M. Alexander Otto

Despite a growing list of Janus kinase (JAK) inhibitors, ruxolitinib remains the go-to for patients with symptomatic, higher risk myelofibrosis, according to Anthony M. Hunter, MD, a myeloid malignancies specialist at Emory University, Atlanta.

“We are thankfully starting to be blessed with more options than we’ve ever had,” he said, but “in the front-line proliferative setting, ruxolitinib has remained the standard of care.” It’s “well established in higher-risk patients and very much an option for very symptomatic lower-risk patients.”

Dr. Hunter helped his colleagues navigate the evolving field of JAK inhibition for myelofibrosis in a presentation titled “Choosing and Properly Using a JAK Inhibitor in Myelofibrosis,”at the Society of Hematologic Oncology annual meeting.

Ruxolitinib was the first JAK inhibitor for myelofibrosis on the U.S. market, approved in 2011. Two more have followed, fedratinib in 2019 and pacritinib in 2022.

A fourth JAK inhibitor for myelofibrosis, momelotinib, is under Food and Drug Administration review with a decision expected shortly.

JAK inhibitors disrupt a key pathogenic pathway in myelofibrosis and are a mainstay of treatment, but Dr. Hunter noted that they should not replace allogeneic transplants in patients who are candidates because transplants remain “the best way to achieve long term survival, especially in higher risk patients.”

He noted that not every patient needs a JAK inhibitor, especially “lower-risk, more asymptomatic patients who are predominantly manifesting with cytopenias. [They] are less likely to benefit.”

Dr. Hunter said that although ruxolitinib remains a treatment of choice, fedratinib “is certainly an option” with comparable rates of symptom control and splenomegaly reduction. Also, while ruxolitinib is dosed according to platelet levels, fedratinib allows for full dosing down to a platelet count of 50 x 10⁹/L.

“But there’s more GI toxicity than with ruxolitinib, especially in the first couple of months,” he said, as well as a black box warning of Wernicke’s encephalopathy. “I generally put all my [fedratinib] patients on thiamine repletion as a precaution.”

One of the most challenging aspects of using JAK inhibitors for myelofibrosis is their tendency to cause cytopenia, particularly anemia and thrombocytopenia, which, ironically, are also hallmarks of myelofibrosis itself.

Although there’s an alternative low-dose ruxolitinib regimen that can be effective in anemic settings, the approval of pacritinib and most likely momelotinib is particularly helpful for cytopenic patients, “a population which historically has been very hard to treat with our prior agents,” Dr. Hunter said.

Pacritinib is approved specifically for patients with platelet counts below 50 x 10⁹/L; momelotinib also included lower platelet counts in several studies. Both agents indirectly boost erythropoiesis with subsequent amelioration of anemia.

“Momelotinib is an important emerging agent for these more anemic patients,” with a spleen response comparable to ruxolitinib and significantly higher rates of transfusion independence, but with lower rates of symptom control, Dr. Hunter said.

Pacritinib “really helps extend the benefit of JAK inhibitors to a group of thrombocytopenic patients who have been hard to treat with ruxolitinib,” with the added potential of improving anemia, although, like fedratinib, it has more GI toxicity, he said.

There are multiple add-on options for JAK inhibitor patients with anemia, including luspatercept, an erythropoiesis-stimulating agent approved for anemia in patients with myelodysplastic syndromes; promising results were reported recently for myelofibrosis.

Fedratinib, pacritinib, and momelotinib all have activity in the second line after ruxolitinib failure, Dr. Hunter noted, but he cautioned that ruxolitinib must be tapered over a few weeks, not stopped abruptly, to avoid withdrawal symptoms. Some clinicians overlap JAK inhibitors a day or two to avoid issues.

“Clinical trials should still be considered in many of these settings,” he said, adding that emerging agents are under development, including multiple combination therapies, often with JAK inhibitors as the background.

No disclosure information was reported.

Despite a growing list of Janus kinase (JAK) inhibitors, ruxolitinib remains the go-to for patients with symptomatic, higher risk myelofibrosis, according to Anthony M. Hunter, MD, a myeloid malignancies specialist at Emory University, Atlanta.

“We are thankfully starting to be blessed with more options than we’ve ever had,” he said, but “in the front-line proliferative setting, ruxolitinib has remained the standard of care.” It’s “well established in higher-risk patients and very much an option for very symptomatic lower-risk patients.”

Dr. Hunter helped his colleagues navigate the evolving field of JAK inhibition for myelofibrosis in a presentation titled “Choosing and Properly Using a JAK Inhibitor in Myelofibrosis,”at the Society of Hematologic Oncology annual meeting.

Ruxolitinib was the first JAK inhibitor for myelofibrosis on the U.S. market, approved in 2011. Two more have followed, fedratinib in 2019 and pacritinib in 2022.

A fourth JAK inhibitor for myelofibrosis, momelotinib, is under Food and Drug Administration review with a decision expected shortly.

JAK inhibitors disrupt a key pathogenic pathway in myelofibrosis and are a mainstay of treatment, but Dr. Hunter noted that they should not replace allogeneic transplants in patients who are candidates because transplants remain “the best way to achieve long term survival, especially in higher risk patients.”

He noted that not every patient needs a JAK inhibitor, especially “lower-risk, more asymptomatic patients who are predominantly manifesting with cytopenias. [They] are less likely to benefit.”

Dr. Hunter said that although ruxolitinib remains a treatment of choice, fedratinib “is certainly an option” with comparable rates of symptom control and splenomegaly reduction. Also, while ruxolitinib is dosed according to platelet levels, fedratinib allows for full dosing down to a platelet count of 50 x 10⁹/L.

“But there’s more GI toxicity than with ruxolitinib, especially in the first couple of months,” he said, as well as a black box warning of Wernicke’s encephalopathy. “I generally put all my [fedratinib] patients on thiamine repletion as a precaution.”

One of the most challenging aspects of using JAK inhibitors for myelofibrosis is their tendency to cause cytopenia, particularly anemia and thrombocytopenia, which, ironically, are also hallmarks of myelofibrosis itself.

Although there’s an alternative low-dose ruxolitinib regimen that can be effective in anemic settings, the approval of pacritinib and most likely momelotinib is particularly helpful for cytopenic patients, “a population which historically has been very hard to treat with our prior agents,” Dr. Hunter said.

Pacritinib is approved specifically for patients with platelet counts below 50 x 10⁹/L; momelotinib also included lower platelet counts in several studies. Both agents indirectly boost erythropoiesis with subsequent amelioration of anemia.

“Momelotinib is an important emerging agent for these more anemic patients,” with a spleen response comparable to ruxolitinib and significantly higher rates of transfusion independence, but with lower rates of symptom control, Dr. Hunter said.

Pacritinib “really helps extend the benefit of JAK inhibitors to a group of thrombocytopenic patients who have been hard to treat with ruxolitinib,” with the added potential of improving anemia, although, like fedratinib, it has more GI toxicity, he said.

There are multiple add-on options for JAK inhibitor patients with anemia, including luspatercept, an erythropoiesis-stimulating agent approved for anemia in patients with myelodysplastic syndromes; promising results were reported recently for myelofibrosis.

Fedratinib, pacritinib, and momelotinib all have activity in the second line after ruxolitinib failure, Dr. Hunter noted, but he cautioned that ruxolitinib must be tapered over a few weeks, not stopped abruptly, to avoid withdrawal symptoms. Some clinicians overlap JAK inhibitors a day or two to avoid issues.

“Clinical trials should still be considered in many of these settings,” he said, adding that emerging agents are under development, including multiple combination therapies, often with JAK inhibitors as the background.

No disclosure information was reported.

Despite a growing list of Janus kinase (JAK) inhibitors, ruxolitinib remains the go-to for patients with symptomatic, higher risk myelofibrosis, according to Anthony M. Hunter, MD, a myeloid malignancies specialist at Emory University, Atlanta.

“We are thankfully starting to be blessed with more options than we’ve ever had,” he said, but “in the front-line proliferative setting, ruxolitinib has remained the standard of care.” It’s “well established in higher-risk patients and very much an option for very symptomatic lower-risk patients.”

Dr. Hunter helped his colleagues navigate the evolving field of JAK inhibition for myelofibrosis in a presentation titled “Choosing and Properly Using a JAK Inhibitor in Myelofibrosis,”at the Society of Hematologic Oncology annual meeting.

Ruxolitinib was the first JAK inhibitor for myelofibrosis on the U.S. market, approved in 2011. Two more have followed, fedratinib in 2019 and pacritinib in 2022.

A fourth JAK inhibitor for myelofibrosis, momelotinib, is under Food and Drug Administration review with a decision expected shortly.

JAK inhibitors disrupt a key pathogenic pathway in myelofibrosis and are a mainstay of treatment, but Dr. Hunter noted that they should not replace allogeneic transplants in patients who are candidates because transplants remain “the best way to achieve long term survival, especially in higher risk patients.”

He noted that not every patient needs a JAK inhibitor, especially “lower-risk, more asymptomatic patients who are predominantly manifesting with cytopenias. [They] are less likely to benefit.”

Dr. Hunter said that although ruxolitinib remains a treatment of choice, fedratinib “is certainly an option” with comparable rates of symptom control and splenomegaly reduction. Also, while ruxolitinib is dosed according to platelet levels, fedratinib allows for full dosing down to a platelet count of 50 x 10⁹/L.

“But there’s more GI toxicity than with ruxolitinib, especially in the first couple of months,” he said, as well as a black box warning of Wernicke’s encephalopathy. “I generally put all my [fedratinib] patients on thiamine repletion as a precaution.”

One of the most challenging aspects of using JAK inhibitors for myelofibrosis is their tendency to cause cytopenia, particularly anemia and thrombocytopenia, which, ironically, are also hallmarks of myelofibrosis itself.

Although there’s an alternative low-dose ruxolitinib regimen that can be effective in anemic settings, the approval of pacritinib and most likely momelotinib is particularly helpful for cytopenic patients, “a population which historically has been very hard to treat with our prior agents,” Dr. Hunter said.

Pacritinib is approved specifically for patients with platelet counts below 50 x 10⁹/L; momelotinib also included lower platelet counts in several studies. Both agents indirectly boost erythropoiesis with subsequent amelioration of anemia.

“Momelotinib is an important emerging agent for these more anemic patients,” with a spleen response comparable to ruxolitinib and significantly higher rates of transfusion independence, but with lower rates of symptom control, Dr. Hunter said.

Pacritinib “really helps extend the benefit of JAK inhibitors to a group of thrombocytopenic patients who have been hard to treat with ruxolitinib,” with the added potential of improving anemia, although, like fedratinib, it has more GI toxicity, he said.

There are multiple add-on options for JAK inhibitor patients with anemia, including luspatercept, an erythropoiesis-stimulating agent approved for anemia in patients with myelodysplastic syndromes; promising results were reported recently for myelofibrosis.

Fedratinib, pacritinib, and momelotinib all have activity in the second line after ruxolitinib failure, Dr. Hunter noted, but he cautioned that ruxolitinib must be tapered over a few weeks, not stopped abruptly, to avoid withdrawal symptoms. Some clinicians overlap JAK inhibitors a day or two to avoid issues.

“Clinical trials should still be considered in many of these settings,” he said, adding that emerging agents are under development, including multiple combination therapies, often with JAK inhibitors as the background.

No disclosure information was reported.

With the advent of artificial intelligence (AI), the era of double reading of mammograms is likely coming to a close, according to Liane Philpotts, MD, a radiology and biomedical imaging professor at Yale University in New Haven, Conn.

The reason is because AI is proving to be as good as humans in interpreting mammograms, at least in the research setting.

In one of the latest reports, published online in Radiology, British investigators found that the performance of a commercially available AI system (INSIGHT MMG version 1.1.7.1 – Lunit) was essentially equivalent to over 500 specialized readers. The results are in line with other recent AI studies.

Double reading – having mammograms read by two clinicians to increase cancer detection rates – is common in the United Kingdom and elsewhere in Europe.

The British team compared the performance of 552 readers with Lunit’s AI program on the Personal Performance in Mammographic Screening exam, a quality assurance test which mammogram readers in the United Kingdom are required to take twice a year. Readers assign a malignancy score to 60 challenging cases, a mix of normal breasts and breasts with benign and cancerous lesions. The study included two test sessions for a total of 120 breast screenings.

Fifty-seven percent of the readers in the study were board-certified radiologists, 37% were radiographers, and 6% were breast clinicians. Each read at least 5,000 mammograms a year.

There was no difference in overall performance between the AI program and the human readers (AUC 0.93 vs. 0.88, P = .15).

Commenting in an editorial published with the investigation, Dr. Philpotts said the results “suggest that AI could confidently act as a second reader to decrease workloads.”

As for the United States, where double reading is generally not done, she pointed out that “many U.S. radiologists interpreting mammograms are nonspecialized and do not read high volumes of mammograms. Thus, the AI system evaluated in the study “could be used as a supplemental tool to aid the performance of readers in the United States or in other countries where screening programs use a single reading.”

There was also no difference in sensitivity between AI and human readers (84% vs. 90%, P = .34), but the AI algorithm had a higher specificity (89% vs. 76%, P = .003).

Using AI recall scores that matched the average human reader performance (90% sensitivity, 76% specificity), there was no difference with AI in regard to sensitivity (91%, P = .73) or specificity (77%, P = .85), but the investigators noted the power of the analysis was limited.

Overall, “diagnostic performance of AI was comparable with that of the average human reader.” It seems “increasingly likely that AI will eventually play a part in the interpretation of screening mammograms,” said investigators led by Yan Chen, PhD, of the Nottingham Breast Institute in England.

“That the AI system was able to match the performance of the average reader in this specialized group of mammogram readers indicates the robustness of this AI algorithm,” Dr. Philpotts said.

However, there are some caveats.

For one, the system was designed for 2D mammography, the current standard of care in the United Kingdom, while digital breast tomosynthesis (DBT) is replacing 2D mammography in the United States.

In the United States, “AI algorithms specific to DBT are necessary and will need to be reliable and reproducible to be embraced by radiologists,” Dr. Philpotts said.

Also in the United Kingdom, screening is performed at 3-year intervals in women aged 50-70 years old, which means that the study population was enriched for older women with less-dense breasts. Screening generally starts earlier in the United States and includes premenopausal women with denser breasts.

A recent study from Korea, where many women have dense breasts, found that 2D mammography and supplementary ultrasound outperformed AI for cancer detection.

“This underscores the challenges of finding cancers in dense breasts, which plague both radiologists and AI alike, and provides evidence that breast density is an important factor to consider when evaluating AI performance,” Dr. Philpotts said.

The work was funded by Lunit, the maker of the AI program used in the study. The investigators and Dr. Philpotts had no disclosures.

With the advent of artificial intelligence (AI), the era of double reading of mammograms is likely coming to a close, according to Liane Philpotts, MD, a radiology and biomedical imaging professor at Yale University in New Haven, Conn.

The reason is because AI is proving to be as good as humans in interpreting mammograms, at least in the research setting.

In one of the latest reports, published online in Radiology, British investigators found that the performance of a commercially available AI system (INSIGHT MMG version 1.1.7.1 – Lunit) was essentially equivalent to over 500 specialized readers. The results are in line with other recent AI studies.

Double reading – having mammograms read by two clinicians to increase cancer detection rates – is common in the United Kingdom and elsewhere in Europe.

The British team compared the performance of 552 readers with Lunit’s AI program on the Personal Performance in Mammographic Screening exam, a quality assurance test which mammogram readers in the United Kingdom are required to take twice a year. Readers assign a malignancy score to 60 challenging cases, a mix of normal breasts and breasts with benign and cancerous lesions. The study included two test sessions for a total of 120 breast screenings.

Fifty-seven percent of the readers in the study were board-certified radiologists, 37% were radiographers, and 6% were breast clinicians. Each read at least 5,000 mammograms a year.

There was no difference in overall performance between the AI program and the human readers (AUC 0.93 vs. 0.88, P = .15).

Commenting in an editorial published with the investigation, Dr. Philpotts said the results “suggest that AI could confidently act as a second reader to decrease workloads.”

As for the United States, where double reading is generally not done, she pointed out that “many U.S. radiologists interpreting mammograms are nonspecialized and do not read high volumes of mammograms. Thus, the AI system evaluated in the study “could be used as a supplemental tool to aid the performance of readers in the United States or in other countries where screening programs use a single reading.”

There was also no difference in sensitivity between AI and human readers (84% vs. 90%, P = .34), but the AI algorithm had a higher specificity (89% vs. 76%, P = .003).

Using AI recall scores that matched the average human reader performance (90% sensitivity, 76% specificity), there was no difference with AI in regard to sensitivity (91%, P = .73) or specificity (77%, P = .85), but the investigators noted the power of the analysis was limited.

Overall, “diagnostic performance of AI was comparable with that of the average human reader.” It seems “increasingly likely that AI will eventually play a part in the interpretation of screening mammograms,” said investigators led by Yan Chen, PhD, of the Nottingham Breast Institute in England.

“That the AI system was able to match the performance of the average reader in this specialized group of mammogram readers indicates the robustness of this AI algorithm,” Dr. Philpotts said.

However, there are some caveats.

For one, the system was designed for 2D mammography, the current standard of care in the United Kingdom, while digital breast tomosynthesis (DBT) is replacing 2D mammography in the United States.

In the United States, “AI algorithms specific to DBT are necessary and will need to be reliable and reproducible to be embraced by radiologists,” Dr. Philpotts said.

Also in the United Kingdom, screening is performed at 3-year intervals in women aged 50-70 years old, which means that the study population was enriched for older women with less-dense breasts. Screening generally starts earlier in the United States and includes premenopausal women with denser breasts.

A recent study from Korea, where many women have dense breasts, found that 2D mammography and supplementary ultrasound outperformed AI for cancer detection.

“This underscores the challenges of finding cancers in dense breasts, which plague both radiologists and AI alike, and provides evidence that breast density is an important factor to consider when evaluating AI performance,” Dr. Philpotts said.

The work was funded by Lunit, the maker of the AI program used in the study. The investigators and Dr. Philpotts had no disclosures.

With the advent of artificial intelligence (AI), the era of double reading of mammograms is likely coming to a close, according to Liane Philpotts, MD, a radiology and biomedical imaging professor at Yale University in New Haven, Conn.

The reason is because AI is proving to be as good as humans in interpreting mammograms, at least in the research setting.

In one of the latest reports, published online in Radiology, British investigators found that the performance of a commercially available AI system (INSIGHT MMG version 1.1.7.1 – Lunit) was essentially equivalent to over 500 specialized readers. The results are in line with other recent AI studies.

Double reading – having mammograms read by two clinicians to increase cancer detection rates – is common in the United Kingdom and elsewhere in Europe.

The British team compared the performance of 552 readers with Lunit’s AI program on the Personal Performance in Mammographic Screening exam, a quality assurance test which mammogram readers in the United Kingdom are required to take twice a year. Readers assign a malignancy score to 60 challenging cases, a mix of normal breasts and breasts with benign and cancerous lesions. The study included two test sessions for a total of 120 breast screenings.

Fifty-seven percent of the readers in the study were board-certified radiologists, 37% were radiographers, and 6% were breast clinicians. Each read at least 5,000 mammograms a year.

There was no difference in overall performance between the AI program and the human readers (AUC 0.93 vs. 0.88, P = .15).

Commenting in an editorial published with the investigation, Dr. Philpotts said the results “suggest that AI could confidently act as a second reader to decrease workloads.”

As for the United States, where double reading is generally not done, she pointed out that “many U.S. radiologists interpreting mammograms are nonspecialized and do not read high volumes of mammograms. Thus, the AI system evaluated in the study “could be used as a supplemental tool to aid the performance of readers in the United States or in other countries where screening programs use a single reading.”

There was also no difference in sensitivity between AI and human readers (84% vs. 90%, P = .34), but the AI algorithm had a higher specificity (89% vs. 76%, P = .003).

Using AI recall scores that matched the average human reader performance (90% sensitivity, 76% specificity), there was no difference with AI in regard to sensitivity (91%, P = .73) or specificity (77%, P = .85), but the investigators noted the power of the analysis was limited.

Overall, “diagnostic performance of AI was comparable with that of the average human reader.” It seems “increasingly likely that AI will eventually play a part in the interpretation of screening mammograms,” said investigators led by Yan Chen, PhD, of the Nottingham Breast Institute in England.

“That the AI system was able to match the performance of the average reader in this specialized group of mammogram readers indicates the robustness of this AI algorithm,” Dr. Philpotts said.

However, there are some caveats.

For one, the system was designed for 2D mammography, the current standard of care in the United Kingdom, while digital breast tomosynthesis (DBT) is replacing 2D mammography in the United States.

In the United States, “AI algorithms specific to DBT are necessary and will need to be reliable and reproducible to be embraced by radiologists,” Dr. Philpotts said.

Also in the United Kingdom, screening is performed at 3-year intervals in women aged 50-70 years old, which means that the study population was enriched for older women with less-dense breasts. Screening generally starts earlier in the United States and includes premenopausal women with denser breasts.

A recent study from Korea, where many women have dense breasts, found that 2D mammography and supplementary ultrasound outperformed AI for cancer detection.

“This underscores the challenges of finding cancers in dense breasts, which plague both radiologists and AI alike, and provides evidence that breast density is an important factor to consider when evaluating AI performance,” Dr. Philpotts said.

The work was funded by Lunit, the maker of the AI program used in the study. The investigators and Dr. Philpotts had no disclosures.

It’s important to have counselors available for people diagnosed with clonal hematopoiesis of indeterminate potential (CHIP) or clonal cytopenia of undetermined significance (CCUS), according to medical oncologist Lachelle D. Weeks, MD, PhD, a specialist in both conditions at the Dana Farber Cancer Institute, Boston.

The reason is that patients will inevitably “go online and see that [the conditions are] associated with lots of bad things; it can really cause patients psychosocial harm if there is no one to explain what their risk is and also provide risk-specific management,” Dr. Weeks said at the annual meeting of the Society of Hematologic Oncology in Houston.

CHIP and CCUS are precursors of myeloid malignancies but for most patients, the risk of progression is less than 1%. CHIPS and CCUS are also associated with cardiovascular, rheumatologic, hepatic, and other diseases.

CHIP is defined by somatic mutations in myeloid malignancy driver genes with a variant allele fraction of 2% or more; CCUS is when those molecular features are accompanied by an unexplained and persistent anemia, thrombocytopenia, or neutropenia.

A small 2017 study suggested that about a third of patients with otherwise unexplained cytopenias have CCUS.

With the increasing use of next generation sequencing for tissue and liquid biopsies and other uses, the incidental diagnosis of both conditions is increasing.

Fortunately, Dr. Weeks’ group recently published a tool for predicting the risk of progression to myeloid malignancy.

Their “clonal hematopoiesis risk score” (CHRS) was developed and validated in over 400,000 healthy volunteers in the UK Biobank, with additional validation in cohorts from Dana Farber and the University of Pavia, Italy.

The CHRS incorporates eight high-risk genetic and clinical prognostic factors, including the type and number of genetic mutations in blood cells, factors related to red blood cell volume, and age over 65. It’s available online.

“You just input the patient’s information and it spits out if the patient is low, intermediate, or high risk for progression to any myeloid malignancy,” Dr. Weeks told her audience.

High-risk patients have about a 50% 10-year cumulative incidence of myeloid malignancy. The large majority of patients are low risk, however, and have a 10-year cumulative incidence of less than 1%. Patients in the middle have a 10-year risk of about 8%.

The low-risk group “is the population of people who probably don’t need to see a specialist,” and can be followed with an annual CBC with their primary care doctors plus further workup with any clinical change. Patients should also be evaluated for cardiovascular and other comorbidity risks.

“It’s the high-risk group we worry most about,” Dr. Weeks said. “We see them more often and repeat the next-generation sequencing” annually with a CBC at least every 6 months and a bone marrow biopsy with any clinical change.

“This is the population we would shuttle towards a clinical trial, as this is the population most likely to benefit,” she said.

The overarching goal of the several ongoing studies in CHIP/CCUS is to find a way to prevent progression to blood cancer. They range from prospective cohorts and single arm pilot studies to randomized clinical trials. One trial is evaluating canakinumab to prevent progression. “Intervention in clonal hematopoiesis might have the dual benefit of both preventing hematologic malignancy as well as reducing [the] inflammatory comorbidities,” Dr. Weeks said.

It’s important to have counselors available for people diagnosed with clonal hematopoiesis of indeterminate potential (CHIP) or clonal cytopenia of undetermined significance (CCUS), according to medical oncologist Lachelle D. Weeks, MD, PhD, a specialist in both conditions at the Dana Farber Cancer Institute, Boston.

The reason is that patients will inevitably “go online and see that [the conditions are] associated with lots of bad things; it can really cause patients psychosocial harm if there is no one to explain what their risk is and also provide risk-specific management,” Dr. Weeks said at the annual meeting of the Society of Hematologic Oncology in Houston.

CHIP and CCUS are precursors of myeloid malignancies but for most patients, the risk of progression is less than 1%. CHIPS and CCUS are also associated with cardiovascular, rheumatologic, hepatic, and other diseases.

CHIP is defined by somatic mutations in myeloid malignancy driver genes with a variant allele fraction of 2% or more; CCUS is when those molecular features are accompanied by an unexplained and persistent anemia, thrombocytopenia, or neutropenia.

A small 2017 study suggested that about a third of patients with otherwise unexplained cytopenias have CCUS.

With the increasing use of next generation sequencing for tissue and liquid biopsies and other uses, the incidental diagnosis of both conditions is increasing.

Fortunately, Dr. Weeks’ group recently published a tool for predicting the risk of progression to myeloid malignancy.

Their “clonal hematopoiesis risk score” (CHRS) was developed and validated in over 400,000 healthy volunteers in the UK Biobank, with additional validation in cohorts from Dana Farber and the University of Pavia, Italy.

The CHRS incorporates eight high-risk genetic and clinical prognostic factors, including the type and number of genetic mutations in blood cells, factors related to red blood cell volume, and age over 65. It’s available online.

“You just input the patient’s information and it spits out if the patient is low, intermediate, or high risk for progression to any myeloid malignancy,” Dr. Weeks told her audience.

High-risk patients have about a 50% 10-year cumulative incidence of myeloid malignancy. The large majority of patients are low risk, however, and have a 10-year cumulative incidence of less than 1%. Patients in the middle have a 10-year risk of about 8%.

The low-risk group “is the population of people who probably don’t need to see a specialist,” and can be followed with an annual CBC with their primary care doctors plus further workup with any clinical change. Patients should also be evaluated for cardiovascular and other comorbidity risks.

“It’s the high-risk group we worry most about,” Dr. Weeks said. “We see them more often and repeat the next-generation sequencing” annually with a CBC at least every 6 months and a bone marrow biopsy with any clinical change.

“This is the population we would shuttle towards a clinical trial, as this is the population most likely to benefit,” she said.

The overarching goal of the several ongoing studies in CHIP/CCUS is to find a way to prevent progression to blood cancer. They range from prospective cohorts and single arm pilot studies to randomized clinical trials. One trial is evaluating canakinumab to prevent progression. “Intervention in clonal hematopoiesis might have the dual benefit of both preventing hematologic malignancy as well as reducing [the] inflammatory comorbidities,” Dr. Weeks said.

It’s important to have counselors available for people diagnosed with clonal hematopoiesis of indeterminate potential (CHIP) or clonal cytopenia of undetermined significance (CCUS), according to medical oncologist Lachelle D. Weeks, MD, PhD, a specialist in both conditions at the Dana Farber Cancer Institute, Boston.

The reason is that patients will inevitably “go online and see that [the conditions are] associated with lots of bad things; it can really cause patients psychosocial harm if there is no one to explain what their risk is and also provide risk-specific management,” Dr. Weeks said at the annual meeting of the Society of Hematologic Oncology in Houston.

CHIP and CCUS are precursors of myeloid malignancies but for most patients, the risk of progression is less than 1%. CHIPS and CCUS are also associated with cardiovascular, rheumatologic, hepatic, and other diseases.

CHIP is defined by somatic mutations in myeloid malignancy driver genes with a variant allele fraction of 2% or more; CCUS is when those molecular features are accompanied by an unexplained and persistent anemia, thrombocytopenia, or neutropenia.

A small 2017 study suggested that about a third of patients with otherwise unexplained cytopenias have CCUS.

With the increasing use of next generation sequencing for tissue and liquid biopsies and other uses, the incidental diagnosis of both conditions is increasing.

Fortunately, Dr. Weeks’ group recently published a tool for predicting the risk of progression to myeloid malignancy.

Their “clonal hematopoiesis risk score” (CHRS) was developed and validated in over 400,000 healthy volunteers in the UK Biobank, with additional validation in cohorts from Dana Farber and the University of Pavia, Italy.

The CHRS incorporates eight high-risk genetic and clinical prognostic factors, including the type and number of genetic mutations in blood cells, factors related to red blood cell volume, and age over 65. It’s available online.

“You just input the patient’s information and it spits out if the patient is low, intermediate, or high risk for progression to any myeloid malignancy,” Dr. Weeks told her audience.

High-risk patients have about a 50% 10-year cumulative incidence of myeloid malignancy. The large majority of patients are low risk, however, and have a 10-year cumulative incidence of less than 1%. Patients in the middle have a 10-year risk of about 8%.

The low-risk group “is the population of people who probably don’t need to see a specialist,” and can be followed with an annual CBC with their primary care doctors plus further workup with any clinical change. Patients should also be evaluated for cardiovascular and other comorbidity risks.

“It’s the high-risk group we worry most about,” Dr. Weeks said. “We see them more often and repeat the next-generation sequencing” annually with a CBC at least every 6 months and a bone marrow biopsy with any clinical change.

“This is the population we would shuttle towards a clinical trial, as this is the population most likely to benefit,” she said.

The overarching goal of the several ongoing studies in CHIP/CCUS is to find a way to prevent progression to blood cancer. They range from prospective cohorts and single arm pilot studies to randomized clinical trials. One trial is evaluating canakinumab to prevent progression. “Intervention in clonal hematopoiesis might have the dual benefit of both preventing hematologic malignancy as well as reducing [the] inflammatory comorbidities,” Dr. Weeks said.

The latest results from the IKEMA trial, which pitted isatuximab (Sarclisa) against placebo on a background of carfilzomib and dexamethasone for relapsed/refractory multiple myeloma (MM), confirm the benefits seen in an earlier, interim analysis that won isatuximab Food and Drug Administration approval for the indication in March 2021.

Median follow up was 44 months in the new update, about 2 additional years past the earlier report.

As in the earlier analysis, adding the anti-CD38 antibody to carfilzomib and dexamethasone brought substantial benefits, including a median progression free survival (PFS) of 35.7 months versus 19.2 months with placebo, as well as a higher rates of complete response (CR, 44.1% vs. 28.5%), minimal residual disease (MRD) negativity (33.5% vs. 15.4%), and MRD negativity CR (26.3% vs. 12.2%).

Although overall survival data are not yet mature, the probability of being alive at 42 months was 66.3% with isatuximab add-on versus 54.5% with placebo.

Investigators led by Thomas G. Martin, MD, director of the University of California, San Francisco, myeloma program, noted that median PFS of nearly 3 years “is the longest PFS reported to date with a PI-based regimen in the relapsed MM [multiple myeloma] setting.” The updated results further support the combination “as a standard of care treatment for patients with relapsed MM.”

Overall, the trial adds “another effective triplet in the treatment of patients with” relapsed/refractory MM, Sergio A. Giralt, MD, head of the division of hematologic malignancies at Memorial Sloan Kettering Cancer Center, New York, said when asked for comment. The study was published May 9 in Blood Cancer Journal.
 

Safety similar to interim analysis

IKEMA randomized 179 patients to isatuximab add-on and 123 to placebo. Patients had relapsed/refractory MM with one to three prior treatment lines. Isatuximab was dosed at10 mg/kg IV in the open-label trial, weekly in the first cycle then biweekly.

The PFS benefit held across various subgroups, including the elderly and others with poor prognoses.

In their write-up, the investigators acknowledged isatuximab’s rival anti-CD38 antibody, daratumumab (Darzalex), which is also approved in the United States for use in combination with carfilzomib and dexamethasone for relapsed/refractory MM after one to three treatment lines.

“Although inter-trial evaluations should be interpreted with caution,” they noted that PFS in the latest analysis of daratumumab’s CANDOR trial in combination with carfilzomib and dexamethasone was shorter than in IKEMA, 28.6 months versus 15.2 months with placebo.

Like efficacy, safety in latest update of IKEMA was similar to that of the interim analysis. However, while there was no difference in the incidence of all-cause serious treatment-emergent adverse events (TEAEs) in the earlier report, the incidence was higher with isatuximab than placebo in the newest findings (70.1% vs. 59.8%).

The investigators said the difference was likely because patients in the isatuximab arm stayed on treatment longer, a median of 94 weeks versus 61.9 weeks in the placebo arm, making adverse events more likely.

The most common, nonhematologic TEAEs were infusion reactions (45.8% in the isatuximab arm vs. 3.3% in the placebo group), diarrhea (39.5% vs. 32%), hypertension (37.9% vs 35.2%), upper respiratory tract infection (37.3% vs 27%), and fatigue (31.6% vs 20.5%).

Grade 3 or higher pneumonia occurred in 18.6% patients in the isatuximab arm versus 12.3% in the placebo group. The incidence of skin cancer was 6.2% with isatuximab versus 3.3%. The incidence of treatment-emergent fatal events remained similar between study arms, 5.6% with isatuximab versus 4.9% with placebo.

The study was funded by Sanofi, maker of isatuximab. Investigators included two Sanofi employees. Others reported a range of ties to the company, including Dr. Martin, who reported research funding and sitting on a Sanofi steering committee.

The latest results from the IKEMA trial, which pitted isatuximab (Sarclisa) against placebo on a background of carfilzomib and dexamethasone for relapsed/refractory multiple myeloma (MM), confirm the benefits seen in an earlier, interim analysis that won isatuximab Food and Drug Administration approval for the indication in March 2021.

Median follow up was 44 months in the new update, about 2 additional years past the earlier report.

As in the earlier analysis, adding the anti-CD38 antibody to carfilzomib and dexamethasone brought substantial benefits, including a median progression free survival (PFS) of 35.7 months versus 19.2 months with placebo, as well as a higher rates of complete response (CR, 44.1% vs. 28.5%), minimal residual disease (MRD) negativity (33.5% vs. 15.4%), and MRD negativity CR (26.3% vs. 12.2%).

Although overall survival data are not yet mature, the probability of being alive at 42 months was 66.3% with isatuximab add-on versus 54.5% with placebo.

Investigators led by Thomas G. Martin, MD, director of the University of California, San Francisco, myeloma program, noted that median PFS of nearly 3 years “is the longest PFS reported to date with a PI-based regimen in the relapsed MM [multiple myeloma] setting.” The updated results further support the combination “as a standard of care treatment for patients with relapsed MM.”

Overall, the trial adds “another effective triplet in the treatment of patients with” relapsed/refractory MM, Sergio A. Giralt, MD, head of the division of hematologic malignancies at Memorial Sloan Kettering Cancer Center, New York, said when asked for comment. The study was published May 9 in Blood Cancer Journal.
 

Safety similar to interim analysis

IKEMA randomized 179 patients to isatuximab add-on and 123 to placebo. Patients had relapsed/refractory MM with one to three prior treatment lines. Isatuximab was dosed at10 mg/kg IV in the open-label trial, weekly in the first cycle then biweekly.

The PFS benefit held across various subgroups, including the elderly and others with poor prognoses.

In their write-up, the investigators acknowledged isatuximab’s rival anti-CD38 antibody, daratumumab (Darzalex), which is also approved in the United States for use in combination with carfilzomib and dexamethasone for relapsed/refractory MM after one to three treatment lines.

“Although inter-trial evaluations should be interpreted with caution,” they noted that PFS in the latest analysis of daratumumab’s CANDOR trial in combination with carfilzomib and dexamethasone was shorter than in IKEMA, 28.6 months versus 15.2 months with placebo.

Like efficacy, safety in latest update of IKEMA was similar to that of the interim analysis. However, while there was no difference in the incidence of all-cause serious treatment-emergent adverse events (TEAEs) in the earlier report, the incidence was higher with isatuximab than placebo in the newest findings (70.1% vs. 59.8%).

The investigators said the difference was likely because patients in the isatuximab arm stayed on treatment longer, a median of 94 weeks versus 61.9 weeks in the placebo arm, making adverse events more likely.

The most common, nonhematologic TEAEs were infusion reactions (45.8% in the isatuximab arm vs. 3.3% in the placebo group), diarrhea (39.5% vs. 32%), hypertension (37.9% vs 35.2%), upper respiratory tract infection (37.3% vs 27%), and fatigue (31.6% vs 20.5%).

Grade 3 or higher pneumonia occurred in 18.6% patients in the isatuximab arm versus 12.3% in the placebo group. The incidence of skin cancer was 6.2% with isatuximab versus 3.3%. The incidence of treatment-emergent fatal events remained similar between study arms, 5.6% with isatuximab versus 4.9% with placebo.

The study was funded by Sanofi, maker of isatuximab. Investigators included two Sanofi employees. Others reported a range of ties to the company, including Dr. Martin, who reported research funding and sitting on a Sanofi steering committee.

The latest results from the IKEMA trial, which pitted isatuximab (Sarclisa) against placebo on a background of carfilzomib and dexamethasone for relapsed/refractory multiple myeloma (MM), confirm the benefits seen in an earlier, interim analysis that won isatuximab Food and Drug Administration approval for the indication in March 2021.

Median follow up was 44 months in the new update, about 2 additional years past the earlier report.

As in the earlier analysis, adding the anti-CD38 antibody to carfilzomib and dexamethasone brought substantial benefits, including a median progression free survival (PFS) of 35.7 months versus 19.2 months with placebo, as well as a higher rates of complete response (CR, 44.1% vs. 28.5%), minimal residual disease (MRD) negativity (33.5% vs. 15.4%), and MRD negativity CR (26.3% vs. 12.2%).

Although overall survival data are not yet mature, the probability of being alive at 42 months was 66.3% with isatuximab add-on versus 54.5% with placebo.

Investigators led by Thomas G. Martin, MD, director of the University of California, San Francisco, myeloma program, noted that median PFS of nearly 3 years “is the longest PFS reported to date with a PI-based regimen in the relapsed MM [multiple myeloma] setting.” The updated results further support the combination “as a standard of care treatment for patients with relapsed MM.”

Overall, the trial adds “another effective triplet in the treatment of patients with” relapsed/refractory MM, Sergio A. Giralt, MD, head of the division of hematologic malignancies at Memorial Sloan Kettering Cancer Center, New York, said when asked for comment. The study was published May 9 in Blood Cancer Journal.
 

Safety similar to interim analysis

IKEMA randomized 179 patients to isatuximab add-on and 123 to placebo. Patients had relapsed/refractory MM with one to three prior treatment lines. Isatuximab was dosed at10 mg/kg IV in the open-label trial, weekly in the first cycle then biweekly.

The PFS benefit held across various subgroups, including the elderly and others with poor prognoses.

In their write-up, the investigators acknowledged isatuximab’s rival anti-CD38 antibody, daratumumab (Darzalex), which is also approved in the United States for use in combination with carfilzomib and dexamethasone for relapsed/refractory MM after one to three treatment lines.

“Although inter-trial evaluations should be interpreted with caution,” they noted that PFS in the latest analysis of daratumumab’s CANDOR trial in combination with carfilzomib and dexamethasone was shorter than in IKEMA, 28.6 months versus 15.2 months with placebo.

Like efficacy, safety in latest update of IKEMA was similar to that of the interim analysis. However, while there was no difference in the incidence of all-cause serious treatment-emergent adverse events (TEAEs) in the earlier report, the incidence was higher with isatuximab than placebo in the newest findings (70.1% vs. 59.8%).

The investigators said the difference was likely because patients in the isatuximab arm stayed on treatment longer, a median of 94 weeks versus 61.9 weeks in the placebo arm, making adverse events more likely.

The most common, nonhematologic TEAEs were infusion reactions (45.8% in the isatuximab arm vs. 3.3% in the placebo group), diarrhea (39.5% vs. 32%), hypertension (37.9% vs 35.2%), upper respiratory tract infection (37.3% vs 27%), and fatigue (31.6% vs 20.5%).

Grade 3 or higher pneumonia occurred in 18.6% patients in the isatuximab arm versus 12.3% in the placebo group. The incidence of skin cancer was 6.2% with isatuximab versus 3.3%. The incidence of treatment-emergent fatal events remained similar between study arms, 5.6% with isatuximab versus 4.9% with placebo.

The study was funded by Sanofi, maker of isatuximab. Investigators included two Sanofi employees. Others reported a range of ties to the company, including Dr. Martin, who reported research funding and sitting on a Sanofi steering committee.

TOPLINE:

Recurrence-free survival (RFS) is not a strong surrogate for overall survival in randomized trials of adjuvant immunotherapy for cancer.

METHODOLOGY:

• FDA approvals in the adjuvant setting for cancer immunotherapy are increasingly based on trials that use RFS as a surrogate endpoint for overall survival, largely because such a design allows for smaller, speedier trials.
• To test the validity of using RFS as a surrogate for overall survival in this setting, investigators conducted a meta-analysis of 15 phase 2 and 3 randomized controlled trials (RCTs) of adjuvant CTLA4 and anti–PD-1/PD-L1 blockers for melanoma, non–small cell lung cancer, renal cell cancer, and other tumors.
• The team used weighted regression at the arm and trial levels to assess the efficacy of RFS as a surrogate for overall survival.
• The strength of the association was quantified by weighted coefficients of determination (R²)12Dante MT Stdplz make sure all mentions of R’2’ are superscript, with a strong correlation considered to be R² of 0.7 or higher.
• If there were strong correlations at both the arm and trial levels, RFS would be considered a robust surrogate endpoint for overall survival; however, if one of the correlations at the arm or trial level was not strong, RFS would not be considered a surrogate endpoint for overall survival.

TAKEAWAY:

• At the arm level, moderate and strong associations were observed between 2-year RFS and 3-year overall survival (R², 0.58) and between 3-year RFS and 5-year overall survival (R², 0.72; 95% confidence interval, 0.38-.00).
• At the trial level, a moderate association was observed between effect of treatment on RFS and overall survival (R², 0.63).
• The findings were confirmed in several sensitivity analyses that were based on different trial phases, experimental arms, cancer types, and treatment strategies.

IN PRACTICE:

“Our meta-analysis failed to find a significantly strong association between RFS and OS in RCTs of adjuvant immunotherapy,” the authors concluded. “RFS should not be used as a surrogate endpoint for OS in this clinical context.” Instead, the finding indicates that overall survival is “the ideal primary endpoint” in this setting.

SOURCE:

The study, led by Yuanfang Li, PhD, of Sun Yat-sen University Cancer Center in Guangzhou, China, was published in the Journal of the National Cancer Institute.

LIMITATIONS:

• Correlations were calculated from a relatively limited number of RCTs that involved different types of cancer, and overall survival data were not fully mature in some of the trials.
• The analysis did not include patient-level data.

DISCLOSURES:

• The work was funded by the National Natural Science Foundation of China and others.
• The investigators had no disclosures.

A version of this article first appeared on Medscape.com.

TOPLINE:

Recurrence-free survival (RFS) is not a strong surrogate for overall survival in randomized trials of adjuvant immunotherapy for cancer.

METHODOLOGY:

• FDA approvals in the adjuvant setting for cancer immunotherapy are increasingly based on trials that use RFS as a surrogate endpoint for overall survival, largely because such a design allows for smaller, speedier trials.
• To test the validity of using RFS as a surrogate for overall survival in this setting, investigators conducted a meta-analysis of 15 phase 2 and 3 randomized controlled trials (RCTs) of adjuvant CTLA4 and anti–PD-1/PD-L1 blockers for melanoma, non–small cell lung cancer, renal cell cancer, and other tumors.
• The team used weighted regression at the arm and trial levels to assess the efficacy of RFS as a surrogate for overall survival.
• The strength of the association was quantified by weighted coefficients of determination (R²)12Dante MT Stdplz make sure all mentions of R’2’ are superscript, with a strong correlation considered to be R² of 0.7 or higher.
• If there were strong correlations at both the arm and trial levels, RFS would be considered a robust surrogate endpoint for overall survival; however, if one of the correlations at the arm or trial level was not strong, RFS would not be considered a surrogate endpoint for overall survival.

TAKEAWAY:

• At the arm level, moderate and strong associations were observed between 2-year RFS and 3-year overall survival (R², 0.58) and between 3-year RFS and 5-year overall survival (R², 0.72; 95% confidence interval, 0.38-.00).
• At the trial level, a moderate association was observed between effect of treatment on RFS and overall survival (R², 0.63).
• The findings were confirmed in several sensitivity analyses that were based on different trial phases, experimental arms, cancer types, and treatment strategies.

IN PRACTICE:

“Our meta-analysis failed to find a significantly strong association between RFS and OS in RCTs of adjuvant immunotherapy,” the authors concluded. “RFS should not be used as a surrogate endpoint for OS in this clinical context.” Instead, the finding indicates that overall survival is “the ideal primary endpoint” in this setting.

SOURCE:

The study, led by Yuanfang Li, PhD, of Sun Yat-sen University Cancer Center in Guangzhou, China, was published in the Journal of the National Cancer Institute.

LIMITATIONS:

• Correlations were calculated from a relatively limited number of RCTs that involved different types of cancer, and overall survival data were not fully mature in some of the trials.
• The analysis did not include patient-level data.

DISCLOSURES:

• The work was funded by the National Natural Science Foundation of China and others.
• The investigators had no disclosures.

A version of this article first appeared on Medscape.com.

TOPLINE:

Recurrence-free survival (RFS) is not a strong surrogate for overall survival in randomized trials of adjuvant immunotherapy for cancer.

METHODOLOGY:

• FDA approvals in the adjuvant setting for cancer immunotherapy are increasingly based on trials that use RFS as a surrogate endpoint for overall survival, largely because such a design allows for smaller, speedier trials.
• To test the validity of using RFS as a surrogate for overall survival in this setting, investigators conducted a meta-analysis of 15 phase 2 and 3 randomized controlled trials (RCTs) of adjuvant CTLA4 and anti–PD-1/PD-L1 blockers for melanoma, non–small cell lung cancer, renal cell cancer, and other tumors.
• The team used weighted regression at the arm and trial levels to assess the efficacy of RFS as a surrogate for overall survival.
• The strength of the association was quantified by weighted coefficients of determination (R²)12Dante MT Stdplz make sure all mentions of R’2’ are superscript, with a strong correlation considered to be R² of 0.7 or higher.
• If there were strong correlations at both the arm and trial levels, RFS would be considered a robust surrogate endpoint for overall survival; however, if one of the correlations at the arm or trial level was not strong, RFS would not be considered a surrogate endpoint for overall survival.

TAKEAWAY:

• At the arm level, moderate and strong associations were observed between 2-year RFS and 3-year overall survival (R², 0.58) and between 3-year RFS and 5-year overall survival (R², 0.72; 95% confidence interval, 0.38-.00).
• At the trial level, a moderate association was observed between effect of treatment on RFS and overall survival (R², 0.63).
• The findings were confirmed in several sensitivity analyses that were based on different trial phases, experimental arms, cancer types, and treatment strategies.

IN PRACTICE:

“Our meta-analysis failed to find a significantly strong association between RFS and OS in RCTs of adjuvant immunotherapy,” the authors concluded. “RFS should not be used as a surrogate endpoint for OS in this clinical context.” Instead, the finding indicates that overall survival is “the ideal primary endpoint” in this setting.

SOURCE:

The study, led by Yuanfang Li, PhD, of Sun Yat-sen University Cancer Center in Guangzhou, China, was published in the Journal of the National Cancer Institute.

LIMITATIONS:

• Correlations were calculated from a relatively limited number of RCTs that involved different types of cancer, and overall survival data were not fully mature in some of the trials.
• The analysis did not include patient-level data.

DISCLOSURES:

• The work was funded by the National Natural Science Foundation of China and others.
• The investigators had no disclosures.

A version of this article first appeared on Medscape.com.

Traditionally, the presence of ductal carcinoma in situ with invasive HER2-positive breast cancer has made surgeons hesitant to offer women breast conserving surgery following neoadjuvant therapy.

The concern has been that ductal carcinoma in situ (DCIS) doesn’t respond well to neoadjuvant treatment, so leaving it behind could increase the risk of recurrence.

A new study, however, calls that thinking into question.

In a nationwide review of over 5,000 women in the Netherlands, Dutch investigators found that neoadjuvant therapy eradicates DCIS about half of the time in women with invasive HER2-positive breast cancer.

The study is the largest look into the issue to date and confirms similar reports from a handful of smaller studies.

“These findings are important to create awareness that the presence of a DCIS component ... should not necessarily indicate the need for mastectomy,” said Roxanne Ploumen, PhD, of Maastricht (the Netherlands) University Medical Centre and colleagues.

The study was published in Breast Cancer Research and Treatment.

The research team compared biopsy results before neoadjuvant therapy with pathology reports following surgery. DCIS had a pathologic complete response rate of 52%. Neoadjuvant therapy generally consisted of anthracyclines followed by docetaxel or paclitaxel, in combination with trastuzumab.

The study also supports the assertion that women with DCIS are less likely to have breast-conserving surgery. Patients with DCIS were more likely to get mastectomies in the study (53.6% vs. 41%; P < .001) although the exact reasons are unclear because the data didn’t capture information relevant to surgical decision-making, including patient preferences and the extent of calcifications on mammography.

The key now is to find a way to assess how well DCIS responds to neoadjuvant therapy to better guide surgical decisions. Future studies should “investigate the evaluation of DCIS response by imaging” to increase the chance of breast-conserving surgery. “Moreover, a thorough investigation of pathologic characteristics” that predict response “could be useful,” Dr. Ploumen and associates said.

The investigators did find a few correlations that might help with response prediction; complete resolution of DCIS was associated with a complete response of the primary tumor to neoadjuvant therapy as well as negative estrogen receptor status and more recent breast cancer diagnosis, likely because of recent improvements in neoadjuvant therapy, including dual anti-HER2 blockade from 2017 onward, the team said.

Asked for comment, Kathy Miller, MD, a breast medical oncologist at Indiana University, Indianapolis, called the findings “interesting.”

“I suspect the challenge is that DCIS is often associated with microcalcifications” that don’t go away with therapy, “so it is common for [surgeons] to remove all areas” with microcalcifications. For now, “we can’t determine if the DCIS has” resolved with neoadjuvant therapy, so leaving calcifications behind “means accepting the possibility that you might be leaving residual disease behind,” she said.

The analysis included 5,598 women diagnosed with HER2-positive invasive breast cancer treated with neoadjuvant therapy and surgery between 2010 and 2020. The investigators coupled the Netherlands Cancer Registry with the Dutch Nationwide Pathology Databank to conduct their analysis.

About a quarter of the women had a DCIS component to their breast tumors.

The work was funded by the Jules Coenegracht Senior Foundation. Dr. Ploumen and Dr. Miller reported no conflicts of interest. Three investigators reported ties to Servier Pharmaceuticals, Bayer, Novartis, and other companies.

Traditionally, the presence of ductal carcinoma in situ with invasive HER2-positive breast cancer has made surgeons hesitant to offer women breast conserving surgery following neoadjuvant therapy.

The concern has been that ductal carcinoma in situ (DCIS) doesn’t respond well to neoadjuvant treatment, so leaving it behind could increase the risk of recurrence.

A new study, however, calls that thinking into question.

In a nationwide review of over 5,000 women in the Netherlands, Dutch investigators found that neoadjuvant therapy eradicates DCIS about half of the time in women with invasive HER2-positive breast cancer.

The study is the largest look into the issue to date and confirms similar reports from a handful of smaller studies.

“These findings are important to create awareness that the presence of a DCIS component ... should not necessarily indicate the need for mastectomy,” said Roxanne Ploumen, PhD, of Maastricht (the Netherlands) University Medical Centre and colleagues.

The study was published in Breast Cancer Research and Treatment.

The research team compared biopsy results before neoadjuvant therapy with pathology reports following surgery. DCIS had a pathologic complete response rate of 52%. Neoadjuvant therapy generally consisted of anthracyclines followed by docetaxel or paclitaxel, in combination with trastuzumab.

The study also supports the assertion that women with DCIS are less likely to have breast-conserving surgery. Patients with DCIS were more likely to get mastectomies in the study (53.6% vs. 41%; P < .001) although the exact reasons are unclear because the data didn’t capture information relevant to surgical decision-making, including patient preferences and the extent of calcifications on mammography.

The key now is to find a way to assess how well DCIS responds to neoadjuvant therapy to better guide surgical decisions. Future studies should “investigate the evaluation of DCIS response by imaging” to increase the chance of breast-conserving surgery. “Moreover, a thorough investigation of pathologic characteristics” that predict response “could be useful,” Dr. Ploumen and associates said.

The investigators did find a few correlations that might help with response prediction; complete resolution of DCIS was associated with a complete response of the primary tumor to neoadjuvant therapy as well as negative estrogen receptor status and more recent breast cancer diagnosis, likely because of recent improvements in neoadjuvant therapy, including dual anti-HER2 blockade from 2017 onward, the team said.

Asked for comment, Kathy Miller, MD, a breast medical oncologist at Indiana University, Indianapolis, called the findings “interesting.”

“I suspect the challenge is that DCIS is often associated with microcalcifications” that don’t go away with therapy, “so it is common for [surgeons] to remove all areas” with microcalcifications. For now, “we can’t determine if the DCIS has” resolved with neoadjuvant therapy, so leaving calcifications behind “means accepting the possibility that you might be leaving residual disease behind,” she said.

The analysis included 5,598 women diagnosed with HER2-positive invasive breast cancer treated with neoadjuvant therapy and surgery between 2010 and 2020. The investigators coupled the Netherlands Cancer Registry with the Dutch Nationwide Pathology Databank to conduct their analysis.

About a quarter of the women had a DCIS component to their breast tumors.

The work was funded by the Jules Coenegracht Senior Foundation. Dr. Ploumen and Dr. Miller reported no conflicts of interest. Three investigators reported ties to Servier Pharmaceuticals, Bayer, Novartis, and other companies.

Traditionally, the presence of ductal carcinoma in situ with invasive HER2-positive breast cancer has made surgeons hesitant to offer women breast conserving surgery following neoadjuvant therapy.

The concern has been that ductal carcinoma in situ (DCIS) doesn’t respond well to neoadjuvant treatment, so leaving it behind could increase the risk of recurrence.

A new study, however, calls that thinking into question.

In a nationwide review of over 5,000 women in the Netherlands, Dutch investigators found that neoadjuvant therapy eradicates DCIS about half of the time in women with invasive HER2-positive breast cancer.

The study is the largest look into the issue to date and confirms similar reports from a handful of smaller studies.

“These findings are important to create awareness that the presence of a DCIS component ... should not necessarily indicate the need for mastectomy,” said Roxanne Ploumen, PhD, of Maastricht (the Netherlands) University Medical Centre and colleagues.

The study was published in Breast Cancer Research and Treatment.

The research team compared biopsy results before neoadjuvant therapy with pathology reports following surgery. DCIS had a pathologic complete response rate of 52%. Neoadjuvant therapy generally consisted of anthracyclines followed by docetaxel or paclitaxel, in combination with trastuzumab.

The study also supports the assertion that women with DCIS are less likely to have breast-conserving surgery. Patients with DCIS were more likely to get mastectomies in the study (53.6% vs. 41%; P < .001) although the exact reasons are unclear because the data didn’t capture information relevant to surgical decision-making, including patient preferences and the extent of calcifications on mammography.

The key now is to find a way to assess how well DCIS responds to neoadjuvant therapy to better guide surgical decisions. Future studies should “investigate the evaluation of DCIS response by imaging” to increase the chance of breast-conserving surgery. “Moreover, a thorough investigation of pathologic characteristics” that predict response “could be useful,” Dr. Ploumen and associates said.

The investigators did find a few correlations that might help with response prediction; complete resolution of DCIS was associated with a complete response of the primary tumor to neoadjuvant therapy as well as negative estrogen receptor status and more recent breast cancer diagnosis, likely because of recent improvements in neoadjuvant therapy, including dual anti-HER2 blockade from 2017 onward, the team said.

Asked for comment, Kathy Miller, MD, a breast medical oncologist at Indiana University, Indianapolis, called the findings “interesting.”

“I suspect the challenge is that DCIS is often associated with microcalcifications” that don’t go away with therapy, “so it is common for [surgeons] to remove all areas” with microcalcifications. For now, “we can’t determine if the DCIS has” resolved with neoadjuvant therapy, so leaving calcifications behind “means accepting the possibility that you might be leaving residual disease behind,” she said.

The analysis included 5,598 women diagnosed with HER2-positive invasive breast cancer treated with neoadjuvant therapy and surgery between 2010 and 2020. The investigators coupled the Netherlands Cancer Registry with the Dutch Nationwide Pathology Databank to conduct their analysis.

About a quarter of the women had a DCIS component to their breast tumors.

The work was funded by the Jules Coenegracht Senior Foundation. Dr. Ploumen and Dr. Miller reported no conflicts of interest. Three investigators reported ties to Servier Pharmaceuticals, Bayer, Novartis, and other companies.

Topline

Even 2 days off from radiotherapy for triple-negative breast cancer (TNBC) may affect overall survival.

Methodology

• Clinicians sometimes give women with TNBC a break between radiation sessions so that their skin can heal.
• To gauge the impact, investigators reviewed data from the National Cancer Database on 35,845 patients with TNBC who were treated between 2010 and 2014.
• The researchers determined the number of interrupted radiation treatment days as the difference between the number of days women received radiotherapy versus the number of expected treatment days.
• The team then correlated treatment interruptions with overall survival.

Takeaway

• Longer duration of treatment was associated with worse overall survival (hazard ratio, 1.023).
• Compared with no days or just 1 day off, 2-5 interrupted days (HR, 1.069), 6-10 interrupted days (HR, 1.239), and 11-15 interrupted days (HR, 1.265) increased the likelihood of death in a stepwise fashion.
• More days between diagnosis and first cancer treatment of any kind (HR, 1.001) were associated with worse overall survival.
• Older age (HR, 1.014), Black race (HR, 1.278), race than other Black or White (HR, 1.337), grade II or III/IV tumors (HR, 1.471 and 1.743, respectively), and clinical N1-N3 stage (HR, 2.534, 3.729, 4.992, respectively) were also associated with worse overall survival.

In practice

“All reasonable efforts should be made to prevent any treatment interruptions,” including “prophylactic measures to reduce the severity of radiation dermatitis,” and consideration should be given to the use of hypofractionated regimens to shorten radiation schedules.

Source

The study was led by Ronald Chow, MS, of the Memorial Sloan Kettering Cancer Center, New York, and was published  in the Journal of the National Cancer Institute.

Limitations

• The findings may not be applicable to less aggressive forms of breast cancer.
• Treatment interruptions may have been caused by poor performance status and other confounders that shorten survival.

Disclosures

The study was funded by the National Cancer Institute. The investigators had no disclosures.

A version of this article appeared on Medscape.com.

Topline

Even 2 days off from radiotherapy for triple-negative breast cancer (TNBC) may affect overall survival.

Methodology

• Clinicians sometimes give women with TNBC a break between radiation sessions so that their skin can heal.
• To gauge the impact, investigators reviewed data from the National Cancer Database on 35,845 patients with TNBC who were treated between 2010 and 2014.
• The researchers determined the number of interrupted radiation treatment days as the difference between the number of days women received radiotherapy versus the number of expected treatment days.
• The team then correlated treatment interruptions with overall survival.

Takeaway

• Longer duration of treatment was associated with worse overall survival (hazard ratio, 1.023).
• Compared with no days or just 1 day off, 2-5 interrupted days (HR, 1.069), 6-10 interrupted days (HR, 1.239), and 11-15 interrupted days (HR, 1.265) increased the likelihood of death in a stepwise fashion.
• More days between diagnosis and first cancer treatment of any kind (HR, 1.001) were associated with worse overall survival.
• Older age (HR, 1.014), Black race (HR, 1.278), race than other Black or White (HR, 1.337), grade II or III/IV tumors (HR, 1.471 and 1.743, respectively), and clinical N1-N3 stage (HR, 2.534, 3.729, 4.992, respectively) were also associated with worse overall survival.

In practice

“All reasonable efforts should be made to prevent any treatment interruptions,” including “prophylactic measures to reduce the severity of radiation dermatitis,” and consideration should be given to the use of hypofractionated regimens to shorten radiation schedules.

Source

The study was led by Ronald Chow, MS, of the Memorial Sloan Kettering Cancer Center, New York, and was published  in the Journal of the National Cancer Institute.

Limitations

• The findings may not be applicable to less aggressive forms of breast cancer.
• Treatment interruptions may have been caused by poor performance status and other confounders that shorten survival.

Disclosures

The study was funded by the National Cancer Institute. The investigators had no disclosures.

A version of this article appeared on Medscape.com.

Topline

Even 2 days off from radiotherapy for triple-negative breast cancer (TNBC) may affect overall survival.

Methodology

• Clinicians sometimes give women with TNBC a break between radiation sessions so that their skin can heal.
• To gauge the impact, investigators reviewed data from the National Cancer Database on 35,845 patients with TNBC who were treated between 2010 and 2014.
• The researchers determined the number of interrupted radiation treatment days as the difference between the number of days women received radiotherapy versus the number of expected treatment days.
• The team then correlated treatment interruptions with overall survival.

Takeaway

• Longer duration of treatment was associated with worse overall survival (hazard ratio, 1.023).
• Compared with no days or just 1 day off, 2-5 interrupted days (HR, 1.069), 6-10 interrupted days (HR, 1.239), and 11-15 interrupted days (HR, 1.265) increased the likelihood of death in a stepwise fashion.
• More days between diagnosis and first cancer treatment of any kind (HR, 1.001) were associated with worse overall survival.
• Older age (HR, 1.014), Black race (HR, 1.278), race than other Black or White (HR, 1.337), grade II or III/IV tumors (HR, 1.471 and 1.743, respectively), and clinical N1-N3 stage (HR, 2.534, 3.729, 4.992, respectively) were also associated with worse overall survival.

In practice

“All reasonable efforts should be made to prevent any treatment interruptions,” including “prophylactic measures to reduce the severity of radiation dermatitis,” and consideration should be given to the use of hypofractionated regimens to shorten radiation schedules.

Source

The study was led by Ronald Chow, MS, of the Memorial Sloan Kettering Cancer Center, New York, and was published  in the Journal of the National Cancer Institute.

Limitations

• The findings may not be applicable to less aggressive forms of breast cancer.
• Treatment interruptions may have been caused by poor performance status and other confounders that shorten survival.

Disclosures

The study was funded by the National Cancer Institute. The investigators had no disclosures.

A version of this article appeared on Medscape.com.

The European Society for Medical Oncology (ESMO), in collaboration with the European Hematology Association, has released a tool to help hematologists evaluate the magnitude of clinical benefit expected from new blood cancer treatments.

It consists of 11 2- to 3-page forms with checklists to grade treatment trials on the extent to which they meet efficacy and safety thresholds. Each of the 11 forms covers a specific trial scenario, such as a randomized controlled trial with curative intent or a trial of a therapy that is not likely to be curative with a primary endpoint of overall survival.

Treatments with curative intent are graded A, B, or C, while treatments in the noncurative setting are graded on a descending scale from 5 to 1. Scores of A and B in the curative setting and 5 and 4 in the noncurative setting represent substantial benefit.

On the form for RCTs with curative intent, for instance, a survival improvement of 5% or more garners an A but an improvement of less than 3% gets a C. Scores are also annotated for serious acute and/or persistent toxicity if present.

The tool, dubbed the ESMO-MCBS:H (European Society for Medical Oncology Magnitude of Clinical Benefit Scale: Hematology), is explained in an article published in Annals of Oncology. The evaluation forms are available online.

The idea behind the work is to help health care professionals and others to more “accurately assess the value of and prioritise therapies for patients with blood cancers. For clinicians, ESMO-MCBS:H will aid in their clinical decision-making and in the development of evidence-based practice and guidelines,” ESMO said in a press release.

To develop ESMO-MCBS:H, the group tailored its tool for evaluating solid tumor therapies, the ESMO-MCBS, to account for the sometimes different endpoints used in hematologic malignancy trials and the very indolent nature of some blood cancers, such as follicular lymphoma, which hampers development of mature data.

Specific changes include adding a new evaluation form to grade single-arm trials with curative intent, such as those used for CAR-T-cell therapies; incorporating molecular surrogate endpoints used in CML trials; and adding a way to grade outcomes for indolent cancers, among others.

The development process included applying the solid tumor tool to 80 blood cancer studies to identify shortcomings and improve its applicability. The final tool was field tested with 51 international experts from EHA and ESMO who largely agreed on the reasonableness of the trial scores.

ESMO said it expects ESMO-MCBS:H will be useful. The solid tumor tool, first published in 2015, is used by the World Health Organization to screen medications for its essential medicines list as well as by ESMO to generate guidelines and oncology centers across Europe to help with resource allocation decisions.

The European Society for Medical Oncology (ESMO), in collaboration with the European Hematology Association, has released a tool to help hematologists evaluate the magnitude of clinical benefit expected from new blood cancer treatments.

It consists of 11 2- to 3-page forms with checklists to grade treatment trials on the extent to which they meet efficacy and safety thresholds. Each of the 11 forms covers a specific trial scenario, such as a randomized controlled trial with curative intent or a trial of a therapy that is not likely to be curative with a primary endpoint of overall survival.

Treatments with curative intent are graded A, B, or C, while treatments in the noncurative setting are graded on a descending scale from 5 to 1. Scores of A and B in the curative setting and 5 and 4 in the noncurative setting represent substantial benefit.

On the form for RCTs with curative intent, for instance, a survival improvement of 5% or more garners an A but an improvement of less than 3% gets a C. Scores are also annotated for serious acute and/or persistent toxicity if present.

The tool, dubbed the ESMO-MCBS:H (European Society for Medical Oncology Magnitude of Clinical Benefit Scale: Hematology), is explained in an article published in Annals of Oncology. The evaluation forms are available online.

The idea behind the work is to help health care professionals and others to more “accurately assess the value of and prioritise therapies for patients with blood cancers. For clinicians, ESMO-MCBS:H will aid in their clinical decision-making and in the development of evidence-based practice and guidelines,” ESMO said in a press release.

To develop ESMO-MCBS:H, the group tailored its tool for evaluating solid tumor therapies, the ESMO-MCBS, to account for the sometimes different endpoints used in hematologic malignancy trials and the very indolent nature of some blood cancers, such as follicular lymphoma, which hampers development of mature data.

Specific changes include adding a new evaluation form to grade single-arm trials with curative intent, such as those used for CAR-T-cell therapies; incorporating molecular surrogate endpoints used in CML trials; and adding a way to grade outcomes for indolent cancers, among others.

The development process included applying the solid tumor tool to 80 blood cancer studies to identify shortcomings and improve its applicability. The final tool was field tested with 51 international experts from EHA and ESMO who largely agreed on the reasonableness of the trial scores.

ESMO said it expects ESMO-MCBS:H will be useful. The solid tumor tool, first published in 2015, is used by the World Health Organization to screen medications for its essential medicines list as well as by ESMO to generate guidelines and oncology centers across Europe to help with resource allocation decisions.

The European Society for Medical Oncology (ESMO), in collaboration with the European Hematology Association, has released a tool to help hematologists evaluate the magnitude of clinical benefit expected from new blood cancer treatments.

It consists of 11 2- to 3-page forms with checklists to grade treatment trials on the extent to which they meet efficacy and safety thresholds. Each of the 11 forms covers a specific trial scenario, such as a randomized controlled trial with curative intent or a trial of a therapy that is not likely to be curative with a primary endpoint of overall survival.

Treatments with curative intent are graded A, B, or C, while treatments in the noncurative setting are graded on a descending scale from 5 to 1. Scores of A and B in the curative setting and 5 and 4 in the noncurative setting represent substantial benefit.

On the form for RCTs with curative intent, for instance, a survival improvement of 5% or more garners an A but an improvement of less than 3% gets a C. Scores are also annotated for serious acute and/or persistent toxicity if present.

The tool, dubbed the ESMO-MCBS:H (European Society for Medical Oncology Magnitude of Clinical Benefit Scale: Hematology), is explained in an article published in Annals of Oncology. The evaluation forms are available online.

The idea behind the work is to help health care professionals and others to more “accurately assess the value of and prioritise therapies for patients with blood cancers. For clinicians, ESMO-MCBS:H will aid in their clinical decision-making and in the development of evidence-based practice and guidelines,” ESMO said in a press release.

To develop ESMO-MCBS:H, the group tailored its tool for evaluating solid tumor therapies, the ESMO-MCBS, to account for the sometimes different endpoints used in hematologic malignancy trials and the very indolent nature of some blood cancers, such as follicular lymphoma, which hampers development of mature data.

Specific changes include adding a new evaluation form to grade single-arm trials with curative intent, such as those used for CAR-T-cell therapies; incorporating molecular surrogate endpoints used in CML trials; and adding a way to grade outcomes for indolent cancers, among others.

The development process included applying the solid tumor tool to 80 blood cancer studies to identify shortcomings and improve its applicability. The final tool was field tested with 51 international experts from EHA and ESMO who largely agreed on the reasonableness of the trial scores.

ESMO said it expects ESMO-MCBS:H will be useful. The solid tumor tool, first published in 2015, is used by the World Health Organization to screen medications for its essential medicines list as well as by ESMO to generate guidelines and oncology centers across Europe to help with resource allocation decisions.

High-risk genetic features do not diminish the response to first-line, fixed-dose ibrutinib (Imbruvica) plus venetoclax (Venclexta) for chronic lymphocytic leukemia (CLL), according to the latest report from AbbVie’s CAPTIVATE trial.

In the new analysis, published in Clinical Cancer Research, investigators compared outcomes in 66 adults without genetic risk factors to 129 with deletion of 17p, mutated TP53, and/or unmutated immunoglobulin heavy chain, all of which are associated with poor outcomes and poor responses to chemoimmunotherapy.

Over 95% of patients responded regardless of risk factors, with complete response in 61% of patients with and 53% of subjects without high-risk features. Progression free-survival (PFS) lasted at least 3 years in 88% of the high-risk group and 92% of low-risk patients, with over 95% of patients in both groups alive at 3 years

“Since high-risk genetic features inform treatment selection, understanding the efficacy of fixed-duration ibrutinib plus venetoclax in patients with high-risk CLL is important to determine how this regimen fits in the first-line treatment algorithm for the disease,” hematologic oncologist John Allan, MD, a CLL specialist at Weill Cornell Medical Center in New York and the lead investigator, said in a press release from American Association for Cancer Research, publisher of CCR.

Although the analysis was not powered to perform statistical comparisons between the two groups, Dr. Allan said the results “support fixed-duration ibrutinib plus venetoclax as a treatment approach for this patient population.”

The press release also noted that the outcomes “compare favorably” to other upfront targeted therapy approaches for CLL.
 

Experts respond

Asked for comment, Thomas LeBlanc, MD, a hematologic oncologist at Duke University in Durham, N.C., said “the advent of some fixed duration regimens with novel therapies has been an exciting thing for patients especially, recognizing that at the start of treatment one already knows the completion date, and one can also thus forgo much of the potentially cumulative physical, psychological, and financial toxicity of an indefinite oral therapy.”

As for the new findings, he said they show “that even in this high-risk population ... we can achieve remarkable remission rates and levels of [minimal residual disease] negativity by combining the two best drug classes to date in CLL: BTK inhibitors and venetoclax.”

Another expert, hematologic oncologist John Byrd, MD, a leukemia specialist at the University of Cincinnati, was more cautious.

“These findings confirm the results of many other prior studies of targeted therapies where high complete response rates with absence of detectable disease is observed,” he said.

However, while “such therapeutic combinations for sure enable treatment discontinuation,” Dr. Byrd noted, they “lack long-term follow-up. Given the added toxicities associated with these combinations and lack of long-term follow up, use of treatments such as those brought forth in the CAPTIVATE trial should be considered only in the context of a well-designed clinical trial.”
 

Study details

The new findings follow previous reports of CAPTIVATE, which found strong first-line response across CLL patients but did not focus as specifically on patients with high-risk genetic features.

Subjects received three 28-day cycles of ibrutinib 420 mg/day followed by twelve 28-day cycles of ibrutinib plus venetoclax, with a 5-week venetoclax ramp-up to 400 mg/day.

Side effects were similar regardless of high-risk features and included, most commonly, diarrhea, neutropenia, nausea, and arthralgia. The most common grade 3/4 treatment-emergent adverse events were neutropenia in 36% of patients in both groups and hypertension in 9% of patients with and 3% of patients without high-risk features.

The study was funded by Pharmacyclics/AbbVie, maker/marketer of both ibrutinib and venetoclax. Investigators had numerous ties to the companies, including Dr. Allan, who reported grants and/or personal fees. Dr. LeBlanc reported speaker/consulting honoraria from AbbVie as well as institutional research funding. Dr. Byrd did not have any connections to the companies.

High-risk genetic features do not diminish the response to first-line, fixed-dose ibrutinib (Imbruvica) plus venetoclax (Venclexta) for chronic lymphocytic leukemia (CLL), according to the latest report from AbbVie’s CAPTIVATE trial.

In the new analysis, published in Clinical Cancer Research, investigators compared outcomes in 66 adults without genetic risk factors to 129 with deletion of 17p, mutated TP53, and/or unmutated immunoglobulin heavy chain, all of which are associated with poor outcomes and poor responses to chemoimmunotherapy.

Over 95% of patients responded regardless of risk factors, with complete response in 61% of patients with and 53% of subjects without high-risk features. Progression free-survival (PFS) lasted at least 3 years in 88% of the high-risk group and 92% of low-risk patients, with over 95% of patients in both groups alive at 3 years

“Since high-risk genetic features inform treatment selection, understanding the efficacy of fixed-duration ibrutinib plus venetoclax in patients with high-risk CLL is important to determine how this regimen fits in the first-line treatment algorithm for the disease,” hematologic oncologist John Allan, MD, a CLL specialist at Weill Cornell Medical Center in New York and the lead investigator, said in a press release from American Association for Cancer Research, publisher of CCR.

Although the analysis was not powered to perform statistical comparisons between the two groups, Dr. Allan said the results “support fixed-duration ibrutinib plus venetoclax as a treatment approach for this patient population.”

The press release also noted that the outcomes “compare favorably” to other upfront targeted therapy approaches for CLL.
 

Experts respond

Asked for comment, Thomas LeBlanc, MD, a hematologic oncologist at Duke University in Durham, N.C., said “the advent of some fixed duration regimens with novel therapies has been an exciting thing for patients especially, recognizing that at the start of treatment one already knows the completion date, and one can also thus forgo much of the potentially cumulative physical, psychological, and financial toxicity of an indefinite oral therapy.”

As for the new findings, he said they show “that even in this high-risk population ... we can achieve remarkable remission rates and levels of [minimal residual disease] negativity by combining the two best drug classes to date in CLL: BTK inhibitors and venetoclax.”

Another expert, hematologic oncologist John Byrd, MD, a leukemia specialist at the University of Cincinnati, was more cautious.

“These findings confirm the results of many other prior studies of targeted therapies where high complete response rates with absence of detectable disease is observed,” he said.

However, while “such therapeutic combinations for sure enable treatment discontinuation,” Dr. Byrd noted, they “lack long-term follow-up. Given the added toxicities associated with these combinations and lack of long-term follow up, use of treatments such as those brought forth in the CAPTIVATE trial should be considered only in the context of a well-designed clinical trial.”
 

Study details

The new findings follow previous reports of CAPTIVATE, which found strong first-line response across CLL patients but did not focus as specifically on patients with high-risk genetic features.

Subjects received three 28-day cycles of ibrutinib 420 mg/day followed by twelve 28-day cycles of ibrutinib plus venetoclax, with a 5-week venetoclax ramp-up to 400 mg/day.

Side effects were similar regardless of high-risk features and included, most commonly, diarrhea, neutropenia, nausea, and arthralgia. The most common grade 3/4 treatment-emergent adverse events were neutropenia in 36% of patients in both groups and hypertension in 9% of patients with and 3% of patients without high-risk features.

The study was funded by Pharmacyclics/AbbVie, maker/marketer of both ibrutinib and venetoclax. Investigators had numerous ties to the companies, including Dr. Allan, who reported grants and/or personal fees. Dr. LeBlanc reported speaker/consulting honoraria from AbbVie as well as institutional research funding. Dr. Byrd did not have any connections to the companies.

High-risk genetic features do not diminish the response to first-line, fixed-dose ibrutinib (Imbruvica) plus venetoclax (Venclexta) for chronic lymphocytic leukemia (CLL), according to the latest report from AbbVie’s CAPTIVATE trial.

In the new analysis, published in Clinical Cancer Research, investigators compared outcomes in 66 adults without genetic risk factors to 129 with deletion of 17p, mutated TP53, and/or unmutated immunoglobulin heavy chain, all of which are associated with poor outcomes and poor responses to chemoimmunotherapy.

Over 95% of patients responded regardless of risk factors, with complete response in 61% of patients with and 53% of subjects without high-risk features. Progression free-survival (PFS) lasted at least 3 years in 88% of the high-risk group and 92% of low-risk patients, with over 95% of patients in both groups alive at 3 years

“Since high-risk genetic features inform treatment selection, understanding the efficacy of fixed-duration ibrutinib plus venetoclax in patients with high-risk CLL is important to determine how this regimen fits in the first-line treatment algorithm for the disease,” hematologic oncologist John Allan, MD, a CLL specialist at Weill Cornell Medical Center in New York and the lead investigator, said in a press release from American Association for Cancer Research, publisher of CCR.

Although the analysis was not powered to perform statistical comparisons between the two groups, Dr. Allan said the results “support fixed-duration ibrutinib plus venetoclax as a treatment approach for this patient population.”

The press release also noted that the outcomes “compare favorably” to other upfront targeted therapy approaches for CLL.
 

Experts respond

Asked for comment, Thomas LeBlanc, MD, a hematologic oncologist at Duke University in Durham, N.C., said “the advent of some fixed duration regimens with novel therapies has been an exciting thing for patients especially, recognizing that at the start of treatment one already knows the completion date, and one can also thus forgo much of the potentially cumulative physical, psychological, and financial toxicity of an indefinite oral therapy.”

As for the new findings, he said they show “that even in this high-risk population ... we can achieve remarkable remission rates and levels of [minimal residual disease] negativity by combining the two best drug classes to date in CLL: BTK inhibitors and venetoclax.”

Another expert, hematologic oncologist John Byrd, MD, a leukemia specialist at the University of Cincinnati, was more cautious.

“These findings confirm the results of many other prior studies of targeted therapies where high complete response rates with absence of detectable disease is observed,” he said.

However, while “such therapeutic combinations for sure enable treatment discontinuation,” Dr. Byrd noted, they “lack long-term follow-up. Given the added toxicities associated with these combinations and lack of long-term follow up, use of treatments such as those brought forth in the CAPTIVATE trial should be considered only in the context of a well-designed clinical trial.”
 

Study details

The new findings follow previous reports of CAPTIVATE, which found strong first-line response across CLL patients but did not focus as specifically on patients with high-risk genetic features.

Subjects received three 28-day cycles of ibrutinib 420 mg/day followed by twelve 28-day cycles of ibrutinib plus venetoclax, with a 5-week venetoclax ramp-up to 400 mg/day.

Side effects were similar regardless of high-risk features and included, most commonly, diarrhea, neutropenia, nausea, and arthralgia. The most common grade 3/4 treatment-emergent adverse events were neutropenia in 36% of patients in both groups and hypertension in 9% of patients with and 3% of patients without high-risk features.

The study was funded by Pharmacyclics/AbbVie, maker/marketer of both ibrutinib and venetoclax. Investigators had numerous ties to the companies, including Dr. Allan, who reported grants and/or personal fees. Dr. LeBlanc reported speaker/consulting honoraria from AbbVie as well as institutional research funding. Dr. Byrd did not have any connections to the companies.

At a median follow-up of 47.2 months, axicabtagene ciloleucel (axi-cel, Yescarta) significantly improved overall survival compared with standard second-line treatments in patients with early relapsed or refractory large B-cell lymphoma, according to a phase 3 investigation reported at the annual meeting of the American Society of Clinical Oncology (ASCO).

The anti-CD19 chimeric antigen receptor T-cell (CAR-T) therapy was approved for second-line treatment in 2022 based on better event-free survival, but standard second-line treatment – chemoimmunotherapy followed by high-dose chemotherapy and autologous stem-cell transplant in responders – still remains the prevailing approach, explained Jason Westin, MD, director of lymphoma research at MD Anderson Cancer Center, Houston. Dr. Westin, lead investigator, presented the trial, dubbed ZUMA-7, at the ASCO meeting.

The new findings might change that. ZUMA-7 “conclusively demonstrates that trying chemotherapy in the second line and saving cell therapy for the third line is an inferior approach ... ZUMA-7 confirms axi-cel is a second-line standard of care for patients with refractory or early relapsed large B cell lymphoma based on superior overall survival,” said Dr. Westin.

Study discussant Asher A. Chanan-Khan, MD, a CAR-T specialist at the Mayo Clinic in Jacksonville, Fla., agreed.

“This data must alter the current standard of care making CAR-T or axi-cel, based on the data we heard, a preferred second-line treatment ... Moving CAR-T earlier in the treatment paradigm is likely a better choice for our patients,” he said.

The study was published in the New England Journal of Medicine to coincide with the presentations.

Dr. Westin noted that axi-cel is now under investigation in ZUMA-23 for first-line treatment of high-risk large B-cell lymphoma (LBCL).


 

Study details

Zuma-7 randomized 180 LBCL patients to a one-time axi-cel infusion and 179 to standard care. Patients were refractory to first line chemoimmunotherapy or had relapsed within 12 months; just 36% of patients in the standard care group did well enough on treatment to go on to stem-cell transplant.

Median progression-free survival (PFS) was 14.7 months with axi-cel versus 3.7 months with standard care.

Significantly, the better PFS appears to have translated into better overall survival (OS).

At a median of almost 4 years, 82 patients in the axi-cel group had died, compared with 95 patients with standard care who had died. Estimated 4-year OS was 54.6% with axi-cel versus 46% with standard care (HR 0.73, P = .03).

The OS benefit held in high-risk subgroups, including patients over 64 years old, those refractory to first-line treatment, and patients with high-grade disease.

Adverse events were in keeping with labeling. Cytokine release syndrome was more common in the axi-cel arm, including grade 3 or worse CRS in 6% of axi-cel patients versus none on standard care. Grade 3 or worse infections were also more common at 16.5% versus 11.9% with standard care. Over 11% of axi-cel patients developed hypogammaglobulinemia versus 0.6% in the standard care group.

Overall, there were no new serious or fatal adverse events since the initial PFS results were reported in 2022, when eight fatal adverse events were reported with axi-cel versus two with standard care.

The work was funded by axi-cel maker Kite Pharma, a subsidiary of Gilead. Investigators included Kite/Gilead employees and others who reported financial relationships with the companies, including Dr. Westin, a Kite/Gilead researcher and adviser. Dr. Chanan-Khan disclosed ties with Cellectar, Starton Therapeutics, Ascentage Pharma, and others.

At a median follow-up of 47.2 months, axicabtagene ciloleucel (axi-cel, Yescarta) significantly improved overall survival compared with standard second-line treatments in patients with early relapsed or refractory large B-cell lymphoma, according to a phase 3 investigation reported at the annual meeting of the American Society of Clinical Oncology (ASCO).

The anti-CD19 chimeric antigen receptor T-cell (CAR-T) therapy was approved for second-line treatment in 2022 based on better event-free survival, but standard second-line treatment – chemoimmunotherapy followed by high-dose chemotherapy and autologous stem-cell transplant in responders – still remains the prevailing approach, explained Jason Westin, MD, director of lymphoma research at MD Anderson Cancer Center, Houston. Dr. Westin, lead investigator, presented the trial, dubbed ZUMA-7, at the ASCO meeting.

The new findings might change that. ZUMA-7 “conclusively demonstrates that trying chemotherapy in the second line and saving cell therapy for the third line is an inferior approach ... ZUMA-7 confirms axi-cel is a second-line standard of care for patients with refractory or early relapsed large B cell lymphoma based on superior overall survival,” said Dr. Westin.

Study discussant Asher A. Chanan-Khan, MD, a CAR-T specialist at the Mayo Clinic in Jacksonville, Fla., agreed.

“This data must alter the current standard of care making CAR-T or axi-cel, based on the data we heard, a preferred second-line treatment ... Moving CAR-T earlier in the treatment paradigm is likely a better choice for our patients,” he said.

The study was published in the New England Journal of Medicine to coincide with the presentations.

Dr. Westin noted that axi-cel is now under investigation in ZUMA-23 for first-line treatment of high-risk large B-cell lymphoma (LBCL).


 

Study details

Zuma-7 randomized 180 LBCL patients to a one-time axi-cel infusion and 179 to standard care. Patients were refractory to first line chemoimmunotherapy or had relapsed within 12 months; just 36% of patients in the standard care group did well enough on treatment to go on to stem-cell transplant.

Median progression-free survival (PFS) was 14.7 months with axi-cel versus 3.7 months with standard care.

Significantly, the better PFS appears to have translated into better overall survival (OS).

At a median of almost 4 years, 82 patients in the axi-cel group had died, compared with 95 patients with standard care who had died. Estimated 4-year OS was 54.6% with axi-cel versus 46% with standard care (HR 0.73, P = .03).

The OS benefit held in high-risk subgroups, including patients over 64 years old, those refractory to first-line treatment, and patients with high-grade disease.

Adverse events were in keeping with labeling. Cytokine release syndrome was more common in the axi-cel arm, including grade 3 or worse CRS in 6% of axi-cel patients versus none on standard care. Grade 3 or worse infections were also more common at 16.5% versus 11.9% with standard care. Over 11% of axi-cel patients developed hypogammaglobulinemia versus 0.6% in the standard care group.

Overall, there were no new serious or fatal adverse events since the initial PFS results were reported in 2022, when eight fatal adverse events were reported with axi-cel versus two with standard care.

The work was funded by axi-cel maker Kite Pharma, a subsidiary of Gilead. Investigators included Kite/Gilead employees and others who reported financial relationships with the companies, including Dr. Westin, a Kite/Gilead researcher and adviser. Dr. Chanan-Khan disclosed ties with Cellectar, Starton Therapeutics, Ascentage Pharma, and others.

At a median follow-up of 47.2 months, axicabtagene ciloleucel (axi-cel, Yescarta) significantly improved overall survival compared with standard second-line treatments in patients with early relapsed or refractory large B-cell lymphoma, according to a phase 3 investigation reported at the annual meeting of the American Society of Clinical Oncology (ASCO).

The anti-CD19 chimeric antigen receptor T-cell (CAR-T) therapy was approved for second-line treatment in 2022 based on better event-free survival, but standard second-line treatment – chemoimmunotherapy followed by high-dose chemotherapy and autologous stem-cell transplant in responders – still remains the prevailing approach, explained Jason Westin, MD, director of lymphoma research at MD Anderson Cancer Center, Houston. Dr. Westin, lead investigator, presented the trial, dubbed ZUMA-7, at the ASCO meeting.

The new findings might change that. ZUMA-7 “conclusively demonstrates that trying chemotherapy in the second line and saving cell therapy for the third line is an inferior approach ... ZUMA-7 confirms axi-cel is a second-line standard of care for patients with refractory or early relapsed large B cell lymphoma based on superior overall survival,” said Dr. Westin.

Study discussant Asher A. Chanan-Khan, MD, a CAR-T specialist at the Mayo Clinic in Jacksonville, Fla., agreed.

“This data must alter the current standard of care making CAR-T or axi-cel, based on the data we heard, a preferred second-line treatment ... Moving CAR-T earlier in the treatment paradigm is likely a better choice for our patients,” he said.

The study was published in the New England Journal of Medicine to coincide with the presentations.

Dr. Westin noted that axi-cel is now under investigation in ZUMA-23 for first-line treatment of high-risk large B-cell lymphoma (LBCL).


 

Study details

Zuma-7 randomized 180 LBCL patients to a one-time axi-cel infusion and 179 to standard care. Patients were refractory to first line chemoimmunotherapy or had relapsed within 12 months; just 36% of patients in the standard care group did well enough on treatment to go on to stem-cell transplant.

Median progression-free survival (PFS) was 14.7 months with axi-cel versus 3.7 months with standard care.

Significantly, the better PFS appears to have translated into better overall survival (OS).

At a median of almost 4 years, 82 patients in the axi-cel group had died, compared with 95 patients with standard care who had died. Estimated 4-year OS was 54.6% with axi-cel versus 46% with standard care (HR 0.73, P = .03).

The OS benefit held in high-risk subgroups, including patients over 64 years old, those refractory to first-line treatment, and patients with high-grade disease.

Adverse events were in keeping with labeling. Cytokine release syndrome was more common in the axi-cel arm, including grade 3 or worse CRS in 6% of axi-cel patients versus none on standard care. Grade 3 or worse infections were also more common at 16.5% versus 11.9% with standard care. Over 11% of axi-cel patients developed hypogammaglobulinemia versus 0.6% in the standard care group.

Overall, there were no new serious or fatal adverse events since the initial PFS results were reported in 2022, when eight fatal adverse events were reported with axi-cel versus two with standard care.

The work was funded by axi-cel maker Kite Pharma, a subsidiary of Gilead. Investigators included Kite/Gilead employees and others who reported financial relationships with the companies, including Dr. Westin, a Kite/Gilead researcher and adviser. Dr. Chanan-Khan disclosed ties with Cellectar, Starton Therapeutics, Ascentage Pharma, and others.