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Huerga-Domínguez S, Villar S, Prósper F, Alfonso-Piérola A. Updates on the Management of Acute Myeloid Leukemia. Cancers (Basel) 2022; 14:4756. [PMID: 36230677 PMCID: PMC9563665 DOI: 10.3390/cancers14194756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/18/2022] [Accepted: 09/26/2022] [Indexed: 11/26/2022] Open
Abstract
Acute myeloid leukemia is a heterogeneous disease defined by a large spectrum of genetic aberrations that are potential therapeutic targets. New targeted therapies have changed the landscape for a disease with poor outcomes. They are more effective than standard chemotherapy with a good safety profile. For "fit patients" in first-line, the combination of gemtuzumab ozogamicin or midostaurin with intensive chemotherapy or Vyxeos is now considered the "standard of care" for selected patients. On the other hand, for "unfit patients", azacitidine-venetoclax has been consolidated as a frontline treatment, while other combinations with magrolimab or ivosidenib are in development. Nevertheless, global survival results, especially in relapsed or refractory patients, remain unfavorable. New immunotherapies or targeted therapies, such as Menin inhibitors or sabatolimab, represent an opportunity in this situation. Future directions will probably come from combinations of different targeted therapies ("triplets") and maintenance strategies guided by measurable residual disease.
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Affiliation(s)
| | | | | | - Ana Alfonso-Piérola
- Hematology and Hemotherapy Department, Clínica Universidad de Navarra, 31008 Pamplona, Spain
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2
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Abstract
BACKGROUND The QUAZAR AML-001 trial (NCT01757535) showed survival benefits with the maintenance treatment of oral azacitidine(CC-486) for acute myeloid leukemia(AML) in first complete remission. We conducted a cost-effectiveness analysis to explore the costs and benefits of oral azacitidine in AML from the perspective of payers in the United States. METHODS We constructed a Markov model to evaluate the economic value of oral azacitidine. The model was conducted with a 10-year time horizon. The health utility scores and until prices of medical costs were acquired from previous studies and GoodRX. The transition probabilities were derived from the survival curves of the QUAZAR AML-001 study. Outcomes were measured in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER). RESULTS Compared with placebo, oral azacitidine improved 0.39 QALY, with an increasing cost of $458928.66. The ICER of oral azacitidine is $1176740.15, higher than the willingness to pay (P < 0.05). Deterministic sensitivity analysis showed that the price of oral azacitidine has a significant impact on ICERs (P < 0.05). Probability sensitivity analysis showed that the probability of cost-effectiveness for oral azacitidine is 0. CONCLUSION In the United States, oral azacitidine is unlikely to be cost-effective for AML patients at current prices. CLINICAL TRIAL REGISTRATION The trial is registered at ClinicalTrials.gov (CT.gov identifier: NCT01757535).
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Affiliation(s)
- Jinbing Zhu
- Department of Hematology, Institute of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Qiuji Wu
- Department of Medical Oncology, Cancer Center, West China Hospital of Sichuan University, Chengdu, China
| | - Jinjin Wang
- Department of Hematology, Institute of Hematology, West China Hospital of Sichuan University, Chengdu, China
| | - Ting Niu
- Department of Hematology, Institute of Hematology, West China Hospital of Sichuan University, Chengdu, China
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Abstract
PURPOSE OF REVIEW Treatment of elderly patients with acute myeloid leukemia is a known challenge for hematologists due to patient diversity, heterogeneous disease biology, and a rapidly evolving treatment landscape. Here, we highlight the importance of determining fitness, review the latest therapeutic developments, and discuss clinical scenarios to provide guidance on individualized treatment for older AML patients. RECENT FINDINGS Several factors, like age, performance status, and comorbidities, play a role in fitness and are associated with outcome. Comorbidity scoring systems and geriatric assessments are tools to help physicians select the most appropriate treatment for each patient. The addition of venetoclax, targeted therapy with IDH1/2 and FLT3 inhibitors, and enhanced formulas of existing drugs like CPX-351 and oral azacitidine have improved responses and outcomes. New drugs and combination therapies have increased the therapeutic options for elderly AML patients but determination of fitness and disease biology is essential to select patient-tailored treatments.
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Affiliation(s)
- David C. de Leeuw
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Gert J. Ossenkoppele
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jeroen J. W. M. Janssen
- grid.509540.d0000 0004 6880 3010Department of Hematology, Amsterdam University Medical Centers, Location VUmc, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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4
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Ravandi F, Roboz GJ, Wei AH, Döhner H, Pocock C, Selleslag D, Montesinos P, Sayar H, Musso M, Figuera-Alvarez A, Safah H, Tse W, Sohn SK, Hiwase D, Chevassut T, Pierdomenico F, La Torre I, Skikne B, Bailey R, Zhong J, Beach CL, Dombret H. Management of adverse events in patients with acute myeloid leukemia in remission receiving oral azacitidine: experience from the phase 3 randomized QUAZAR AML-001 trial. J Hematol Oncol 2021; 14:133. [PMID: 34454540 PMCID: PMC8401338 DOI: 10.1186/s13045-021-01142-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/17/2021] [Indexed: 02/08/2023] Open
Abstract
Background Most older patients with acute myeloid leukemia (AML) who attain morphologic remission with intensive chemotherapy (IC) will eventually relapse and post-relapse prognosis is dismal. In the pivotal QUAZAR AML-001 trial, oral azacitidine maintenance therapy significantly prolonged overall survival by 9.9 months (P < 0.001) and relapse-free survival by 5.3 months (P < 0.001) compared with placebo in patients with AML in first remission after IC who were not candidates for transplant. Currently, the QUAZAR AML-001 trial provides the most comprehensive safety information associated with oral azacitidine maintenance therapy. Reviewed here are common adverse events (AEs) during oral azacitidine treatment in QUAZAR AML-001, and practical recommendations for AE management based on guidance from international cancer consortiums, regulatory authorities, and the authors’ clinical experience treating patients in the trial. Methods QUAZAR AML-001 is an international, placebo-controlled randomized phase 3 study. Patients aged ≥ 55 years with AML and intermediate- or poor-risk cytogenetics at diagnosis, who had attained first complete remission (CR) or CR with incomplete blood count recovery (CRi) within 4 months before study entry, were randomized 1:1 to receive oral azacitidine 300 mg or placebo once-daily for 14 days in repeated 28-day cycles. Safety was assessed in all patients who received ≥ 1 dose of study drug. Results A total of 469 patients received oral azacitidine (n = 236) or placebo (n = 233). Median age was 68 years. Patients received a median of 12 (range 1–80) oral azacitidine treatment cycles or 6 (1–73) placebo cycles. Gastrointestinal AEs were common and typically low-grade. The most frequent grade 3–4 AEs during oral azacitidine therapy were hematologic events. AEs infrequently required permanent discontinuation of oral azacitidine (13%), suggesting they were effectively managed with use of concomitant medications and oral azacitidine dosing modifications. Conclusion Oral azacitidine maintenance had a generally favorable safety profile. Prophylaxis with antiemetic agents, and blood count monitoring every other week, are recommended for at least the first 2 oral azacitidine treatment cycles, and as needed thereafter. Awareness of the type, onset, and duration of common AEs, and implementation of effective AE management, may maximize treatment adherence and optimize the survival benefits of oral azacitidine AML remission maintenance therapy. Trial registration This trial is registered on clinicaltrials.gov: NCT01757535 as of December 2012. Supplementary Information The online version contains supplementary material available at 10.1186/s13045-021-01142-x.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
| | - Gail J Roboz
- Weill Cornell Medicine, New York, NY, USA.,New York Presbyterian Hospital, New York, NY, USA
| | - Andrew H Wei
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | | | | | - Pau Montesinos
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Hamid Sayar
- Indiana University Cancer Center, Indianapolis, IN, USA
| | | | | | - Hana Safah
- Tulane University Health Science Center, New Orleans, LA, USA
| | - William Tse
- University of Louisville School of Medicine, Louisville, KY, USA
| | | | | | | | | | | | - Barry Skikne
- University of Kansas Medical Center, Kansas City, KS, USA.,Bristol Myers Squibb, Princeton, NJ, USA
| | | | | | - C L Beach
- Bristol Myers Squibb, Princeton, NJ, USA
| | - Herve Dombret
- Hôpital Saint-Louis, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France.,Institut de Recherche Saint-Louis, Université de Paris, Paris, France
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5
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Jaramillo S, Schlenk RF. Post-Induction Treatment for Acute Myeloid Leukemia: Something Change? Curr Oncol Rep 2021; 23:109. [PMID: 34272619 PMCID: PMC8285306 DOI: 10.1007/s11912-021-01092-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Until recently, improvement in terms of survival for patients with acute myeloid leukemia (AML) was achieved mostly in younger patients with dose intensification of conventional chemotherapy and a broadening use of allogeneic hematopoietic cell transplantation (allo-HCT) whereas the results remained dismal and very stable in patients older than 60 years. The current review highlights the recent developments in standard intensive post-remission chemotherapy, evidence for the use of recently approved agents, and discusses the relevance of measurable residual disease (MRD) measurement in treatment adaptation. RECENT FINDINGS Current approvals of midostaurin, venetoclax, gemtuzumab ozogamicin, VYXEOS, ivosidenib, enasidenib, glasdegib, and CC-486 have changed the structure, aim, and schedule of consolidation therapy, and new, well-tolerated agents are being evaluated as maintenance therapies. Furthermore, MRD assessment has been implemented to guide the duration and type of consolidation and maintenance therapy as well as indicate the optimal timing of allo-HCT. Novel therapies have changed the structure and perspective of post-remission therapy in AML for both young and elderly patients. In addition, MRD assessment could guide the type, duration, and intensity of consolidation and maintenance therapy.
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Affiliation(s)
- Sonia Jaramillo
- Department of Hematology, Oncology, and Rheumatology at Heidelberg University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Richard F. Schlenk
- Department of Hematology, Oncology, and Rheumatology at Heidelberg University Hospital, University of Heidelberg, Heidelberg, Germany
- NCT-Trial Center, NCT Heidelberg, DKFZ and Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
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6
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Abstract
Two oral hypomethylating agents, oral azacitidine (CC-486) and decitabine/cedazuridine (ASTX727), have recently entered the clinical domain. CC-486 has been shown to improve overall survival as maintenance therapy for older patients with acute myeloid leukemia in complete remission, whereas the combination of decitabine with cedazuridine, a cytidine deaminase inhibitor, is indicated for the treatment of adult patients with myelodysplastic syndromes and chronic myelomonocytic leukemia with intermediate-1, or higher, International Prognostic Scoring System risk. This article briefly summarizes the clinical development of both drugs, the pivotal studies that led to their approval and some of the issues faced in extending the use of these drugs to other indications.
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Affiliation(s)
- David Kipp
- Department of Haematology, University Hospital Geelong, Geelong, 3220, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, 3004, Australia
| | - Andrew H Wei
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, 3004, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, 3004, Australia
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7
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Abstract
The past three years have witnessed remarkable progress in acute myeloid leukemia (AML). The approval and development of targeted therapies and novel agents has improved outcomes for patients with traditionally poor survival rates. This review has summarized the survival impact of chemotherapy-based regimens in AML and described recent advances that will be of significance in the near future.
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Affiliation(s)
- Jacob M Rowe
- Department of Hematology, Rambam Health Care Campus, Shaare Zedek Medical Center, 12 Shmuel Bait St, Jerusalem, IL, 9103102, Israel.
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8
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Babiker HM, Milhem M, Aisner J, Edenfield W, Shepard D, Savona M, Iyer S, Abdelrahim M, Beach CL, Skikne B, Laille E, Tsai KT, Ho T. Evaluation of the bioequivalence and food effect on the bioavailability of CC-486 (oral azacitidine) tablets in adult patients with cancer. Cancer Chemother Pharmacol 2020; 85:621-626. [PMID: 32036412 PMCID: PMC7036073 DOI: 10.1007/s00280-020-04037-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 01/22/2020] [Indexed: 12/04/2022]
Abstract
Purpose CC-486 is an oral formulation of azacitidine that allows for extended dosing schedules to prolong azacitidine exposure to malignant cells and maximize clinical activity. CC-486 300 mg daily, administered for 14 or 21 days of 28-day treatment cycles, is currently under investigation in two ongoing phase III trials. The 300-mg daily dose in these studies is administered as two 150-mg tablets (Formulation A). Methods We evaluated the bioequivalence of one 300-mg CC-486 tablet (Formulation B) with Formulation A and food effect on Formulation B, in adult patients with cancer in a 2-stage crossover design study. Results The ratios of the geometric means of the maximum azacitidine plasma concentration (Cmax) and of the area under the plasma concentration–time curve from time 0 extrapolated to infinity (AUC∞) were 101.5% and 105.7%, demonstrating the bioequivalence of Formulations A and B. Formulation B was rapidly absorbed under fasted and fed conditions. The geometric mean of Cmax was significantly decreased by ~ 21% in the fed state. Median Tmax was reached at 2 h and 1 h post-dose in fed and fasted states, respectively (P < 0.001). Nevertheless, systemic drug exposure (AUC) in fed and fasted states was within the 80–125% boundaries of bioequivalence and differences in Cmax and Tmax are not expected to have a clinical impact. Conclusion The single 300-mg CC-486 tablet was bioequivalent to two 150-mg tablets, which have shown to be efficacious and generally well-tolerated in clinical trials, and can be taken with or without food. Electronic supplementary material The online version of this article (10.1007/s00280-020-04037-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hani M Babiker
- University of Arizona Comprehensive Cancer Center, Tucson, AZ, USA.
| | | | - Joseph Aisner
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | | | - Michael Savona
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - C L Beach
- Celgene Corporation, Summit, NJ, USA
| | - Barry Skikne
- Celgene Corporation, Summit, NJ, USA.,University of Kansas Medical Center, Kansas City, KS, USA
| | | | | | - Thai Ho
- Mayo Clinic, Phoenix, AZ, USA
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9
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Mesia R, Bossi P, Hansen AR, Hsieh CY, Licitra LF, Tan EH, Chen P, Miller J, Siu LL, Haddad RI. Phase II study of CC-486 (oral azacitidine) in previously treated patients with locally advanced or metastatic nasopharyngeal carcinoma. Eur J Cancer 2019; 123:138-145. [PMID: 31698327 DOI: 10.1016/j.ejca.2019.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/11/2019] [Accepted: 10/01/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Treatment options are limited for recurrent nasopharyngeal carcinoma (NPC). We report results from a phase II study of CC-486 (oral azacitidine) in advanced NPC. PATIENTS AND METHODS Patients with locally advanced or metastatic NPC and 1-2 prior treatment regimens received CC-486 300 mg daily on days 1-14 of 21-day cycles until disease progression or unacceptable toxicity. The first 6 patients of Asian-Pacific Islander (API) ethnicity received a reduced dose of 200 mg to preserve safety and tolerability; if well tolerated, subsequent API patients received CC-486 300 mg. The study could advance to stage 2 if > 4 patients achieved a response. Co-primary end-points were overall response rate (ORR) and progression-free survival (independent review). Key secondary end-points were overall survival and safety. RESULTS Owing to faster-than-anticipated enrolment, 36 patients, including 13 of API ethnicity, were enrolled; the median age was 54.0 years. Most patients were male (81%) and had an Eastern Cooperative Oncology Group performance status ≤ 1 (97%). Among 25 efficacy-evaluable patients, the ORR was 12%; the median progression-free and overall survival were 4.7 and 18.0 months, respectively. The most common grade III/IV treatment-emergent adverse events were neutropenia (33%) and febrile neutropenia (11%). Twenty-one posttreatment deaths, primarily due to progressive disease or disease complications, and 1 on-treatment death (epistaxis, unrelated to study drug) occurred. The study did not advance to stage 2. CONCLUSION CC-486 did not show sufficient clinical activity to support further development as monotherapy in this patient population. The safety profile of CC-486 in NPC was consistent with that in other solid tumours.
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Affiliation(s)
- Ricard Mesia
- Department of Medical Oncology, B-ARGO Group, Institut Català d'Oncologia (ICO), Badalona, Spain.
| | - Paolo Bossi
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | | | - Lisa F Licitra
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; University of Milan, Milan, Italy
| | | | - Peng Chen
- Celgene Corporation, Summit, NJ, USA
| | | | - Lilian L Siu
- Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Robert I Haddad
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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10
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Gaillard SL, Zahurak M, Sharma A, Reiss KA, Sartorius-Mergenthaler S, Downs M, Anders NM, Ahuja N, Rudek MA, Azad N. A phase 1 trial of the oral DNA methyltransferase inhibitor CC-486 and the histone deacetylase inhibitor romidepsin in advanced solid tumors. Cancer 2019; 125:2837-2845. [PMID: 31012962 PMCID: PMC6663621 DOI: 10.1002/cncr.32138] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Epigenetic abnormalities are manifold in all solid tumors and include changes in chromatin configuration and DNA methylation. The authors designed a phase 1 study to evaluate the oral DNA methyltransferase inhibitor CC-486 combined with the histone deacetylase inhibitor romidepsin in advanced solid tumors with dose expansion to further evaluate pharmacodynamics and possible clinical benefit of the recommended phase 2 dose (RP2D). METHODS This was a phase 1 study with a 3 + 3 dose-escalation design and an expansion phase for patients with virally mediated cancers. The disease control rate (DCR) was the primary outcome for the expansion cohort. Correlative studies included long interspersed nucleotide element 1 (LINE-1) methylation and drug exposure in blood samples (clinicaltrials.gov identifier NCT01537744). RESULTS Fourteen patients were enrolled in the dose-escalation portion at 3 dose levels. Three patients experienced dose-limiting toxicities; the RP2D was oral CC-486 300 mg daily on days 1 through 14 and romidepsin 8 mg/m2 on days 8 and 15. Because of slow accrual into the expansion phase, the trial was closed after 4 patients enrolled. Common toxicities of the combination included nausea (83.3%), anorexia (72.2%), fatigue (61.1%), and constipation (55.6%). There were 12 patients evaluable for response, 5 with stable disease, of whom 2 received >4 cycles; there were no responses. Exposure to CC-486 and romidepsin was consistent with prior data. LINE-1 methylation on C1D8 was significantly reduced (mean, -6.23; 95% CI, -12.23, -0.24; P = .04). CONCLUSIONS Although, at the RP2D, the combination of CC-486 and romidepsin was tolerable, no significant anticancer activity was observed. Significant demethylation in post-treatment circulating tumor DNA and biopsies provided proof of target acquisition.
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Affiliation(s)
- Stéphanie L. Gaillard
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Gynecology and Obstetrics Division of Gynecologic Oncology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Marianna Zahurak
- Department of Oncology Division of Biostatistics and Bioinformatics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Anup Sharma
- Department of Surgery Division of Surgical Oncology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Kim A. Reiss
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Melinda Downs
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Nicole M. Anders
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Nita Ahuja
- Department of Surgery Division of Surgical Oncology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Michelle A. Rudek
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Medicine Division of Clinical Pharmacology, Johns Hopkins School of Medicine, Baltimore, MD
| | - Nilofer Azad
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD
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11
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Levy BP, Giaccone G, Besse B, Felip E, Garassino MC, Domine Gomez M, Garrido P, Piperdi B, Ponce-Aix S, Menezes D, MacBeth KJ, Risueño A, Slepetis R, Wu X, Fandi A, Paz-Ares L. Randomised phase 2 study of pembrolizumab plus CC-486 versus pembrolizumab plus placebo in patients with previously treated advanced non-small cell lung cancer. Eur J Cancer 2019; 108:120-128. [PMID: 30654297 DOI: 10.1016/j.ejca.2018.11.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/15/2018] [Accepted: 11/23/2018] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Preclinical and early clinical studies suggest that combining epigenetic agents with checkpoint inhibitors can potentially improve outcomes in patients with previously treated advanced non-small cell lung cancer (NSCLC). This phase 2 trial examined second-line pembrolizumab + CC-486 (oral azacitidine) in patients with advanced NSCLC. METHODS Patients with one prior line of platinum-containing therapy were randomised in a ratio of 1:1 to CC-486 or placebo, on days 1-14, in combination with pembrolizumab on day 1 of a 21-day cycle. The primary end-point was progression-free survival (PFS). Key secondary end-points included overall survival (OS), overall response rate (ORR) and safety. RESULTS Among 100 patients randomised (pembrolizumab + CC-486: 51; pembrolizumab + placebo: 49), most were male (57.0%), were white (87.0%) and had Eastern Cooperative Oncology Group performance status 1 (68.0%). No significant difference in PFS was observed between the pembrolizumab + CC-486 and pembrolizumab + placebo arms (median, 2.9 and 4.0 months, respectively; hazard ratio [HR], 1.374; 90% confidence interval [CI], 0.926-2.038; P = 0.1789). Median OS was 11.9 months versus not estimable (HR, 1.375; 90% CI, 0.830-2.276; P = 0.2968); ORR was 20% versus 14%. Median treatment duration was shorter (15.0 versus 24.1 weeks), and the number of cycles was lower (5.0 versus 7.0) with pembrolizumab + CC-486 versus pembrolizumab + placebo. No new safety signals for CC-486 or pembrolizumab were detected. Treatment-emergent adverse events were more common in the pembrolizumab + CC-486 arm, particularly gastrointestinal, potentially impacting treatment feasibility. CONCLUSIONS No improvement in PFS was observed with pembrolizumab + CC-486 versus pembrolizumab + placebo. Decreased treatment exposure due to adverse events may have impacted efficacy with pembrolizumab + CC-486.
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MESH Headings
- Adenocarcinoma of Lung/drug therapy
- Adenocarcinoma of Lung/pathology
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Azacitidine/administration & dosage
- Carcinoma, Non-Small-Cell Lung/drug therapy
- Carcinoma, Non-Small-Cell Lung/pathology
- Carcinoma, Squamous Cell/drug therapy
- Carcinoma, Squamous Cell/pathology
- Female
- Humans
- Lung Neoplasms/drug therapy
- Lung Neoplasms/pathology
- Male
- Middle Aged
- Progression-Free Survival
- Survival Rate
- Treatment Outcome
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Affiliation(s)
- Benjamin P Levy
- Johns Hopkins Sidney Kimmel Cancer Center, Washington, DC, USA.
| | - Giuseppe Giaccone
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Benjamin Besse
- Department of Cancer Medicine, Gustave Roussy, Villejuif and Paris-Sud University, Orsay, France
| | | | | | - Manuel Domine Gomez
- Instituto de Investigacion Sanitaria-Fundación Jimenez Diaz (IIS- FJD), Madrid, Spain
| | - Pilar Garrido
- IRYCIS, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Santiago Ponce-Aix
- Hospital Universitario 12 de Octubre, Universidad Complutense, CNIO and CiberOnc, Madrid, Spain
| | | | | | - Alberto Risueño
- Celgene Institute for Translational Research Europe, Seville, Spain
| | | | | | | | - Luis Paz-Ares
- Hospital Universitario 12 de Octubre, Universidad Complutense, CNIO and CiberOnc, Madrid, Spain.
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12
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Garcia-Manero G, Scott BL, Cogle CR, Boyd TE, Kambhampati S, Hetzer J, Dong Q, Kumar K, Ukrainskyj SM, Beach CL, Skikne BS. CC-486 (oral azacitidine) in patients with myelodysplastic syndromes with pretreatment thrombocytopenia. Leuk Res 2018; 72:79-85. [PMID: 30114559 DOI: 10.1016/j.leukres.2018.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/18/2018] [Accepted: 08/02/2018] [Indexed: 11/24/2022]
Abstract
Thrombocytopenia is among the strongest predictors of decreased survival for patients with myelodysplastic syndromes (MDS) across all prognostic risk groups. The safety and efficacy of CC-486 (oral azacitidine) was investigated in early-phase studies; we assessed clinical outcomes among subgroups of MDS patients from these studies, defined by presence or lack of pretreatment thrombocytopenia (≤75 × 109/L platelet count). Patients received CC-486 300 mg once-daily for 14 or 21 days of repeated 28-day cycles. Overall, 81 patients with MDS, median age 72 years, comprised the Low Platelets (n = 45) and High Platelets (n = 36) cohorts. Pretreatment median platelet counts were 34 × 109/L and 198 × 109/L, respectively. Grade 3-4 bleeding events occurred in 2 patients in the Low Platelets and 1 patient in the High Platelets groups; events resolved without sequelae. Treatment-related mortality was reported for 7 patients, 5 of whom had pretreatment platelet values <25 × 109/L. Overall response rates were 38% and 46% in the Low Platelets and High Platelets groups, respectively. Five thrombocytopenic patients attained complete remission and 9 attained platelet hematologic improvement. In both cohorts, platelet counts dropped during the first CC-486 treatment cycle, then increased thereafter. Extended CC-486 dosing was generally well tolerated and induced hematologic responses in these patients regardless of pretreatment thrombocytopenia.
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Affiliation(s)
- Guillermo Garcia-Manero
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Bart L Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Christopher R Cogle
- Medicine/Hematology & Oncology, University of Florida, Gainesville, FL, United States
| | - Thomas E Boyd
- Willamette Valley Cancer Institute, Eugene, OR, United States
| | - Suman Kambhampati
- University of Kansas Medical Center, Kansas City, KS, United States; Sarah Cannon at Research Medical Center, Kansas City, MO, United States
| | - Joel Hetzer
- Celgene Corporation, Summit, NJ, United States
| | - Qian Dong
- Celgene Corporation, Summit, NJ, United States
| | | | | | - C L Beach
- Celgene Corporation, Summit, NJ, United States
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de Lima M, Oran B, Champlin RE, Papadopoulos EB, Giralt SA, Scott BL, William BM, Hetzer J, Laille E, Hubbell B, Skikne BS, Craddock C. CC-486 Maintenance after Stem Cell Transplantation in Patients with Acute Myeloid Leukemia or Myelodysplastic Syndromes. Biol Blood Marrow Transplant 2018; 24:2017-2024. [PMID: 29933073 PMCID: PMC8059405 DOI: 10.1016/j.bbmt.2018.06.016] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 06/11/2018] [Indexed: 12/21/2022]
Abstract
Relapse is the main cause of treatment failure after allogeneic stem cell transplant (alloSCT) in acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). Injectable azacitidine can improve post-transplant outcomes but presents challenges with exposure and compliance. Oral CC-486 allows extended dosing to prolong azacitidine activity. We investigated use of CC-486 maintenance therapy after alloSCT. Adults with MDS or AML in morphologic complete remission at CC-486 initiation (42 to 84 days after alloSCT) were included. Patients received 1 of 4 CC-486 dosing schedules per 28-day cycle for up to 12 cycles. Endpoints included safety, pharmacokinetics, graft-versus-host disease (GVHD) incidence, relapse/progression rate, and survival. Of 30 patients, 7 received CC-486 once daily for 7 days per cycle (200 mg, n = 3; 300 mg, n = 4) and 23 for 14 days per cycle (150 mg, n = 4; 200 mg, n = 19 [expansion cohort]). Grades 3 to 4 adverse events were infrequent and occurred with similar frequency across regimens. Standard concomitant medications did not alter CC-486 pharmacokinetic parameters. Three patients (10%) experienced grade III acute GVHD and 9 experienced chronic GVHD. Of 28 evaluable patients, 6 (21%) relapsed or had progressive disease: 3 of 7 patients (43%) who had received 7-day dosing and 3 of 23 (13%) who had received 14-day dosing. Transplant-related mortality was 3%. At 19 months of follow-up, median overall survival was not reached. Estimated 1-year survival rates were 86% and 81% in the 7-day and 14-day dosing cohorts, respectively. CC-486 maintenance was generally well tolerated, with low rates of relapse, disease progression, and GVHD. CC-486 maintenance may permit epigenetic manipulation of the alloreactive response postallograft. Findings require confirmation in randomized trials. (ClinicalTrials.govNCT01835587.)
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Affiliation(s)
- Marcos de Lima
- University Hospitals of Cleveland and Case Western Reserve University, Cleveland, Ohio.
| | - Betul Oran
- Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Esperanza B Papadopoulos
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio A Giralt
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bart L Scott
- Transplantation Biology, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Basem M William
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio
| | | | | | | | | | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Schuh AC, Döhner H, Pleyer L, Seymour JF, Fenaux P, Dombret H. Azacitidine in adult patients with acute myeloid leukemia. Crit Rev Oncol Hematol 2017; 116:159-177. [PMID: 28693797 DOI: 10.1016/j.critrevonc.2017.05.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/23/2017] [Accepted: 05/28/2017] [Indexed: 01/13/2023] Open
Abstract
Azacitidine is recommended front-line treatment for older patients with acute myeloid leukemia (AML) who are not candidates for intensive treatment regimens, and was recently granted approval in the European Union for treatment of adult AML. Reviewed here is azacitidine experience in AML, including: mechanistic and pharmacokinetic data; safety and efficacy in controlled trials; treatment effects in AML subpopulations defined by disease characteristics; experience in unselected patients treated in the community setting; clinical outcomes relative to other approved AML therapies; and experience with azacitidine-based combination treatment regimens. Collectively, these data suggest that (a) azacitidine may prolong overall survival to a similar or greater extent than do other approved AML treatments, but with less toxicity, (b) azacitidine may be the preferred treatment option for older patients with unfavorable cytogenetics, and (c) experience and outcomes with azacitidine in the clinic are similar to those seen in clinical trials. Continued investigation of combination regimens on an azacitidine backbone is warranted.
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Affiliation(s)
- Andre C Schuh
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada.
| | | | - Lisa Pleyer
- 3rd Medical Department with Hematology and Medical Oncology, Hemostaseology, Rheumatology and Infectious Diseases, Laboratory for Immunological and Molecular Cancer Research, Oncologic Center, Paracelsus Medical University Salzburg, Austria; Salzburg Cancer Research Institute - Center for Clinical Cancer and Immunology Trials, Salzburg, Austria; Cancer Cluster Salzburg, Austria
| | - John F Seymour
- Peter MacCallum Cancer Centre, Melbourne, Australia; University of Melbourne, Parkville, Australia
| | - Pierre Fenaux
- Hôpital Saint Louis, Institut Universitaire d'Hématologie, Paris, France
| | - Hervé Dombret
- Hôpital Saint Louis, Institut Universitaire d'Hématologie, Paris, France
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Garcia-Manero G, Almeida A, Giagounidis A, Platzbecker U, Garcia R, Voso MT, Larsen SR, Valcarcel D, Silverman LR, Skikne B, Santini V. Design and rationale of the QUAZAR Lower-Risk MDS (AZA-MDS-003) trial: a randomized phase 3 study of CC-486 (oral azacitidine) plus best supportive care vs placebo plus best supportive care in patients with IPSS lower-risk myelodysplastic syndromes and poor prognosis due to red blood cell transfusion-dependent anemia and thrombocytopenia. BMC Hematol 2016; 16:12. [PMID: 27148452 PMCID: PMC4855808 DOI: 10.1186/s12878-016-0049-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 04/14/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND CC-486 is an oral formulation of the epigenetic modifier azacitidine. In an expanded phase 1 trial, CC-486 demonstrated clinical and biological activity in patients with International Prognostic Scoring System (IPSS) lower-risk (low- and intermediate-1-risk) myelodysplastic syndromes (MDS) with poor prognostic features including anemia and/or thrombocytopenia who may have required red blood cell or platelet transfusions. The overall response rate was 40 %, including hematologic improvement in 28 % of patients and RBC transfusion independence sustained for 56 days in 47 % of patients with baseline transfusion dependence. Based on the results of this study, the randomized, placebo-controlled phase 3 QUAZAR Lower-Risk MDS trial (AZA-MDS-003) was initiated. The design and rationale for this trial comparing CC-486 with placebo for the treatment of patients with IPSS lower-risk MDS with poor prognostic features are described. METHODS Patients must have IPSS lower-risk MDS with red blood cell (RBC) transfusion-dependent anemia and thrombocytopenia. Eligible patients are randomized 1:1 to receive 300 mg of CC-486 or placebo once daily for the first 21 days of 28-day treatment cycles. Disease status assessments occur at the end of cycle 6 and patients may continue to receive treatment unless there is evidence of progressive disease, lack of efficacy, or unacceptable toxicity. The primary endpoint is RBC transfusion independence for ≥ 84 days, assessed according to International Working Group 2006 criteria. Secondary endpoints include overall survival, hematologic response including platelet response and erythroid response, RBC transfusion independence for ≥ 56 days, duration of RBC transfusion independence, time to RBC transfusion independence, rate of acute myeloid leukemia (AML) progression, time to AML progression, clinically significant bleeding events, safety, health-related quality of life, and healthcare resource utilization. CONCLUSIONS This study will provide data on the efficacy and safety of CC-486 in the treatment of IPSS lower-risk MDS with poor prognosis due to the presence of both RBC transfusion-dependent anemia and thrombocytopenia. Positive results of the AZA-MDS-003 study may expand treatment options for patients with IPSS lower-risk MDS. TRIAL REGISTRATION ClinicalTrials.gov NCT01566695, registered March 27, 2012.
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Affiliation(s)
- Guillermo Garcia-Manero
- />Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Antonio Almeida
- />Instituto Portugues de Oncologia Francisco Gentil, Lisbon, Portugal
| | | | - Uwe Platzbecker
- />Medizinschen Fakultat Carl Gustav Carus der TU Dresden, Dresden, Germany
| | - Regina Garcia
- />Hospital Clinico Universitario Virgen de la Victoria, Malaga, Spain
| | | | | | | | | | | | - Valeria Santini
- />Hematology, University of Florence, AOU Careggi, Florence, Italy
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16
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Roboz GJ, Montesinos P, Selleslag D, Wei A, Jang JH, Falantes J, Voso MT, Sayar H, Porkka K, Marlton P, Almeida A, Mohan S, Ravandi F, Garcia-Manero G, Skikne B, Kantarjian H. Design of the randomized, Phase III, QUAZAR AML Maintenance trial of CC-486 (oral azacitidine) maintenance therapy in acute myeloid leukemia. Future Oncol 2016; 12:293-302. [PMID: 26785287 PMCID: PMC5684733 DOI: 10.2217/fon.15.326] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Older patients with acute myeloid leukemia (AML) have worse rates of complete remission and shorter overall survival than younger patients. The epigenetic modifier CC-486 is an oral formulation of azacitidine with promising clinical activity in patients with AML in Phase I studies. The Phase III, randomized, double-blind, placebo-controlled QUAZAR AML Maintenance trial (CC-486-AML-001) examines CC-486 maintenance therapy (300 mg/day for 14 days of 28-day treatment cycles) for patients aged ≥55 years with AML in first complete remission. The primary end point is overall survival. Secondary end points include relapse-free survival, safety, health-related quality of life and healthcare resource utilization. This trial will investigate whether CC-486 maintenance can prolong remission and improve survival for older patients with AML.
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Affiliation(s)
- Gail J Roboz
- Weill Medical College of Cornell University & New York-Presbyterian Hospital, New York, NY, USA
| | - Pau Montesinos
- Hospital Univeritari I Politecnic La Fe de Valencia, Valencia, Spain
| | | | - Andrew Wei
- The Alfred Hospital & Monash University, Melbourne, Australia
| | | | - Jose Falantes
- Hospital Universitario Virgen del Rocio & Instituto de Biomedicinia de Sevilla, Seville, Spain
| | - Maria T Voso
- Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Hamid Sayar
- Indiana University Cancer Center, Indianapolis, IN, USA
| | - Kimmo Porkka
- Helsinki University Central Hospital, Helsinki, Finland
| | - Paula Marlton
- Princess Alexandra Hospital, University of Queensland School of Medicine, Brisbane, Australia
| | - Antonio Almeida
- Instituto Portugues de Oncologia Francisco Gentil, Lisbon, Portugal
| | - Sanjay Mohan
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Farhad Ravandi
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Hagop Kantarjian
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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