Utility of measurable residual disease for predicting treatment outcomes with BCR- and BCL2-Targeted therapies in patients with CLL

Inhibitors targeting B-cell receptor (BCR) signaling pathway proteins and B-cell lymphoma-2 (BCL2) in chronic lymphocytic leukemia (CLL) are recommended in the first-line and relapsed/refractory disease settings. Measurable residual disease (MRD) is an important prognostic tool in patients treated with the BCL2-targeted agent, venetoclax. We explored the relationship between MRD status and progression-free (PFS)/overall survival (OS) in patients with CLL, following treatment with novel BCR- and BCL2-targeted agents. Compared with chemoimmunotherapy, higher rates of undetectable (u)MRD were achieved with BCL2-targeted therapies; achieving uMRD status was associated with longer PFS and OS than MRD-positivity. Continuous treatment with BCR-targeted agents did not achieve uMRD status in many patients, and outcomes were not correlated with uMRD status. Future clinical trials of targeted treatment combinations could be designed to demonstrate uMRD as a treatment objective, and allow a response-driven, personalized strategy to optimize treatment and improve OS outcomes.

A review of the incidence of tumor lysis syndrome in patients with chronic lymphocytic leukemia treated with venetoclax and debulking strategies

We reviewed the literature (January 2010-June 2021) on the effectiveness of debulking strategies before venetoclax initiation in patients with chronic lymphocytic leukemia to reduce tumor burden, downgrade tumor lysis syndrome (TLS) risk, and avoid hospitalization. Low TLS incidence and reduced TLS risk based on tumor burden were reported following debulking in clinical trials. Real-world observational studies reporting debulking regimens recorded no TLS events, and those without debulking strategies had greater TLS incidence. Debulking prior to venetoclax considerably reduces TLS incidence. Further clinical trials and real-world studies may provide additional evidence on effectiveness of debulking in reducing TLS incidence and hospitalization need.

Racial, ethnic, and socioeconomic disparities in treatment outcomes in patients (pts) with diffuse large B-cell lymphoma (DLBCL): A U.S. real-world study using a de-identified electronic health record (EHR)-derived database

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Background: DLBCL, an aggressive disease, is the most common subtype of non-Hodgkin lymphoma. Few studies have addressed socioeconomic and racial/ethnic disparities in treatment patterns and health outcomes for pts with DLBCL. We present a retrospective cohort study, leveraging real-world data from a nationwide database, to investigate these disparities. Methods: Pts with DLBCL treated with first-line (1L) therapy within 90 days of diagnosis were selected from the nationwide Flatiron Health EHR-derived de-identified database from January 2011 to May 2020. During the study, the de-identified data originated from approximately 280 US cancer clinics (̃800 sites of care). Pts’ baseline characteristics, treatment patterns, overall survival (OS), time to next therapy or death to any cause (TTNTD) were compared between race groups (non-Hispanic White [W], non-Hispanic African American [AA], Hispanic or Latino [H], non-Hispanic Asian [A]) and socioeconomic groups (Medicaid without Commercial [Medicaid] vs Commercial without Medicaid [Commercial]). Baseline characteristics were compared using Fisher’s exact, chi-squared or t-tests. Time to event endpoints were compared using Cox models adjusting baseline characteristics. Results: In total, 4,648 pts with DLBCL (82% W, 7% AA, 8% H, 3% A) were included. Compared with other race groups, W pts were older (mean age: 67 vs 60, 62, 62 [W vs AA, H, A]), had a higher proportion of pts with Eastern Cooperative Oncology Group score ≥2 (8% vs 5%, 4%, 4%), and fewer pts with Medicaid insurance (1.7% vs 5%, 6%, 3%). Across race groups, 1L treatments received were similar; 82% had R-CHOP. There were no significant differences in OS (P = 0.278; HR [AA, H, A vs W]: 0.87, 0.85, 0.84) and TTNTD (P = 0.158; HR: 0.89, 0.88, 1.19). There were statistically significant differences in time from diagnosis to treatment (P < 0.0001; HR: 0.83, 0.79, 1.12), although the magnitude of the median differences were relatively small (22, 24, 25, 19 days [W, AA, H, A]). In pts aged < 65, commercially insured pts had less advanced disease (Group Stage IV: 28% vs 59%), better OS (HR [95% CI]: 0.50 [0.31–0.81], P = 0.005) and later TTNTD (HR: 0.70 [0.48–1.03], P = 0.067) compared with Medicaid insured pts. In pts aged ≥65, commercially insured pts had similar disease stage, OS (HR: 1.09 [0.65–1.84], P = 0.756) and TTNTD (HR: 0.94 [0.61–1.44], P = 0.763) compared with Medicaid insured pts. Insurance was not a significant factor for time from diagnosis to treatment for pts aged < 65 (HR: 1.05 [0.80–1.37], P = 0.727) and ≥65 (HR: 1.05 [0.78–1.42], P = 0.742). Conclusions: In this analysis of over 4,500 pts with DLBCL treated in the real-world, access to commercial insurance was associated with health outcomes in pts under 65 years of age, possibly due to earlier diagnosis; race was not a significant factor.

The impact of early discontinuation/dose modification of venetoclax on outcomes in patients with relapsed/refractory chronic lymphocytic leukemia: post-hoc analyses from the phase III MURANO study

Fixed-duration venetoclax plus rituximab (VenR) has a manageable safety profile and improves survival in patients with relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL). We present data from the phase III MURANO study on the impact of venetoclax modification or premature discontinuation on outcomes in patients with R/R CLL. Time-dependent Cox proportional hazards regression models, stratified by 17p deletion and risk status, evaluated the impact of venetoclax discontinuation/modification on investigator-assessed progression-free survival (PFS) and overall survival (OS). Analyses were performed retrospectively (without type-1 error control) in intention-to-treat patients from the VenR arm of MURANO. Overall, 140/194 (72%) patients in the VenR arm completed 2 years of therapy; 54/194 (28%) patients prematurely discontinued treatment. Inferior PFS was observed in patients prematurely discontinuing venetoclax for any reason (disease progression excluded; p