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Tam C, Zhao FL, Azam S, Li SC, Tang B. Real-world treatment patterns and outcomes for patients with CLL using the Australian pharmaceutical benefits scheme (PBS) dataset. Leuk Lymphoma 2024:1-10. [PMID: 38967513 DOI: 10.1080/10428194.2024.2374040] [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: 02/29/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024]
Abstract
This real-world retrospective cohort study using Australian Pharmaceutical Benefits Scheme (PBS) 10% investigated changes in chronic lymphocytic leukemia (CLL) treatment by line of therapy, time-to-next-treatment, treatment duration, and overall survival (OS). Overall, 803 patients received their first PBS-reimbursed CLL medication between 1 January 2011 to 31 July 2021 (median age: 70 years; 64.6% male), 289 post-1 August 2020. In 2011, most first-line (1 L) prescribing was fludarabine, cyclophosphamide, and rituximab (FCR). By 2021, common 1L were chlorambucil ± CD20 (26.1%), Bruton Tyrosine Kinase inhibitor (BTKi) (26.1%), and CD20 monotherapy (23.9%). In 2011, relapsed/refractory (R/R) CLL treatment was CD20 monotherapy or FCR. By 2021, BTKi (57.7%) and venetoclax ± CD20 (26.1%) were most common. Compared to FCR, 1 L treatment duration (Hazard Ratio) was shorter for CD20 monotherapy (1.7) or chlorambucil ± CD20 (2.5). In R/R CLL, median duration was 24 (ibrutinib) and 19 months (venetoclax). Median OS was 127 months. CLLtreatment pattern shave greatly changed in Australia since the introduction of novel therapies.
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Affiliation(s)
- Constantine Tam
- The Alfred Hospital, Melbourne, Australia
- Leukemia, Monash University, Clayton, Australia
| | - Fei-Li Zhao
- BeiGene Proprietary Limited, Sydney,Australia
| | - Safee Azam
- Prospection Proprietary Limited, Australia
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Loscertales J, Abrisqueta-Costa P, Gutierrez A, Hernández-Rivas JÁ, Andreu-Lapiedra R, Mora A, Leiva-Farré C, López-Roda MD, Callejo-Mellén Á, Álvarez-García E, García-Marco JA. Real-World Evidence on the Clinical Characteristics and Management of Patients with Chronic Lymphocytic Leukemia in Spain Using Natural Language Processing: The SRealCLL Study. Cancers (Basel) 2023; 15:4047. [PMID: 37627075 PMCID: PMC10452602 DOI: 10.3390/cancers15164047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/04/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
The SRealCLL study aimed to obtain real-world evidence on the clinical characteristics and treatment patterns of patients with chronic lymphocytic leukemia (CLL) using natural language processing (NLP). Electronic health records (EHRs) from seven Spanish hospitals (January 2016-December 2018) were analyzed using EHRead® technology, based on NLP and machine learning. A total of 534 CLL patients were assessed. No treatment was detected in 270 (50.6%) patients (watch-and-wait, W&W). First-line (1L) treatment was identified in 230 (43.1%) patients and relapsed/refractory (2L) treatment was identified in 58 (10.9%). The median age ranged from 71 to 75 years, with a uniform male predominance (54.8-63.8%). The main comorbidities included hypertension (W&W: 35.6%; 1L: 38.3%; 2L: 39.7%), diabetes mellitus (W&W: 24.4%; 1L: 24.3%; 2L: 31%), cardiac arrhythmia (W&W: 16.7%; 1L: 17.8%; 2L: 17.2%), heart failure (W&W 16.3%, 1L 17.4%, 2L 17.2%), and dyslipidemia (W&W: 13.7%; 1L: 18.7%; 2L: 19.0%). The most common antineoplastic treatment was ibrutinib in 1L (64.8%) and 2L (62.1%), followed by bendamustine + rituximab (12.6%), obinutuzumab + chlorambucil (5.2%), rituximab + chlorambucil (4.8%), and idelalisib + rituximab (3.9%) in 1L and venetoclax (15.5%), idelalisib + rituximab (6.9%), bendamustine + rituximab (3.5%), and venetoclax + rituximab (3.5%) in 2L. This study expands the information available on patients with CLL in Spain, describing the diversity in patient characteristics and therapeutic approaches in clinical practice.
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Affiliation(s)
- Javier Loscertales
- Hematology Department, Hospital Universitario de la Princesa, Calle de Diego de León 62, 28006 Madrid, Spain;
| | - Pau Abrisqueta-Costa
- Hematology Department, Hospital Universitari Vall d’Hebron, Pg de la vall d’Hebron 199, 08035 Barcelona, Spain
| | - Antonio Gutierrez
- Hematology Department, Hospital Son Espases/IdISBa, Carretera de Valldemossa 79, 07120 Palma de Mallorca, Spain;
| | - José Ángel Hernández-Rivas
- Hematology Department, Hospital Universitario Infanta Leonor, Avda. Gran Vía del Este 80, 28031 Madrid, Spain;
| | - Rafael Andreu-Lapiedra
- Hematology Department, Hospital Universitario La Fe, Avinguda de Fernando Abril Martorell 106, 46026 Valencia, Spain;
| | - Alba Mora
- Hematology Department, Hospital de la Santa Creu i Sant Pau, Calle de St. Antoni Maria Claret 167, 08025 Barcelona, Spain;
| | - Carolina Leiva-Farré
- Medical Department, Astrazeneca Farmacéutica Spain S.A., Calle del Puerto de Somport 21, 28050 Madrid, Spain; (C.L.-F.); (M.D.L.-R.); (Á.C.-M.); (E.Á.-G.)
| | - María Dolores López-Roda
- Medical Department, Astrazeneca Farmacéutica Spain S.A., Calle del Puerto de Somport 21, 28050 Madrid, Spain; (C.L.-F.); (M.D.L.-R.); (Á.C.-M.); (E.Á.-G.)
| | - Ángel Callejo-Mellén
- Medical Department, Astrazeneca Farmacéutica Spain S.A., Calle del Puerto de Somport 21, 28050 Madrid, Spain; (C.L.-F.); (M.D.L.-R.); (Á.C.-M.); (E.Á.-G.)
| | - Esther Álvarez-García
- Medical Department, Astrazeneca Farmacéutica Spain S.A., Calle del Puerto de Somport 21, 28050 Madrid, Spain; (C.L.-F.); (M.D.L.-R.); (Á.C.-M.); (E.Á.-G.)
| | - José Antonio García-Marco
- Hematology Department, Hospital Universitario Puerta de Hierro-Majadahonda, Calle Joaquín Rodrigo 1, 28222 Majadahonda, Spain;
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Urso A, Cavazzini F, Ballardini MP, Gambara S, Consolo S, Rigolin GM, Cuneo A. First-Line Treatment of Older Patients with CLL: A New Approach in the Chemo-Free Era. Cancers (Basel) 2023; 15:3859. [PMID: 37568676 PMCID: PMC10417156 DOI: 10.3390/cancers15153859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Bruton tyrosine kinase inhibitors (BTKi) and the BCL2 inhibitor venetoclax, with or without the anti-CD20 monoclonal antibody Obinutuzumab, represent the preferred options for the first-line therapy of CLL because they are more effective and may improve quality of life. However, patient inclusion criteria are heterogeneous across trials designed for older patients, and the identification of CLL-specific parameters identifying unfit patients at risk of developing drug-specific adverse events is required to guide treatment choice. Due to inclusion/exclusion criteria in trials, higher discontinuation rates with BTKi were reported in real-world studies, and registry analyses provided useful information on factors predicting earlier discontinuation in a real-world setting. Though targeted agents were shown to be cost-effective treatments in high-income countries, the out-of-pocket expenses may limit accessibility to these drugs, and the overall expenditure for new drugs in CLL is projected to increase substantially, posing an issue for sustainability. This being said, the choice of a finite-duration treatment based on venetoclax-containing regimens or treatment until progression with BTKi is today possible in high-income countries, and the therapy choice drivers are represented by coexisting medical conditions rather than age, patient expectations, logistics, and sustainability.
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Affiliation(s)
| | | | | | | | | | | | - Antonio Cuneo
- Hematology Unit, University of Ferrara, 44121 Ferrara, Italy (F.C.); (M.P.B.); (S.C.)
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Visentin A, Puthenparampil M, Briani C. Bruton tyrosine kinase inhibitors: can they be optimized for the treatment of neuroinflammatory disorders? Expert Opin Investig Drugs 2023; 32:1105-1111. [PMID: 38153100 DOI: 10.1080/13543784.2023.2288076] [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: 08/18/2023] [Accepted: 11/22/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Bruton's tyrosine kinase (BTK) is a multifaceted player of the immune system which has been involved in the survival of hematological malignancies but also in the pathogenesis of immune-mediated diseases. Oral BTK inhibitors (BTKi) have become a cornerstone for the treatment of patients with B-cell malignancies, and are under investigation for several immune-mediated diseases. AREAS COVERED We reviewed the biology of BTK and emerging data on BTKi in patients with neuroinflammatory disorders of both the peripheral and central nervous system. EXPERT OPINION We support the use of BTKi in relapsed/refractory patients with multiple sclerosis and anti-MAG antibody neuropathies. However, other immune-mediated neuroinflammatory disorders are likely to benefit from BTKi. Whether BTKi will improve the response rates than conventional therapies in previously untreated patients is unknown and will be assessed within future clinical trials. Furthermore, the availability of more selective BTKi, with less adverse events, will improve patients' tolerability and expand our treatment landscape.
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Affiliation(s)
- Andrea Visentin
- Neurology Unit, Department of Neurosciences, University of Padova, Padua, Italy
| | | | - Chiara Briani
- Hematology Unit, Department of Medicine, University of Padova, Padua, Italy
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Robak P, Robak T. Immunotherapy combinations for chronic lymphocytic leukemia: advantages and disadvantages. Expert Opin Biol Ther 2023; 23:21-35. [PMID: 36374125 DOI: 10.1080/14712598.2022.2145881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the last few years, BTK inhibitors, PI3K inhibitors, and venetoclax have been approved for clinical use against chronic lymphocytic leukemia (CLL), both as single agents, and in combination. This article summarizes recent achievements in the treatment of patients with CLL, and pays special attention to novel targeted drugs and monoclonal antibodies (Mabs). A literature search was conducted of the PubMed and Google Scholar databases. Rituximab and obinutuzumab have been combined with chemotherapy, and more recently, with BTK inhibitors, PI3K inhibitors, and venetoclax. These agents have demonstrated high activity in treatment naïve (TN) and relapsed or refractory (RR) CLL. Immunochemotherapy regimens are currently considered in TN younger patients with IGHV-mutated disease and should not be given in patients without IGHV mutation. BTK inhibitors are more commonly used as monotherapy in TN and RR patients. PI3K inhibitors can be combined with CD20 Mabs, but their use in CLL is limited due to safety concerns. Venetoclax is typically combined with anti-CD20 Mabs in CLL. Generally, the optimal sequencing of therapies remains to be established, and the selection of upfront therapy needs to be tailored to the individual patient.
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Affiliation(s)
- Pawel Robak
- Department of Experimental Hematology, Medical University of Lodz, Łódź, Poland
| | - Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Łódź, Poland
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Visentin A, Molinari MC, Pravato S, Cellini A, Angotzi F, Cavaretta CA, Ruocco V, Imbergamo S, Piazza F, Proietti G, Mauro FR, Trentin L. A Retrospective Study on the Efficacy of Subcutaneous Immunoglobulin as Compared to Intravenous Formulation in Patients with Chronic Lymphocytic Leukemia and Secondary Antibody Deficiency. Curr Oncol 2022; 30:274-283. [PMID: 36661671 PMCID: PMC9857433 DOI: 10.3390/curroncol30010022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/11/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
Secondary antibody deficiency (SAD) is a common complication in chronic lymphocytic leukemia (CLL) which favors the development of life-threatening infections. Subcutaneous immunoglobulins (IG) (SCIG) have been proven to be as effective as intravenous immunoglobulin (IVIG) in primary immunodeficiencies. Since only a few studies investigated SCIG in secondary antibody deficiency, the aim of this study was to assess the efficacy and safety of SCIG or IVIG in CLL patients with secondary antibody deficiency. One hundred and sixteen CLL patients were recruited, 63% were males, and the median age was 68 years; 44% had bronchiectasis and 76% never smoked. Forty-nine patients received IVIG and 88 SCIG, including 28 patients who shifted from IVIG to SCIG. Despite similar baseline IgG levels, patients receiving SCIG achieved higher IgG after at least +6 months (p = 0.0009). We observed that SCIG can decrease the cumulative incidence of first (HR 0.39 p < 0.0001) and second (HR 0.56 p = 0.0411) infection more than IVIG. The effect was remarkable in that patients were able to reach at least 6 g/L of IgG after 6 months of treatments (p < 0.0001). Replacement therapies were well tolerated with less adverse events and a lower discontinuation rate in patients was managed with SCIG than IVIG. In this study we describe the clinical features of a large cohort of CLL with secondary antibody deficiency receiving IG. We demonstrated that SCIG are active and well tolerated drugs that allows to reach higher IgG levels and decrease the rate of infections better than IVIG, in particular when IgG levels reach 6 g/L.
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Affiliation(s)
- Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy
- Hematology Unit, Department of Medicine of Systems (DIDAS), Azienda Ospedale Università Padova, 35128 Padova, Italy
| | - Maria Chiara Molinari
- Hematology Unit, Department of Translational and Precision Medicine, Sapienza University, 00185 Rome, Italy
| | - Stefano Pravato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Alessandro Cellini
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Francesco Angotzi
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Chiara Adele Cavaretta
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Valeria Ruocco
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Silvia Imbergamo
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Francesco Piazza
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy
| | - Giulia Proietti
- Hematology Unit, Department of Translational and Precision Medicine, Sapienza University, 00185 Rome, Italy
| | - Francesca Romana Mauro
- Hematology Unit, Department of Translational and Precision Medicine, Sapienza University, 00185 Rome, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padova, 35128 Padova, Italy
- Hematology Unit, Department of Medicine of Systems (DIDAS), Azienda Ospedale Università Padova, 35128 Padova, Italy
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7
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Visentin A, Mauro FR, Catania G, Fresa A, Vitale C, Sanna A, Mattiello V, Cibien F, Sportoletti P, Gentile M, Rigolin GM, Quaglia FM, Murru R, Gozzetti A, Molica S, Marchetti M, Pravato S, Angotzi F, Cellini A, Scarfò L, Reda G, Coscia M, Laurenti L, Ghia P, Foà R, Cuneo A, Trentin L. Obinutuzumab plus chlorambucil versus ibrutinib in previously untreated chronic lymphocytic leukemia patients without TP53 disruptions: A real-life CLL campus study. Front Oncol 2022; 12:1033413. [PMID: 36479077 PMCID: PMC9719965 DOI: 10.3389/fonc.2022.1033413] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/20/2022] [Indexed: 08/13/2023] Open
Abstract
One of the main issues in the treatment of patients with chronic lymphocytic leukemia (CLL) deals with the choice between continuous or fixed-duration therapy. Continuous ibrutinib (IB), the first-in-class BTK inhibitor, and obinutuzumab-chlorambucil (G-CHL) are commonly used therapies for elderly and/or comorbid patients. No head-to-head comparison has been carried out. Within the Italian campus CLL network, we performed a retrospective study on CLL patients without TP53 disruption treated with IB or G-CHL as first-line therapy. Patients in the G-CHL arm had a higher CIRS score and the worst renal function. The overall response rates between the G-CHL and IB arms were similar, but more complete remissions (CRs) were achieved with G-CHL (p = 0.0029). After a median follow-up of 30 months, the progression-free survival (PFS, p = 0.0061) and time to next treatment (TTNT, p = 0.0043), but not overall survival (OS, p = 0.6642), were better with IB than with G-CHL. Similar results were found after propensity score matching and multivariate analysis. While PFS and TTNT were longer with IB than with G-CHL in IGHV unmutated patients (p = 0.0190 and 0.0137), they were superimposable for IGHV mutated patients (p = 0.1900 and 0.1380). In the G-CHL arm, the depth of response (79% vs. 68% vs. 38% for CR, PR and SD/PD; p < 0.0001) and measurable residual disease (MRD) influenced PFS (78% vs. 53% for undetectable MRD vs. detectable MRD, p = 0.0203). Hematological toxicities were common in the G-CHL arm, while IB was associated with higher costs. Although continuous IB provides better disease control in CLL, IGHV mutated patients and those achieving an undetectable MRD show a marked clinical and economic benefit from a fixed-duration obinutuzumab-based treatment.
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Affiliation(s)
- Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padova, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
| | - Francesca Romana Mauro
- Hematology, Department of Translational and Precision Medicine, “Sapienza” University, Rome, Italy
| | - Gioachino Catania
- Division of Hematology, Hospital Saints (A. O. SS) Antonio e Biagio and Cesare Arrigo, Alessandria, Italy
| | - Alberto Fresa
- Hematology Institute, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - Candida Vitale
- Department of Molecular Biotechnology and health Sciences, University of Torino and Division of Hematology, University Hospital (A.O.U.) Città della Salute e della Scienza di Torino, Torino, Italy
| | | | - Veronica Mattiello
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore, University of Milan, Milan, Italy
| | | | - Paolo Sportoletti
- Hematology and Clinical Immunology Unit, University of Perugia, Perugia, Italy
| | | | - Gian Matteo Rigolin
- Hematology Section, Department of Medical Sciences, Azienda Ospedaliera-Universitaria, Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - Francesca Maria Quaglia
- Department of Medicine, Section of Hematology, University of Verona and Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Roberta Murru
- Hematology and Stem Cell Transplantation Unit, Ospedale A. Businco ARNAS “G. Brotzu”, Cagliari, Italy
| | | | - Stefano Molica
- Department Hematology-Oncology, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy
| | - Monia Marchetti
- Division of Hematology, Hospital Saints (A. O. SS) Antonio e Biagio and Cesare Arrigo, Alessandria, Italy
| | - Stefano Pravato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padova, Italy
| | - Francesco Angotzi
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padova, Italy
| | - Alessandro Cellini
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padova, Italy
| | - Lydia Scarfò
- Strategic Program on CLL, University Health and Science “San Raffaele”, Milan, Italy
| | - Gianluigi Reda
- Hematology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore, University of Milan, Milan, Italy
| | - Marta Coscia
- Department of Molecular Biotechnology and health Sciences, University of Torino and Division of Hematology, University Hospital (A.O.U.) Città della Salute e della Scienza di Torino, Torino, Italy
| | - Luca Laurenti
- Hematology Institute, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | - Paolo Ghia
- Strategic Program on CLL, University Health and Science “San Raffaele”, Milan, Italy
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, “Sapienza” University, Rome, Italy
| | - Antonio Cuneo
- Hematology Section, Department of Medical Sciences, Azienda Ospedaliera-Universitaria, Arcispedale S. Anna, University of Ferrara, Ferrara, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Padova, Italy
- Veneto Institute of Molecular Medicine, Padua, Italy
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