxolitinib or best available therapy after developing resistance/intolerance to hydroxyurea. Cancer 2022; 128:2441-2448. [PMID: 35417564 PMCID: PMC9324831 DOI: 10.1002/cncr.34195] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/21/2022] [Accepted: 02/14/2022] [Indexed: 11/16/2022]
Abstract
Background Ruxolitinib is approved for patients with polycythemia vera (PV) who are resistant/intolerant to hydroxyurea, but its impact on preventing thrombosis or disease‐progression is unknown. Methods A retrospective, real‐world analysis was performed on the outcomes of 377 patients with resistance/intolerance to hydroxyurea from the Spanish Registry of Polycythemia Vera according to subsequent treatment with ruxolitinib (n = 105) or the best available therapy (BAT; n = 272). Survival probabilities and rates of thrombosis, hemorrhage, acute myeloid leukemia, myelofibrosis, and second primary cancers were calculated according to treatment. To minimize biases in treatment allocation, all results were adjusted by a propensity score for receiving ruxolitinib or BAT. Results Patients receiving ruxolitinib had a significantly lower rate of arterial thrombosis than those on BAT (0.4% vs 2.3% per year; P = .03), and this persisted as a trend after adjustment for the propensity to have received the drug (incidence rate ratio, 0.18; 95% confidence interval, 0.02‐1.3; P = .09). There were no significant differences in the rates of venous thrombosis (0.8% and 1.1% for ruxolitinib and BAT, respectively; P = .7) and major bleeding (0.8% and 0.9%, respectively; P = .9). Ruxolitinib exposure was not associated with a higher rate of second primary cancers, including all types of neoplasia, noncutaneous cancers, and nonmelanoma skin cancers. After a median follow‐up of 3.5 years, there were no differences in survival or progression to acute leukemia or myelofibrosis between the 2 groups. Conclusions The results suggest that ruxolitinib treatment for PV patients with resistance/intolerance to hydroxyurea may reduce the incidence of arterial thrombosis. Lay Summary Ruxolitinib is better than other available therapies in achieving hematocrit control and symptom relief in patients with polycythemia vera who are resistant/intolerant to hydroxyurea, but we still do not know whether ruxolitinib provides an additional benefit in preventing thrombosis or disease progression. We retrospectively studied the outcomes of 377 patients with resistance/intolerance to hydroxyurea from the Spanish Registry of Polycythemia Vera according to whether they subsequently received ruxolitinib (n = 105) or the best available therapy (n = 272). Our findings suggest that ruxolitinib could reduce the incidence of arterial thrombosis, but a disease‐modifying effect could not be demonstrated for ruxolitinib in this patient population.
Ruxolitinib may reduce the incidence of arterial thrombosis in patients with polycythemia vera resistant/intolerant to hydroxyurea.
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Affiliation(s)
- Alberto Alvarez-Larrán
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Marta Garrote
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Francisca Ferrer-Marín
- Hospital Morales Messeguer, Universidad Católica San Antonio de Murcia, Murcia, Centro de Investigación Biomédica en Red de Enfermedades Raras, Murcia, Spain
| | | | | | | | | | | | | | | | | | | | - Anna Angona
- Hospital Josep Trueta, Institut Català d'Oncologia, Girona, Spain
| | | | | | - Elena Magro
- Hospital Príncipe de Asturias, Alcalá de Henares, Spain
| | - Rosa Ayala
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - José-María Raya
- Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | | | | | | | | | - Blanca Xicoy
- Hospital Germans Trias i Pujol, Institut Català d'Oncologia, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | | | | | - Arturo Pereira
- Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
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13
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Appropriate management of polycythaemia vera with cytoreductive drug therapy: European LeukemiaNet 2021 recommendations. Lancet Haematol 2022; 9:e301-e311. [DOI: 10.1016/s2352-3026(22)00046-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 02/06/2023]
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14
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Barbui T, Carobbio A, De Stefano V. Thrombosis in myeloproliferative neoplasms during cytoreductive and antithrombotic drug treatment. Res Pract Thromb Haemost 2022; 6:e12657. [PMID: 35155976 PMCID: PMC8822262 DOI: 10.1002/rth2.12657] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/31/2021] [Accepted: 01/12/2022] [Indexed: 12/16/2022] Open
Abstract
A state-of-the-art lecture titled "Myeloproliferative Neoplasm-associated Thrombosis" was presented at the ISTH congress in 2021. We summarize here the main points of the lecture with two purposes: to report the incidence rates of major thrombosis in polycythemia vera and essential thrombocythemia and to discuss to what extent cytoreductive therapy and antithrombotic drugs have reduced the incidence of these events. Unfortunately, the incidence rate of thrombosis remains high, ranging between 2 and 5/100 person-years. It is likely that new drugs such as interferon and ruxolitinib can be more efficacious given their cytoreductive and anti-inflammatory activities. Despite prophylaxis with vitamin K antagonists and direct oral anticoagulants after venous thrombosis in either common sites or splanchnic or cerebral sites, the incidence rate is still elevated, as high as 4 to 5/100 person-years. Future studies with new drugs or new strategies should consider thrombosis as the primary endpoint or surrogate biomarkers only if previously validated.
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Affiliation(s)
- Tiziano Barbui
- FROM Research FoundationPapa Giovanni XXIII HospitalBergamoItaly
| | | | - Valerio De Stefano
- Section of HematologyDepartment of Radiological and Hematological SciencesCatholic UniversityFondazione Policlinico A. Gemelli IRCCSRomeItaly
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Tefferi A, Vannucchi AM, Barbui T. Polycythemia vera: historical oversights, diagnostic details, and therapeutic views. Leukemia 2021; 35:3339-3351. [PMID: 34480106 PMCID: PMC8632660 DOI: 10.1038/s41375-021-01401-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/17/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
Polycythemia vera (PV) is a relatively indolent myeloid neoplasm with median survival that exceeds 35 years in young patients, but its natural history might be interrupted by thrombotic, fibrotic, or leukemic events, with respective 20-year rates of 26%, 16%, and 4%. Current treatment strategies in PV have not been shown to prolong survival or lessen the risk of leukemic or fibrotic progression and instead are directed at preventing thrombotic complications. In the latter regard, two risk categories are considered: high (age >60 years or thrombosis history) and low (absence of both risk factors). All patients require phlebotomy to keep hematocrit below 45% and once-daily low-dose aspirin, in the absence of contraindications. Cytoreductive therapy is recommended for high-risk or symptomatic low-risk disease; our first-line drug of choice in this regard is hydroxyurea but we consider pegylated interferon as an alternative in certain situations, including in young women of reproductive age, in patients manifesting intolerance or resistance to hydroxyurea therapy, and in situations where treatment is indicated for curbing phlebotomy requirement rather than preventing thrombosis. Additional treatment options include busulfan and ruxolitinib; the former is preferred in older patients and the latter in the presence of symptoms reminiscent of post-PV myelofibrosis or protracted pruritus. Our drug choices reflect our appreciation for long-term track record of safety, evidence for reduction of thrombosis risk, and broader suppression of myeloproliferation. Controlled studies are needed to clarify the added value of twice- vs once-daily aspirin dosing and direct oral anticoagulants. In this invited review, we discuss our current approach to diagnosis, prognostication, and treatment of PV in general, as well as during specific situations, including pregnancy and splanchnic vein thrombosis.
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Affiliation(s)
- Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Alessandro M Vannucchi
- Department of Experimental and Clinical Medicine, CRIMM, Center Research and Innovation of Myeloproliferative Neoplasms, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Tiziano Barbui
- Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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16
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Dam MJB, Pedersen RK, Knudsen TA, Andersen M, Skov V, Kjaer L, Hasselbalch HC, Ottesen JT. Data-driven analysis of the kinetics of the JAK2V617F allele burden and blood cell counts during hydroxyurea treatment of patients with polycythemia vera, essential thrombocythemia, and primary myelofibrosis. Eur J Haematol 2021; 107:624-633. [PMID: 34411333 DOI: 10.1111/ejh.13700] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/15/2021] [Accepted: 08/17/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hydroxyurea (HU) treatment of patients with essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis (PMF) (MPNs) normalizes elevated blood cell counts within weeks in the large majority of patients. Studies on the impact of HU upon the kinetics of the JAK2V617F allele burden, leukocyte, and platelet counts over time are scarce. PURPOSE Using data-driven analysis as a novel tool to model the kinetics of the JAK2V617F allele burden and blood cell counts over time during treatment with HU. MATERIAL AND METHODS Using serial measurements of JAK2V617F and correlation analysis of routine hematological values (the Hb-concentration, leukocyte count, platelet count, and lactic dehydrogenase), we present a detailed description and analysis of the kinetics of the JAK2V617F, leukocyte, and platelet counts and lactic dehydrogenase in 27 patients (PV = 18; ET = 7; PMF = 2), who were followed in the Danish randomized trial (DALIAH). To further analyze the JAK2V617F kinetics, we use a machine learning clustering algorithm to group the response patterns. RESULTS Response patterns were highly heterogeneous, with clustering resulting in 3 groups and 3 outliers. In the large majority of patients, HU treatment was initially associated with a modest decline in the JAK2V617F allele burden in concert with a decline in leukocyte and platelet counts. However, HU did not induce a sustained and continuous decrease in the JAK2V617F allele burden. CONCLUSION Using data-driven analysis of the JAK2V617F allele burden, leukocyte, and platelet kinetics during treatment with HU, we have shown that HU does not induce a sustained decrease in the JAK2V617F allele burden and neither induces sustained normalization of elevated cell counts in MPN patients. Our results may explain why MPN patients during treatment with HU still have a substantially increased risk of thrombosis.
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Affiliation(s)
- Marc J B Dam
- Center for Mathematical Modeling - Human Health and Disease, IMFUFA, Department of Science and Environment, Roskilde University, Roskilde, Denmark
| | - Rasmus K Pedersen
- Center for Mathematical Modeling - Human Health and Disease, IMFUFA, Department of Science and Environment, Roskilde University, Roskilde, Denmark
| | - Trine A Knudsen
- Department of Haematology, Zealand University Hospital, Roskilde, Denmark
| | - Morten Andersen
- Center for Mathematical Modeling - Human Health and Disease, IMFUFA, Department of Science and Environment, Roskilde University, Roskilde, Denmark
| | - Vibe Skov
- Department of Haematology, Zealand University Hospital, Roskilde, Denmark
| | - Lasse Kjaer
- Department of Haematology, Zealand University Hospital, Roskilde, Denmark
| | - Hans C Hasselbalch
- Department of Haematology, Zealand University Hospital, Roskilde, Denmark
| | - Johnny T Ottesen
- Center for Mathematical Modeling - Human Health and Disease, IMFUFA, Department of Science and Environment, Roskilde University, Roskilde, Denmark
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17
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Improving the investigative approach to polycythaemia vera: a critical assessment of current evidence and vision for the future. LANCET HAEMATOLOGY 2021; 8:e605-e612. [PMID: 34329580 DOI: 10.1016/s2352-3026(21)00171-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 12/19/2022]
Abstract
Polycythaemia vera is a challenging disease to study given its low prevalence and prolonged time-to-event for important clinical endpoints such as thrombosis, progression, and mortality. Although researchers in this space often rise to meet these challenges, there is considerable room for improvement in the analysis of retrospective data, the development of risk-stratification tools, and the design of randomised controlled trials. In this Viewpoint, we review the evidence behind the contemporary approach to risk stratification and treatment of polycythaemia vera. Frameworks for using data more efficiently, constructing more nuanced prognostic models, and overcoming challenges in clinical trial design are discussed.
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Altomare I, Parasuraman S, Paranagama D, Kish J, Lord K, Yu J, Colucci P. Real-World Dosing Patterns of Ruxolitinib in Patients With Polycythemia Vera Who Are Resistant to or Intolerant of Hydroxyurea. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:e915-e921. [PMID: 34353779 DOI: 10.1016/j.clml.2021.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Approximately one-quarter of patients with polycythemia vera become resistant to and/or intolerant of hydroxyurea. This analysis characterizes reasons patients were switched from hydroxyurea to ruxolitinib and describes ruxolitinib dosing patterns and outcomes in real-world clinical practice. PATIENTS AND METHODS This medical chart review of United States community hematology/oncology practices in the Cardinal Health Oncology Provider Extended Network included patients with polycythemia vera who were ≥18 years old, received hydroxyurea for ≥3 months, started ruxolitinib between January 1, 2015 and December 31, 2016, and had ≥2 visits during the subsequent 6 months. Clinical data were collected at predefined intervals from diagnosis to last provider visit. RESULTS Providers identified 249 patients for inclusion. jcauses of hydroxyurea discontinuation were resistance (78%; frequently for hematocrit ≥45% [79%]) and intolerance (28%; frequently for nausea/vomiting [50%]). Initial ruxolitinib dosing was 10 mg twice daily (recommended dose) in 131 patients (53%). Among these patients, median treatment duration was 29.2 months, 35 (27%) had dose modification (increase, n = 24; decrease, n = 11) and 4 had interruptions within 6 months. The most common reason for dose increase was continued need for phlebotomy (46%); 6 patients had dose reductions owing to reduced platelets. Hematocrit control at initiation and during the first 6 months of ruxolitinib treatment was 15% and 63%, respectively. CONCLUSION Most patients initiated ruxolitinib upon hydroxyurea resistance. Approximately half initiated ruxolitinib at the recommended dose, 27% of whom experienced dosing modifications within the first 6 months. After switching to ruxolitinib, most patients achieved hematocrit control and continued treatment for extended time frames.
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Affiliation(s)
| | | | | | | | - Kevin Lord
- Cardinal Health Specialty Solutions, Dublin, OH
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Bewersdorf JP, Giri S, Wang R, Podoltsev N, Williams RT, Tallman MS, Rampal RK, Zeidan AM, Stahl M. Interferon alpha therapy in essential thrombocythemia and polycythemia vera-a systematic review and meta-analysis. Leukemia 2021; 35:1643-1660. [PMID: 32868875 PMCID: PMC7917159 DOI: 10.1038/s41375-020-01020-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/28/2020] [Accepted: 08/06/2020] [Indexed: 01/28/2023]
Abstract
Data on the efficacy and safety of interferon (IFN)-α for the treatment of essential thrombocythemia (ET) and polycythemia vera (PV) are inconsistent. We conducted a systematic review and meta-analysis and searched MEDLINE and EMBASE via Ovid, Scopus, COCHRANE registry of clinical trials, and Web of Science from inception through 03/2019 for studies of pegylated IFN (peg-IFN) and non-pegylated IFN (non-peg-IFN) in PV and ET patients. Random-effects models were used to pool response rates for the primary outcome of overall response rate (ORR) defined as a composite of complete response, partial response, complete hematologic response (CHR) and partial hematologic response. Peg-IFN and non-peg-IFN were compared by meta-regression analyses. In total, 44 studies with 1359 patients (730 ET, 629 PV) were included. ORR were 80.6% (95% confidence interval: 76.6-84.1%, CHR: 59.0% [51.5%-66.1%]) and 76.7% (67.4-84.0%; CHR: 48.5% [37.8-59.4%]) for ET and PV patients, respectively. In meta-regression analyses results did not differ significantly for non-peg-IFN vs. peg-IFN. Annualized rates of thromboembolic complications and treatment discontinuation due to adverse events were low at 1.2% and 8.8% for ET and 0.5% and 6.5% for PV patients, respectively. Both peg-IFN and non-peg-IFN can be effective and safe long-term treatments for ET and PV.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT, USA
| | - Smith Giri
- Division of Hematology and Oncology, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Rong Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, USA
| | - Nikolai Podoltsev
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT, USA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | | | - Martin S Tallman
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Raajit K Rampal
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, CT, USA
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, CT, USA
| | - Maximilian Stahl
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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20
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Tan G, Meier-Abt F. Differential expression of hydroxyurea transporters in normal and polycythemia vera hematopoietic stem and progenitor cell subpopulations. Exp Hematol 2021; 97:47-56.e5. [PMID: 33677043 DOI: 10.1016/j.exphem.2021.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/18/2021] [Accepted: 02/28/2021] [Indexed: 11/16/2022]
Abstract
Polycythemia vera (PV) is a myeloproliferative neoplasm marked by hyperproliferation of the myeloid lineages and the presence of an activating JAK2 mutation. Hydroxyurea (HU) is a standard treatment for high-risk patients with PV. Because disease-driving mechanisms are thought to arise in PV stem cells, effective treatments should target primarily the stem cell compartment. We tested for the antiproliferative effect of patient treatment with HU in fluorescence-activated cell sorting-isolated hematopoietic stem/multipotent progenitor cells (HSC/MPPs) and more committed erythroid progenitors (common myeloid/megakaryocyte-erythrocyte progenitors [CMP/MEPs]) in PV using RNA-sequencing and gene set enrichment analysis. HU treatment led to significant downregulation of gene sets associated with cell proliferation in PV HSCs/MPPs, but not in PV CMP/MEPs. To explore the mechanism underlying this finding, we assessed for expression of solute carrier membrane transporters, which mediate transmembrane movement of drugs such as HU into target cells. The active HU uptake transporter OCTN1 was upregulated in HSC/MPPs compared with CMP/MEPs of untreated patients with PV, and the HU diffusion facilitator urea transporter B (UTB) was downregulated in HSC/MPPs compared with CMP/MEPs in all patient and control groups tested. These findings indicate a higher accumulation of HU within PV HSC/MPPs compared with PV CMP/MEPs and provide an explanation for the differential effects of HU in HSC/MPPs and CMP/MEPs of patients with PV. In general, the findings highlight the importance of transporter expression in linking therapeutics with human disease.
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Affiliation(s)
- Ge Tan
- Functional Genomics Center Zurich, University and ETH Zurich, Zurich, Switzerland
| | - Fabienne Meier-Abt
- Department of Medical Oncology and Hematology, University Hospital Zurich and University of Zurich, Zurich, Switzerland; Department of Biology, Institute of Molecular Systems Biology, ETH Zurich, Zurich, Switzerland.
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21
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Arya Y, Syal A, Gupta M, Gaba S. Advances in the Treatment of Polycythemia Vera: Trends in Disease Management. Cureus 2021; 13:e14193. [PMID: 33936902 PMCID: PMC8084584 DOI: 10.7759/cureus.14193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Treatment modalities for polycythemia vera (PV) have evolved over time. Phlebotomy and low-dose aspirin suffice in low-risk patients, but cytoreductive therapies are indicated in all high-risk patients (age ≥ 65 years or those with a history of PV-related thrombotic event) and may be considered for low-risk patients with progressively increasing splenomegaly, progressively increasing leucocyte and platelet counts, and for those who do not tolerate phlebotomy. Hydroxyurea/hydroxycarbamide or interferons can be used as first-line drugs. Hydroxyurea may not be tolerated by some patients, and it also carries risk of myelosuppression. Interferon alfa is especially useful for PV symptoms, and the newer preparation, ropeginterferon alfa-2b, has lesser incidence of flu-like reactions. Ruxolitinib reduces the JAK2V617F mutation burden and is used as a second-line drug. Anagrelide reduces platelet production and can be used in conjunction with hydroxyurea in patients with excessive thrombocytosis. The alkylating agent, busulfan, can also be used as a last resort in patients with a limited life expectancy. Prospective future treatments include givinostat, a histone deacetylase inhibitor, and idasanutlin, a murine double minute 2 antagonist.
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Affiliation(s)
- Yajur Arya
- Internal Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, IND
| | - Arshi Syal
- Internal Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, IND
| | - Monica Gupta
- Internal Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, IND
| | - Saurabh Gaba
- Internal Medicine, Government Medical College and Hospital, Chandigarh, Chandigarh, IND
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22
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Brabrand M, Frederiksen H. Risks of Solid and Lymphoid Malignancies in Patients with Myeloproliferative Neoplasms: Clinical Implications. Cancers (Basel) 2020; 12:cancers12103061. [PMID: 33092233 PMCID: PMC7589412 DOI: 10.3390/cancers12103061] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/05/2020] [Accepted: 10/19/2020] [Indexed: 01/21/2023] Open
Abstract
Simple Summary Patients with chronic myeloproliferative neoplasms (MPNs) such as polycythemia vera and essential thrombocythemia have an elevated risk of acute leukemia. Recently, it has been recognized that the risk of solid cancers is also increased. In the past decade, several studies have compared cancer frequency in patients with MPNs with the general population. In our study, we present results sampled from 12 previous studies, totaling more than 65,000 patients with MPNs identified through large registries. Patients with MPNs were compared to the age/sex-matched general population. Our results show that risk of new cancers is 1.5–3.0-fold elevated in patients with MPNs. In particular, lymphomas and cancers of the skin, lung, kidney, and thyroid gland occur more frequently. The difference in cancer occurrence is highest in the age group 60–79 years. Our results indicate that clinical follow up of patients with MPNs should include awareness of the increased cancer risk. Abstract In the past decade, several studies have reported that patients with chronic myeloproliferative neoplasms (MPNs) have an increased risk of second solid cancer or lymphoid hematological cancer. In this qualitative review study, we present results from studies that report on these cancer risks in comparison to cancer incidences in the general population or a control group. Our literature search identified 12 such studies published in the period 2009–2018 including analysis of more than 65,000 patients. The results showed that risk of solid cancer is 1.5- to 3.0-fold elevated and the risk of lymphoid hematological cancer is 2.5- to 3.5-fold elevated in patients with MPNs compared to the general population. These elevated risks apply to all MPN subtypes. For solid cancers, particularly risks of skin cancer, lung cancer, thyroid cancer, and kidney cancer are elevated. The largest difference in cancer risk between patients with MPN and the general population is seen in patients below 80 years. Cancer prognosis is negatively affected due to cardiovascular events, thrombosis, and infections by a concurrent MPN diagnosis mainly among patients with localized cancer. Our review emphasizes that clinicians caring for patients with MPNs should be aware of the very well-documented increased risk of second non-myeloid cancers.
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Affiliation(s)
- Mette Brabrand
- Department of Haematology, Odense University Hospital, 5000 Odense, Denmark;
- Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, 5000 Odense, Denmark
| | - Henrik Frederiksen
- Department of Haematology, Odense University Hospital, 5000 Odense, Denmark;
- Department of Clinical Epidemiology, Aarhus University Hospital, 8200 Aarhus, Denmark
- Correspondence:
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23
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Buxhofer-Ausch V, Wolf D, Sormann S, Forjan E, Schimetta W, Gisslinger B, Heibl S, Krauth MT, Thiele J, Ruckser R, Gisslinger H. Impact of platelets on major thrombosis in patients with a normal white blood cell count in essential thrombocythemia. Eur J Haematol 2020; 106:58-63. [PMID: 32909297 PMCID: PMC7756407 DOI: 10.1111/ejh.13516] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 12/17/2022]
Abstract
Objectives Cell counts have a significant impact on the complex mechanism of thrombosis in patients with essential thrombocythemia (ET). We recently demonstrated a considerable impact of white blood cell (WBC) counts on thrombotic risk in patients with optimized platelet counts by analysing a large anagrelide registry. In contrast, the current analysis of the registry aimed to estimate the influence of platelet counts on thrombotic risk in patients with optimized WBC counts. Methods Cox regression analysis and Kaplan‐Meier plot were applied on all patients in the registry with optimized WBC counts. Results By using the calculated cut‐off of 593 G/L for platelets, Cox regression analysis revealed a clear influence of elevated platelet counts on the occurrence of a major thrombotic event (P < .001). A Kaplan‐Meier plot revealed a markedly shorter time to a major thrombotic event for patients with platelet counts above the cut‐off (P < .001). Conclusions The data show clear impact of platelet lowering on the thrombotic risk in ET patients with normal WBC counts. Therefore, selective platelet lowering with anagrelide appears sufficient for thrombotic risk reduction in WHO‐diagnosed ET patients lacking leukocytosis.
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Affiliation(s)
- Veronika Buxhofer-Ausch
- Department of Internal Medicine I for Haematology with Stem Cell Transplantation, Haemostasis and Medical Oncology, Ordensklinikum Linz Elisabethinen, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Dominik Wolf
- Division of Haematology and Oncology, Innsbruck Medical University, Innsbruck, Austria
| | - Siegfried Sormann
- Department of Haematology, Medical University of Graz, Graz, Austria
| | - Ernst Forjan
- Department of Internal Medicine 3, Hanusch Hospital, Vienna, Austria
| | - Wolfgang Schimetta
- Department of Applied Systems Research and Statistics, Johannes Kepler University, Linz, Austria
| | - Bettina Gisslinger
- Department of Haematology and Blood Coagulation, Division of Internal Medicine I,, Medical University of Vienna, Vienna, Austria
| | - Sonja Heibl
- Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Maria Theresa Krauth
- Department of Haematology and Blood Coagulation, Division of Internal Medicine I,, Medical University of Vienna, Vienna, Austria
| | - Jürgen Thiele
- Department of Pathology, University of Cologne, Cologne, Germany
| | | | - Heinz Gisslinger
- Department of Haematology and Blood Coagulation, Division of Internal Medicine I,, Medical University of Vienna, Vienna, Austria
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24
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Ruxolitinib for the prevention of thrombosis in polycythemia vera: a systematic review and meta-analysis. Blood Adv 2020; 4:380-386. [PMID: 31985808 DOI: 10.1182/bloodadvances.2019001158] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/27/2019] [Indexed: 12/13/2022] Open
Abstract
Ruxolitinib is a recommended second-line treatment for the prevention of thrombosis in patients with polycythemia vera who become resistant or intolerant to hydroxyurea; however, evidence regarding its efficacy in terms of thrombosis reduction is uncertain. We searched Medline, Embase, and archives of abstracts from the European Hematology Association and the American Society of Hematology annual congresses from 2014 onward for randomized controlled trials comparing the treatment vs best available therapy (BAT). Our search retrieved 80 records; after screening of abstracts and full text, the total was reduced to 16. Evidence came from 4 randomized controlled trials, including 663 patients (1057 patients per year). We estimated a thrombosis risk ratio of 0.56 for ruxolitinib BAT, corresponding to an incidence of 3.09% and 5.51% patients per year, respectively. The number of thrombotic events reported with ruxolitinib was consistently lower than that with BAT in our sample, but, globally, the difference did not reach significance (P = .098). Hard evidence in favor of ruxolitinib is lacking; a clinical trial on selected patients at high risk of thrombosis would be warranted, but its feasibility is questionable.
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25
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From leeches to interferon: should cytoreduction be prescribed for all patients with polycythemia vera? Leukemia 2020; 34:2837-2839. [PMID: 32678292 DOI: 10.1038/s41375-020-0984-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 06/25/2020] [Accepted: 07/08/2020] [Indexed: 11/08/2022]
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26
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Stein BL, Martin K. From Budd-Chiari syndrome to acquired von Willebrand syndrome: thrombosis and bleeding complications in the myeloproliferative neoplasms. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:397-406. [PMID: 31808903 PMCID: PMC6913438 DOI: 10.1182/hematology.2019001318] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Thrombotic and hemorrhagic complications are prevalent in patients with essential thrombocythemia, polycythemia vera, and myelofibrosis. Given the impact on morbidity and mortality, reducing the risk of thrombosis and/or hemorrhage is a major therapeutic goal. Historically, patients have been risk stratified on the basis of traditional factors, such as advanced age and thrombosis history. However, multiple factors contribute to the thrombotic tendency, including gender, mutational profile, inflammatory stress, and abnormal cell adhesion. Management includes cardiovascular risk reduction and use of antiplatelet therapy, depending on myeloproliferative neoplasm subtype and mutational status. Anticoagulation is a mainstay of therapy for those with venous thrombosis, but practice patterns remain heterogeneous. Cytoreduction is indicated for higher-risk patients, but efficacy may depend on the involved vascular bed. Management of special situations, such as unusual site thrombosis, bleeding, the perioperative period, and pregnancy, are especially challenging. In this article, risk factors and treatment strategies for myeloproliferative neoplasm thrombosis and bleeding, including special situations, are reviewed. Insights gained from recent studies may lead to the development of a more precise risk classification and tailored therapy.
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Affiliation(s)
- Brady L Stein
- Division of Hematology/Oncology and Robert H. Lurie Comprehensive Cancer Center, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Karlyn Martin
- Division of Hematology/Oncology and Robert H. Lurie Comprehensive Cancer Center, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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