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Chemotherapy in AML

Curator: Larry H. Bernstein, MD, FCAP

 

 

Sorafenib Showed Efficacy as Chemotherapy Add-On in AML
Results from the phase II SORAML trial indicated that adding sorafenib to standard chemotherapy for younger patients with acute myeloid leukemia was effective, but also resulted in increased toxicity

Reduced-Intensity HSCT Extends Remission in Older AML Patients
The use of reduced-intensity conditioning HSCT as a method to maintain remission was effective in a select group of older patients with acute myeloid leukemia

 

Sorafenib Showed Efficacy as Chemotherapy Add-On in AML

– See more at: http://www.cancernetwork.com/leukemia-lymphoma/sorafenib-showed-efficacy-chemotherapy-add-aml

 

Results from the phase II SORAML trial indicated that adding sorafenib to standard chemotherapy for younger patients with acute myeloid leukemia (AML) was effective, but also resulted in increased toxicity.

 

The drug increased event-free survival and reduced need for salvage therapy and allogeneic stem cell transplantation, but also produced worse grade 3 or higher fever, diarrhea, bleeding, cardiac events, and rash compared with placebo.

“After a decade of assessing the potential of kinase inhibitors in acute myeloid leukemia, their use in combination with standard treatment is becoming an important option for newly diagnosed younger patients,” wrote Christoph Röllig, MD, of Medizinische Klinik und Poliklinik I, Universitätsklinikum der Technischen Universität in Dresden, Germany, and colleagues in Lancet Oncology.

Patients age 18 to 60 years were enrolled in the phase II study between 2009 and 2011. All patients had to have newly diagnosed, treatment-naive AML and a performance status of 0–2. Patients were randomly assigned to 2 cycles of induction daunorubicin plus cytarabine followed by 3 cycles of high-dose cytarabine consolidation therapy plus either sorafenib 400 mg twice daily (n = 134) or placebo (n = 133).

With a median follow-up of 3 years, the researchers found that adding sorafenib to standard chemotherapy significantly improved event-free survival, from a median of 9 months with placebo to a median of 21 months with sorafenib. Patients assigned sorafenib had a 3-year event-free survival rate of 40% compared with 22% for patients assigned placebo (P = .013).

“The improvement in event-free survival and relapse-free survival is significant and clinically relevant since salvage treatment with or without allogeneic stem cell transplantation could be prevented or substantially delayed by sorafenib treatment,” the researchers wrote.

At 3 years, 63% of patients assigned sorafenib and 56% of patients assigned placebo were still alive, and the median overall survival was not reached in either group. Patients assigned sorafenib had fewer relapses after complete remission compared with placebo (54 vs 34) and, therefore, fewer allogeneic stem cell transplantations were required among patients assigned sorafenib (31 vs 18).

Finally, withdrawal from the trial due to adverse events was more common among patients assigned sorafenib (24% vs 12%).

In an editorial published with the study, Naval Daver, MD, and Marina Konopleva, MD, PhD, of the University of Texas MD Anderson Cancer Center in Houston, pointed out that these results contrast findings by Serve et al who found that “the addition of sorafenib to standard chemotherapy in patients older than 60 years with acute myeloid leukemia resulted in increased toxicity and early mortality,” without improved antileukemic efficacy compared with placebo, suggesting that older patients were unable to tolerate the toxicities associated with the addition of sorafenib to standard chemotherapy.

Daver and Konopleva agreed with Röllig and colleagues, writing that the lack of improvement in overall survival despite an improvement in event-free survival requires “further investigation to develop future strategies that will improve overall survival.”

 

Sorafenib and novel multikinase inhibitors in AML

Naval Daver, Marina Konopleva

The Lancet Oncology 2015.          DOI: http://dx.doi.org/10.1016/S1470-2045(15)00454-4

Induction chemotherapy can produce complete remission in most (50–70%) patients with acute myeloid leukaemia.¹ However, between 50% and 80% of patients relapse, and only 20–30% achieve long-term disease-free survival.

 

Reduced-Intensity HSCT Extends Remission in Older AML Patients

– See more at: http://www.cancernetwork.com/leukemia-lymphoma/reduced-intensity-hsct-extends-remission-older-aml-patients

 

The use of reduced-intensity conditioning hematopoietic stem cell transplantation (HSCT) as a method to maintain remission was effective in a select group of older patients with acute myeloid leukemia (AML), resulting in a nonrelapse mortality (NRM) similar to that seen in younger patients, according to the results of the phase II Cancer and Leukemia Group B 100103/Blood and Marrow Transplant Clinical Trial Network 0502 trial. 

 

“Of critical importance, for the first time (to the best of our knowledge), favorable results in transplantation of older patients have been obtained in a multicenter cooperative group setting, which makes the results more likely to be generalizable,” wrote Steven M. Devine, MD, of the Ohio State University in Columbus, Ohio, and colleagues in the Journal of Clinical Oncology.

According to the study, although patients aged older than 60 have complete remission rates of 50% to 60%, many will ultimately relapse. HSCT is associated with lower rates of relapse compared with chemotherapy in younger patients, but has been considered too toxic for older patients.

This study looked at the use of reduced-intensity conditioning HSCT in an older patient population aged 60 to 74 years. It included 114 patients with AML who were in first complete remission. The median age of patients was 65 years. A little more than half of the patients received transplants from unrelated donors and were given rabbit antithymocyte globulin (ATG) for graft-versus-host disease (GVHD) prophylaxis.

At follow-up, 71 patients had died. The median follow-up of the 43 surviving patients was 1,602 days. At 2 years, the rate of disease-free survival (DFS) was 42% and overall survival (OS) was 48%. Among patients who had unrelated donors, the 2-year DFS was 40% and the OS was 50%.

“The 2-year DFS and OS rates in this group compare favorably to those in studies of conventional chemotherapy–based approaches to remission consolidation in which DFS and OS rates beyond 2 years are typically below 20%,” the researchers wrote.

The NRM at 2 years was 15% and was not different among those patients with related vs unrelated donors. Forty-four percent of patients relapsed at 2 years.

“The 44% relapse rate at 2 years was high, although relapse rates approaching 80% to 90% have been observed in older patients after conventional chemotherapy, suggesting a potential graft-versus-leukemia effect,” the researchers wrote. “Interpretation of our trial results is limited somewhat by lack of consistent knowledge of the mutational status of the patients at diagnosis or of disease burden at complete remission by minimal residual disease assessment.”

There was a cumulative incidence of grades 2 to 4 GVHD of 9.6% and of grade 3 to 4 GVHD of 2.6% at 100 days. The incidence of GVHD did not vary by donor type. Chronic GVHD occurred in 28% of patients.

Devine and colleagues noted that these rates were lower than they anticipated.

“The incorporation of rabbit ATG into the conditioning regimen for all patients, including recipients with matched sibling donors, may have contributed to the relatively low rates of GVHD and NRM, as has been observed in previous studies,” they wrote.