Clinical Edge Journal Scan Commentary

Torrelo and colleagues described the efficacy and safety of baricitinib in combination with topical corticosteroids in pediatric patients with moderate to severe atopic dermatitis. At the high dose of 4 mg daily, the IGA success rate was about 40%, similar to what we expect for adults treated with dupilumab and less than what we might expect with upadacitinib.

Studies have already been done on efficacy and safety of baricitinib in adults with atopic dermatitis. But baricitinib is indicated for the treatment of adult patients with severe alopecia areata and is not currently indicated as a treatment for anyone with atopic dermatitis, at least not in the United States. At this time, I think the most useful aspect of Torrelo and colleagues' findings is being able to tell our adult patients with alopecia areata that baricitinib was safe enough that they could test it in children as young as 2 years old with eczema.

Perälä and colleagues' report comparing topical tacrolimus and topical corticosteroids (1% hydrocortisone acetate or, if needed, 0.1% hydrocortisone butyrate ointment) in young children with atopic dermatitis is fascinating. They saw patients back at 1 week and followed them for 3 years. In just 1 week, both groups had massive and similar improvement in their atopic dermatitis, and that improvement continued throughout the study. Here are some take-home points:

• Atopic dermatitis responds rapidly to low-to-medium–strength topical steroids.
• Bringing patients back at 1 week may have been a critical aspect of this study, as adherence to topicals can be abysmal; bringing patients back at 1 week probably enables them to use their treatment much better than they would otherwise.
• If we need a nonsteroidal topical, we have an excellent one available at low cost in the form of topical tacrolimus.

Perälä and colleagues also did this study to see whether good treatment of atopic dermatitis in these young children would have long-term benefits on atopic airway issues. Because the researchers didn't have a placebo group (and considered it unethical to have one), we cannot tell whether the topical treatment provided any benefit in that regard.

Yamamoto-Hanada and colleaguesexamined whether "enhanced" topical steroid treatment would prevent food allergy in children with eczema compared with standard topical steroid treatment. Perhaps a better word than "enhanced" would be "aggressive." The enhanced treatment entailed having infants receive alclometasone dipropionate for the whole face and betamethasone valerate for the whole body except face and scalp. While the researchers saw a reduction in egg allergy (from roughly 40% to 30%), they also saw reduced body weight and height. A key take-home message is that with extensive use of topical steroids, we can see systemic effects.

Torrelo and colleagues described the efficacy and safety of baricitinib in combination with topical corticosteroids in pediatric patients with moderate to severe atopic dermatitis. At the high dose of 4 mg daily, the IGA success rate was about 40%, similar to what we expect for adults treated with dupilumab and less than what we might expect with upadacitinib.

Studies have already been done on efficacy and safety of baricitinib in adults with atopic dermatitis. But baricitinib is indicated for the treatment of adult patients with severe alopecia areata and is not currently indicated as a treatment for anyone with atopic dermatitis, at least not in the United States. At this time, I think the most useful aspect of Torrelo and colleagues' findings is being able to tell our adult patients with alopecia areata that baricitinib was safe enough that they could test it in children as young as 2 years old with eczema.

Perälä and colleagues' report comparing topical tacrolimus and topical corticosteroids (1% hydrocortisone acetate or, if needed, 0.1% hydrocortisone butyrate ointment) in young children with atopic dermatitis is fascinating. They saw patients back at 1 week and followed them for 3 years. In just 1 week, both groups had massive and similar improvement in their atopic dermatitis, and that improvement continued throughout the study. Here are some take-home points:

• Atopic dermatitis responds rapidly to low-to-medium–strength topical steroids.
• Bringing patients back at 1 week may have been a critical aspect of this study, as adherence to topicals can be abysmal; bringing patients back at 1 week probably enables them to use their treatment much better than they would otherwise.
• If we need a nonsteroidal topical, we have an excellent one available at low cost in the form of topical tacrolimus.

Perälä and colleagues also did this study to see whether good treatment of atopic dermatitis in these young children would have long-term benefits on atopic airway issues. Because the researchers didn't have a placebo group (and considered it unethical to have one), we cannot tell whether the topical treatment provided any benefit in that regard.

Yamamoto-Hanada and colleaguesexamined whether "enhanced" topical steroid treatment would prevent food allergy in children with eczema compared with standard topical steroid treatment. Perhaps a better word than "enhanced" would be "aggressive." The enhanced treatment entailed having infants receive alclometasone dipropionate for the whole face and betamethasone valerate for the whole body except face and scalp. While the researchers saw a reduction in egg allergy (from roughly 40% to 30%), they also saw reduced body weight and height. A key take-home message is that with extensive use of topical steroids, we can see systemic effects.

Torrelo and colleagues described the efficacy and safety of baricitinib in combination with topical corticosteroids in pediatric patients with moderate to severe atopic dermatitis. At the high dose of 4 mg daily, the IGA success rate was about 40%, similar to what we expect for adults treated with dupilumab and less than what we might expect with upadacitinib.

Studies have already been done on efficacy and safety of baricitinib in adults with atopic dermatitis. But baricitinib is indicated for the treatment of adult patients with severe alopecia areata and is not currently indicated as a treatment for anyone with atopic dermatitis, at least not in the United States. At this time, I think the most useful aspect of Torrelo and colleagues' findings is being able to tell our adult patients with alopecia areata that baricitinib was safe enough that they could test it in children as young as 2 years old with eczema.

Perälä and colleagues' report comparing topical tacrolimus and topical corticosteroids (1% hydrocortisone acetate or, if needed, 0.1% hydrocortisone butyrate ointment) in young children with atopic dermatitis is fascinating. They saw patients back at 1 week and followed them for 3 years. In just 1 week, both groups had massive and similar improvement in their atopic dermatitis, and that improvement continued throughout the study. Here are some take-home points:

• Atopic dermatitis responds rapidly to low-to-medium–strength topical steroids.
• Bringing patients back at 1 week may have been a critical aspect of this study, as adherence to topicals can be abysmal; bringing patients back at 1 week probably enables them to use their treatment much better than they would otherwise.
• If we need a nonsteroidal topical, we have an excellent one available at low cost in the form of topical tacrolimus.

Perälä and colleagues also did this study to see whether good treatment of atopic dermatitis in these young children would have long-term benefits on atopic airway issues. Because the researchers didn't have a placebo group (and considered it unethical to have one), we cannot tell whether the topical treatment provided any benefit in that regard.

Yamamoto-Hanada and colleaguesexamined whether "enhanced" topical steroid treatment would prevent food allergy in children with eczema compared with standard topical steroid treatment. Perhaps a better word than "enhanced" would be "aggressive." The enhanced treatment entailed having infants receive alclometasone dipropionate for the whole face and betamethasone valerate for the whole body except face and scalp. While the researchers saw a reduction in egg allergy (from roughly 40% to 30%), they also saw reduced body weight and height. A key take-home message is that with extensive use of topical steroids, we can see systemic effects.

Patients with active PsA require early effective therapy to improve long-term outcomes. The choice of therapy should balance effectiveness and potential toxicity. Janus kinase (JAK) inhibitors are a relatively new class of drugs that have been shown to be efficacious in treating PsA, but there are concerns about safety. To evaluate the efficacy and safety of JAK inhibitors in patients with psoriatic disease, Yang and colleagues conducted a systematic review and meta-analysis of 17 phase 2/3 randomized controlled trials including 6802 patients with PsA or moderate to severe plaque psoriasis who received at least one JAK inhibitor. They demonstrated that, compared with placebo, JAK inhibitors were associated with a significantly higher American College of Rheumatology 20 response rate (relative risk [RR] 2.09; P < .00001), with the response being the highest for filgotinib (RR 2.40; P < .00001), followed by upadacitinib, tofacitinib, and deucravacitinib. However, the overall incidence of adverse events was higher with JAK inhibitors vs placebo (RR 1.17; P < .00001) and significantly higher with 10-mg vs 5-mg tofacitinib (P = .03). Thus, JAK inhibitors are efficacious in the treatment of PsA but are associated with adverse effects, particularly at higher doses.

Safety is best assessed in real-world observational studies. Clinical trials have raised concerns about a higher cancer risk in rheumatoid arthritis (RA) patients treated with JAK inhibitors compared with patients treated with tumor necrosis factor (TNF) inhibitors. To evaluate this further, Huss and colleagues conducted an observational cohort study that evaluated prospectively collected data from national Swedish data sources on 4443 patients with PsA and 10,447 patients with RA, all without previous cancer, who received JAK inhibitors, TNF inhibitors, or other non–TNF inhibitor biologic disease-modifying antirheumatic drugs. Overall, use of JAK inhibitors vs TNF inhibitors was not significantly associated with a higher risk for cancer other than nonmelanoma skin cancer, especially in RA. In patients with PsA, there was a trend toward higher risk for nonmelanoma skin cancer, but it was not statistically significant. The study provides reassurance that JAK inhibitors are generally as safe, as are TNF inhibitors in PsA, but continued vigilance is required.

There are limited data on the effect of disease activity on pregnancy outcomes in individuals with PsA. Using data from the Medical Birth Registry of Norway linked to data from a Norwegian nationwide observational register recruiting women with inflammatory rheumatic diseases, Skorpen and colleagues evaluated the association of active disease and cesarean section (CS) rates in singleton births in women with PsA (n = 121), axial spondyloarthritis (n = 312), and controls (n = 575,798). Compared with control individuals, women with PsA had a higher risk for CS (risk difference [RD] 15.0%; P < .001) and for emergency CS (RD 10.6%; P < .001), with active disease in the third trimester further amplifying both risks (CS: RD 17.7%; P = .028; emergency CS: RD 15.9%; P = .015). Thus, although in many patients disease activity decreases during pregnancy, this study highlights the importance of pregestational counseling and disease control along with regular monitoring of PsA during pregnancy such that disease activity remains well controlled.

Patients with active PsA require early effective therapy to improve long-term outcomes. The choice of therapy should balance effectiveness and potential toxicity. Janus kinase (JAK) inhibitors are a relatively new class of drugs that have been shown to be efficacious in treating PsA, but there are concerns about safety. To evaluate the efficacy and safety of JAK inhibitors in patients with psoriatic disease, Yang and colleagues conducted a systematic review and meta-analysis of 17 phase 2/3 randomized controlled trials including 6802 patients with PsA or moderate to severe plaque psoriasis who received at least one JAK inhibitor. They demonstrated that, compared with placebo, JAK inhibitors were associated with a significantly higher American College of Rheumatology 20 response rate (relative risk [RR] 2.09; P < .00001), with the response being the highest for filgotinib (RR 2.40; P < .00001), followed by upadacitinib, tofacitinib, and deucravacitinib. However, the overall incidence of adverse events was higher with JAK inhibitors vs placebo (RR 1.17; P < .00001) and significantly higher with 10-mg vs 5-mg tofacitinib (P = .03). Thus, JAK inhibitors are efficacious in the treatment of PsA but are associated with adverse effects, particularly at higher doses.

Safety is best assessed in real-world observational studies. Clinical trials have raised concerns about a higher cancer risk in rheumatoid arthritis (RA) patients treated with JAK inhibitors compared with patients treated with tumor necrosis factor (TNF) inhibitors. To evaluate this further, Huss and colleagues conducted an observational cohort study that evaluated prospectively collected data from national Swedish data sources on 4443 patients with PsA and 10,447 patients with RA, all without previous cancer, who received JAK inhibitors, TNF inhibitors, or other non–TNF inhibitor biologic disease-modifying antirheumatic drugs. Overall, use of JAK inhibitors vs TNF inhibitors was not significantly associated with a higher risk for cancer other than nonmelanoma skin cancer, especially in RA. In patients with PsA, there was a trend toward higher risk for nonmelanoma skin cancer, but it was not statistically significant. The study provides reassurance that JAK inhibitors are generally as safe, as are TNF inhibitors in PsA, but continued vigilance is required.

There are limited data on the effect of disease activity on pregnancy outcomes in individuals with PsA. Using data from the Medical Birth Registry of Norway linked to data from a Norwegian nationwide observational register recruiting women with inflammatory rheumatic diseases, Skorpen and colleagues evaluated the association of active disease and cesarean section (CS) rates in singleton births in women with PsA (n = 121), axial spondyloarthritis (n = 312), and controls (n = 575,798). Compared with control individuals, women with PsA had a higher risk for CS (risk difference [RD] 15.0%; P < .001) and for emergency CS (RD 10.6%; P < .001), with active disease in the third trimester further amplifying both risks (CS: RD 17.7%; P = .028; emergency CS: RD 15.9%; P = .015). Thus, although in many patients disease activity decreases during pregnancy, this study highlights the importance of pregestational counseling and disease control along with regular monitoring of PsA during pregnancy such that disease activity remains well controlled.

Patients with active PsA require early effective therapy to improve long-term outcomes. The choice of therapy should balance effectiveness and potential toxicity. Janus kinase (JAK) inhibitors are a relatively new class of drugs that have been shown to be efficacious in treating PsA, but there are concerns about safety. To evaluate the efficacy and safety of JAK inhibitors in patients with psoriatic disease, Yang and colleagues conducted a systematic review and meta-analysis of 17 phase 2/3 randomized controlled trials including 6802 patients with PsA or moderate to severe plaque psoriasis who received at least one JAK inhibitor. They demonstrated that, compared with placebo, JAK inhibitors were associated with a significantly higher American College of Rheumatology 20 response rate (relative risk [RR] 2.09; P < .00001), with the response being the highest for filgotinib (RR 2.40; P < .00001), followed by upadacitinib, tofacitinib, and deucravacitinib. However, the overall incidence of adverse events was higher with JAK inhibitors vs placebo (RR 1.17; P < .00001) and significantly higher with 10-mg vs 5-mg tofacitinib (P = .03). Thus, JAK inhibitors are efficacious in the treatment of PsA but are associated with adverse effects, particularly at higher doses.

Safety is best assessed in real-world observational studies. Clinical trials have raised concerns about a higher cancer risk in rheumatoid arthritis (RA) patients treated with JAK inhibitors compared with patients treated with tumor necrosis factor (TNF) inhibitors. To evaluate this further, Huss and colleagues conducted an observational cohort study that evaluated prospectively collected data from national Swedish data sources on 4443 patients with PsA and 10,447 patients with RA, all without previous cancer, who received JAK inhibitors, TNF inhibitors, or other non–TNF inhibitor biologic disease-modifying antirheumatic drugs. Overall, use of JAK inhibitors vs TNF inhibitors was not significantly associated with a higher risk for cancer other than nonmelanoma skin cancer, especially in RA. In patients with PsA, there was a trend toward higher risk for nonmelanoma skin cancer, but it was not statistically significant. The study provides reassurance that JAK inhibitors are generally as safe, as are TNF inhibitors in PsA, but continued vigilance is required.

There are limited data on the effect of disease activity on pregnancy outcomes in individuals with PsA. Using data from the Medical Birth Registry of Norway linked to data from a Norwegian nationwide observational register recruiting women with inflammatory rheumatic diseases, Skorpen and colleagues evaluated the association of active disease and cesarean section (CS) rates in singleton births in women with PsA (n = 121), axial spondyloarthritis (n = 312), and controls (n = 575,798). Compared with control individuals, women with PsA had a higher risk for CS (risk difference [RD] 15.0%; P < .001) and for emergency CS (RD 10.6%; P < .001), with active disease in the third trimester further amplifying both risks (CS: RD 17.7%; P = .028; emergency CS: RD 15.9%; P = .015). Thus, although in many patients disease activity decreases during pregnancy, this study highlights the importance of pregestational counseling and disease control along with regular monitoring of PsA during pregnancy such that disease activity remains well controlled.

Patients with active PsA require early effective therapy to improve long-term outcomes. The choice of therapy should balance effectiveness and potential toxicity. Janus kinase (JAK) inhibitors are a relatively new class of drugs that have been shown to be efficacious in treating PsA, but there are concerns about safety. To evaluate the efficacy and safety of JAK inhibitors in patients with psoriatic disease, Yang and colleagues conducted a systematic review and meta-analysis of 17 phase 2/3 randomized controlled trials including 6802 patients with PsA or moderate to severe plaque psoriasis who received at least one JAK inhibitor. They demonstrated that, compared with placebo, JAK inhibitors were associated with a significantly higher American College of Rheumatology 20 response rate (relative risk [RR] 2.09; P < .00001), with the response being the highest for filgotinib (RR 2.40; P < .00001), followed by upadacitinib, tofacitinib, and deucravacitinib. However, the overall incidence of adverse events was higher with JAK inhibitors vs placebo (RR 1.17; P < .00001) and significantly higher with 10-mg vs 5-mg tofacitinib (P = .03). Thus, JAK inhibitors are efficacious in the treatment of PsA but are associated with adverse effects, particularly at higher doses.

Safety is best assessed in real-world observational studies. Clinical trials have raised concerns about a higher cancer risk in rheumatoid arthritis (RA) patients treated with JAK inhibitors compared with patients treated with tumor necrosis factor (TNF) inhibitors. To evaluate this further, Huss and colleagues conducted an observational cohort study that evaluated prospectively collected data from national Swedish data sources on 4443 patients with PsA and 10,447 patients with RA, all without previous cancer, who received JAK inhibitors, TNF inhibitors, or other non–TNF inhibitor biologic disease-modifying antirheumatic drugs. Overall, use of JAK inhibitors vs TNF inhibitors was not significantly associated with a higher risk for cancer other than nonmelanoma skin cancer, especially in RA. In patients with PsA, there was a trend toward higher risk for nonmelanoma skin cancer, but it was not statistically significant. The study provides reassurance that JAK inhibitors are generally as safe, as are TNF inhibitors in PsA, but continued vigilance is required.

There are limited data on the effect of disease activity on pregnancy outcomes in individuals with PsA. Using data from the Medical Birth Registry of Norway linked to data from a Norwegian nationwide observational register recruiting women with inflammatory rheumatic diseases, Skorpen and colleagues evaluated the association of active disease and cesarean section (CS) rates in singleton births in women with PsA (n = 121), axial spondyloarthritis (n = 312), and controls (n = 575,798). Compared with control individuals, women with PsA had a higher risk for CS (risk difference [RD] 15.0%; P < .001) and for emergency CS (RD 10.6%; P < .001), with active disease in the third trimester further amplifying both risks (CS: RD 17.7%; P = .028; emergency CS: RD 15.9%; P = .015). Thus, although in many patients disease activity decreases during pregnancy, this study highlights the importance of pregestational counseling and disease control along with regular monitoring of PsA during pregnancy such that disease activity remains well controlled.

Patients with active PsA require early effective therapy to improve long-term outcomes. The choice of therapy should balance effectiveness and potential toxicity. Janus kinase (JAK) inhibitors are a relatively new class of drugs that have been shown to be efficacious in treating PsA, but there are concerns about safety. To evaluate the efficacy and safety of JAK inhibitors in patients with psoriatic disease, Yang and colleagues conducted a systematic review and meta-analysis of 17 phase 2/3 randomized controlled trials including 6802 patients with PsA or moderate to severe plaque psoriasis who received at least one JAK inhibitor. They demonstrated that, compared with placebo, JAK inhibitors were associated with a significantly higher American College of Rheumatology 20 response rate (relative risk [RR] 2.09; P < .00001), with the response being the highest for filgotinib (RR 2.40; P < .00001), followed by upadacitinib, tofacitinib, and deucravacitinib. However, the overall incidence of adverse events was higher with JAK inhibitors vs placebo (RR 1.17; P < .00001) and significantly higher with 10-mg vs 5-mg tofacitinib (P = .03). Thus, JAK inhibitors are efficacious in the treatment of PsA but are associated with adverse effects, particularly at higher doses.

Safety is best assessed in real-world observational studies. Clinical trials have raised concerns about a higher cancer risk in rheumatoid arthritis (RA) patients treated with JAK inhibitors compared with patients treated with tumor necrosis factor (TNF) inhibitors. To evaluate this further, Huss and colleagues conducted an observational cohort study that evaluated prospectively collected data from national Swedish data sources on 4443 patients with PsA and 10,447 patients with RA, all without previous cancer, who received JAK inhibitors, TNF inhibitors, or other non–TNF inhibitor biologic disease-modifying antirheumatic drugs. Overall, use of JAK inhibitors vs TNF inhibitors was not significantly associated with a higher risk for cancer other than nonmelanoma skin cancer, especially in RA. In patients with PsA, there was a trend toward higher risk for nonmelanoma skin cancer, but it was not statistically significant. The study provides reassurance that JAK inhibitors are generally as safe, as are TNF inhibitors in PsA, but continued vigilance is required.

There are limited data on the effect of disease activity on pregnancy outcomes in individuals with PsA. Using data from the Medical Birth Registry of Norway linked to data from a Norwegian nationwide observational register recruiting women with inflammatory rheumatic diseases, Skorpen and colleagues evaluated the association of active disease and cesarean section (CS) rates in singleton births in women with PsA (n = 121), axial spondyloarthritis (n = 312), and controls (n = 575,798). Compared with control individuals, women with PsA had a higher risk for CS (risk difference [RD] 15.0%; P < .001) and for emergency CS (RD 10.6%; P < .001), with active disease in the third trimester further amplifying both risks (CS: RD 17.7%; P = .028; emergency CS: RD 15.9%; P = .015). Thus, although in many patients disease activity decreases during pregnancy, this study highlights the importance of pregestational counseling and disease control along with regular monitoring of PsA during pregnancy such that disease activity remains well controlled.

Patients with active PsA require early effective therapy to improve long-term outcomes. The choice of therapy should balance effectiveness and potential toxicity. Janus kinase (JAK) inhibitors are a relatively new class of drugs that have been shown to be efficacious in treating PsA, but there are concerns about safety. To evaluate the efficacy and safety of JAK inhibitors in patients with psoriatic disease, Yang and colleagues conducted a systematic review and meta-analysis of 17 phase 2/3 randomized controlled trials including 6802 patients with PsA or moderate to severe plaque psoriasis who received at least one JAK inhibitor. They demonstrated that, compared with placebo, JAK inhibitors were associated with a significantly higher American College of Rheumatology 20 response rate (relative risk [RR] 2.09; P < .00001), with the response being the highest for filgotinib (RR 2.40; P < .00001), followed by upadacitinib, tofacitinib, and deucravacitinib. However, the overall incidence of adverse events was higher with JAK inhibitors vs placebo (RR 1.17; P < .00001) and significantly higher with 10-mg vs 5-mg tofacitinib (P = .03). Thus, JAK inhibitors are efficacious in the treatment of PsA but are associated with adverse effects, particularly at higher doses.

Safety is best assessed in real-world observational studies. Clinical trials have raised concerns about a higher cancer risk in rheumatoid arthritis (RA) patients treated with JAK inhibitors compared with patients treated with tumor necrosis factor (TNF) inhibitors. To evaluate this further, Huss and colleagues conducted an observational cohort study that evaluated prospectively collected data from national Swedish data sources on 4443 patients with PsA and 10,447 patients with RA, all without previous cancer, who received JAK inhibitors, TNF inhibitors, or other non–TNF inhibitor biologic disease-modifying antirheumatic drugs. Overall, use of JAK inhibitors vs TNF inhibitors was not significantly associated with a higher risk for cancer other than nonmelanoma skin cancer, especially in RA. In patients with PsA, there was a trend toward higher risk for nonmelanoma skin cancer, but it was not statistically significant. The study provides reassurance that JAK inhibitors are generally as safe, as are TNF inhibitors in PsA, but continued vigilance is required.

There are limited data on the effect of disease activity on pregnancy outcomes in individuals with PsA. Using data from the Medical Birth Registry of Norway linked to data from a Norwegian nationwide observational register recruiting women with inflammatory rheumatic diseases, Skorpen and colleagues evaluated the association of active disease and cesarean section (CS) rates in singleton births in women with PsA (n = 121), axial spondyloarthritis (n = 312), and controls (n = 575,798). Compared with control individuals, women with PsA had a higher risk for CS (risk difference [RD] 15.0%; P < .001) and for emergency CS (RD 10.6%; P < .001), with active disease in the third trimester further amplifying both risks (CS: RD 17.7%; P = .028; emergency CS: RD 15.9%; P = .015). Thus, although in many patients disease activity decreases during pregnancy, this study highlights the importance of pregestational counseling and disease control along with regular monitoring of PsA during pregnancy such that disease activity remains well controlled.

In evaluating the importance of early aggressive treatment of rheumatoid arthritis (RA), we often look at prognostic factors for severe disease, such as seropositivity, elevated inflammatory markers, and erosions. Eberhard and colleagues looked at the relationship between damage as seen on radiography (including erosions and joint space narrowing) and pain and disability in early RA using an inception cohort with <12 months of symptoms. Over 200 patients in Sweden were followed for 5 years with clinical, laboratory, and radiographic evaluations. Of interest, pain was associated with female sex, tender joint count, and inflammatory markers at various time points but not with radiographic damage. This may reflect that pain is related to current inflammation rather than past joint damage or that pain is related to other factors, such as central sensitization. Radiographic damage was, however, associated with disability and thus remains an important target and outcome measure for assessing treatment effectiveness.

Leon and colleagues also looked at early RA but instead, at the category of difficult-to-treat RA (D2T RA), meaning persistent RA symptoms after a trial of at least two biologic or targeted synthetic disease-modifying antirheumatic drugs. In order to gain better insight in preventing D2T RA, the authors examined its association with potentially modifiable risk factors early in the course of disease. Of the over 600 patients followed in this inception cohort, only about 6% were classified as having D2T RA. The study found that patients who had D2T RA tended to be younger, with a higher tender joint count, higher pain scores, and a higher initial level of disability. The Disease Activity Score (DAS28) itself was higher in patients with D2T RA, but the difference did not reach statistical significance. The small number of patients (35) in the D2T RA group may have affected the findings as well as their wider applicability. However, it is interesting to consider whether the associations may also reflect the impact of noninflammatory factors, as in the previous study, on the classification of D2T RA.

Park and colleagues evaluated the difference in clinical outcomes in postmenopausal patients with RA who underwent menopause at younger than 45 years or 45 years or older. Among over 2800 patients in Korea, those who underwent early menopause were more likely to be seronegative and have high disease activity and worse patient-reported outcome scores in fatigue, sleep, and health-related quality of life despite comparable treatments and prevalence of erosions. The authors suggest this may be related to lower cumulative estrogen exposure; whether this correlates to inflammatory cytokine signatures is not yet known. However, as with the prior studies, central sensitization and noninflammatory pain may also contribute and should be considered in interpreting response to therapy.

Finally, addressing the potential risk for cancer in patients with RA before or during treatment with immunosuppressive medications, Miyata and colleagues reported a study that screened nearly 2200 patients who underwent CT (from neck to pelvis) and compared them with those who underwent routine screening with physical exam plus radiography. The study found that CT screening enhanced cancer detection, with a large number of cancers detected at an earlier stage with CT screening compared with routine screening. The overall number of cancers detected was low (33), and thus routine screening with neck-to-pelvis CT for all patients with RA may not be a cost-effective practice. However, it bears further examination for potentially higher-risk populations or specific cancers.

In evaluating the importance of early aggressive treatment of rheumatoid arthritis (RA), we often look at prognostic factors for severe disease, such as seropositivity, elevated inflammatory markers, and erosions. Eberhard and colleagues looked at the relationship between damage as seen on radiography (including erosions and joint space narrowing) and pain and disability in early RA using an inception cohort with <12 months of symptoms. Over 200 patients in Sweden were followed for 5 years with clinical, laboratory, and radiographic evaluations. Of interest, pain was associated with female sex, tender joint count, and inflammatory markers at various time points but not with radiographic damage. This may reflect that pain is related to current inflammation rather than past joint damage or that pain is related to other factors, such as central sensitization. Radiographic damage was, however, associated with disability and thus remains an important target and outcome measure for assessing treatment effectiveness.

Leon and colleagues also looked at early RA but instead, at the category of difficult-to-treat RA (D2T RA), meaning persistent RA symptoms after a trial of at least two biologic or targeted synthetic disease-modifying antirheumatic drugs. In order to gain better insight in preventing D2T RA, the authors examined its association with potentially modifiable risk factors early in the course of disease. Of the over 600 patients followed in this inception cohort, only about 6% were classified as having D2T RA. The study found that patients who had D2T RA tended to be younger, with a higher tender joint count, higher pain scores, and a higher initial level of disability. The Disease Activity Score (DAS28) itself was higher in patients with D2T RA, but the difference did not reach statistical significance. The small number of patients (35) in the D2T RA group may have affected the findings as well as their wider applicability. However, it is interesting to consider whether the associations may also reflect the impact of noninflammatory factors, as in the previous study, on the classification of D2T RA.

Park and colleagues evaluated the difference in clinical outcomes in postmenopausal patients with RA who underwent menopause at younger than 45 years or 45 years or older. Among over 2800 patients in Korea, those who underwent early menopause were more likely to be seronegative and have high disease activity and worse patient-reported outcome scores in fatigue, sleep, and health-related quality of life despite comparable treatments and prevalence of erosions. The authors suggest this may be related to lower cumulative estrogen exposure; whether this correlates to inflammatory cytokine signatures is not yet known. However, as with the prior studies, central sensitization and noninflammatory pain may also contribute and should be considered in interpreting response to therapy.

Finally, addressing the potential risk for cancer in patients with RA before or during treatment with immunosuppressive medications, Miyata and colleagues reported a study that screened nearly 2200 patients who underwent CT (from neck to pelvis) and compared them with those who underwent routine screening with physical exam plus radiography. The study found that CT screening enhanced cancer detection, with a large number of cancers detected at an earlier stage with CT screening compared with routine screening. The overall number of cancers detected was low (33), and thus routine screening with neck-to-pelvis CT for all patients with RA may not be a cost-effective practice. However, it bears further examination for potentially higher-risk populations or specific cancers.

In evaluating the importance of early aggressive treatment of rheumatoid arthritis (RA), we often look at prognostic factors for severe disease, such as seropositivity, elevated inflammatory markers, and erosions. Eberhard and colleagues looked at the relationship between damage as seen on radiography (including erosions and joint space narrowing) and pain and disability in early RA using an inception cohort with <12 months of symptoms. Over 200 patients in Sweden were followed for 5 years with clinical, laboratory, and radiographic evaluations. Of interest, pain was associated with female sex, tender joint count, and inflammatory markers at various time points but not with radiographic damage. This may reflect that pain is related to current inflammation rather than past joint damage or that pain is related to other factors, such as central sensitization. Radiographic damage was, however, associated with disability and thus remains an important target and outcome measure for assessing treatment effectiveness.

Leon and colleagues also looked at early RA but instead, at the category of difficult-to-treat RA (D2T RA), meaning persistent RA symptoms after a trial of at least two biologic or targeted synthetic disease-modifying antirheumatic drugs. In order to gain better insight in preventing D2T RA, the authors examined its association with potentially modifiable risk factors early in the course of disease. Of the over 600 patients followed in this inception cohort, only about 6% were classified as having D2T RA. The study found that patients who had D2T RA tended to be younger, with a higher tender joint count, higher pain scores, and a higher initial level of disability. The Disease Activity Score (DAS28) itself was higher in patients with D2T RA, but the difference did not reach statistical significance. The small number of patients (35) in the D2T RA group may have affected the findings as well as their wider applicability. However, it is interesting to consider whether the associations may also reflect the impact of noninflammatory factors, as in the previous study, on the classification of D2T RA.

Park and colleagues evaluated the difference in clinical outcomes in postmenopausal patients with RA who underwent menopause at younger than 45 years or 45 years or older. Among over 2800 patients in Korea, those who underwent early menopause were more likely to be seronegative and have high disease activity and worse patient-reported outcome scores in fatigue, sleep, and health-related quality of life despite comparable treatments and prevalence of erosions. The authors suggest this may be related to lower cumulative estrogen exposure; whether this correlates to inflammatory cytokine signatures is not yet known. However, as with the prior studies, central sensitization and noninflammatory pain may also contribute and should be considered in interpreting response to therapy.

Finally, addressing the potential risk for cancer in patients with RA before or during treatment with immunosuppressive medications, Miyata and colleagues reported a study that screened nearly 2200 patients who underwent CT (from neck to pelvis) and compared them with those who underwent routine screening with physical exam plus radiography. The study found that CT screening enhanced cancer detection, with a large number of cancers detected at an earlier stage with CT screening compared with routine screening. The overall number of cancers detected was low (33), and thus routine screening with neck-to-pelvis CT for all patients with RA may not be a cost-effective practice. However, it bears further examination for potentially higher-risk populations or specific cancers.

Mantle cell lymphoma (MCL) is an uncommon subtype of non-Hodgkin lymphoma (NHL) that is clinically heterogeneous, ranging from indolent to aggressive in nature. As with other subtypes of NHL, the treatment landscape is rapidly evolving.

Chemoimmunotherapy remains the standard first-line therapy for younger, fit patients. Although multiple induction regimens are used in this setting, it is typical to use a cytarabine-containing approach. Recently, the long-term analysis of the MCL Younger trial continued to demonstrate improved outcomes with this strategy.¹ This phase 3 study included 497 patients aged ≥ 18 to < 66 years with previously untreated MCL who were randomly assigned to R-CHOP (cyclophosphamide, doxorubicin, prednisone, rituximab, and vincristine; n = 249) or R-DHAP (rituximab, dexamethasone, cytarabine, cisplatin; n = 248). After a median follow-up of 10.6 years, the R-DHAP vs R-CHOP arm continued to have a significantly longer time to treatment failure (hazard ratio [HR] 0.59; P = .038) and overall survival (Mantle Cell Lymphoma International Prognostic Index + Ki-67–adjusted HR 0.60; P = .0066).

Following chemoimmunotherapy, treatment for this patient population typically consists of consolidation with autologous stem cell transplantation (ASCT) and maintenance rituximab.² Recently, the role of ASCT has been called into question.³ Preliminary data from the phase 3 TRIANGLE study demonstrated improvement in outcomes when the Bruton tyrosine kinase (BTK) inhibitor ibrutinib was added to chemoimmunotherapy, regardless of whether patients received ASCT.⁴ Additional studies evaluating the role of transplantation, particularly among patients who are minimal residual disease negative after chemoimmunotherapy, are ongoing (NCT03267433).

Options continue to expand in the relapsed/refractory setting. The chimeric antigen receptor (CAR) T-cell therapy, brexucabtagene autoleucel (brexu-cel), was approved by the US Food and Drug Administration for relapsed/refractory MCL on the basis of the results of the ZUMA-2 study.⁵ Recently, a multicenter, retrospective study demonstrated promising efficacy in the real world as well (Wang et al). This study was performed across 16 medical centers and included 189 patients with relapsed/refractory MCL who underwent leukapheresis for commercial manufacturing of brexu-cel, of which 168 received brexu-cel infusion. Of all patients receiving leukapheresis, 149 (79%) would not have met the eligibility criteria for ZUMA-2. At a median follow-up of 14.3 months after infusion, the best overall and complete response rates were 90% and 82%, respectively. The 6- and 12-month progression-free survival (PFS) rates were 69% (95% CI 61%-75%) and 59% (95% CI 51%-66%), respectively. This approach, however, was associated with significant toxicity, with a nonrelapse mortality rate of 9.1% at 1 year, primarily because of infections. The grade ≥ 3 cytokine release syndrome and neurotoxicity rates were 8% and 32%, respectively. Despite risks, this study confirms the role of CAR T-cell therapy for patients with relapsed/refractory MCL.

Other options in the relapsed setting include BTK and anti-apoptotic protein B-cell lymphoma (BCL-2) inhibitors. Although venetoclax, a BCL-2 inhibitor, has demonstrated activity in MCL in early-phase clinical trials, the role of this drug in clinical practice remains unclear.^6,7 A recent multicenter, retrospective study evaluated the use of venetoclax in 81 adult patients with relapsed/refractory MCL, most of whom were heavily pretreated (median of three prior treatments) and had high-risk features, including high Ki-67 and TP53 alterations, who received venetoclax without (n = 50) or with (n = 31) other agents (Sawalha et al). In this study, venetoclax resulted in a good overall response rate (ORR) but short PFS. At a median follow-up of 16.4 months, patients had a median PFS and overall survival of 3.7 months (95% CI 2.3-5.6) and 12.5 months (95% CI 6.2-28.2), respectively, and an ORR of 40%. Studies of venetoclax in earlier lines of therapy and in combination with other agents are ongoing. There may also be a role for this treatment as a bridge to more definitive therapies, including CAR T-cell therapy or allogeneic stem cell transplantation. Other studies that are evaluating the role of bispecific antibodies and antibody drug conjugates are also underway, suggesting the potential for additional options in this patient population.

Additional References

1.         Hermine O, Jiang L, Walewski J, et al. High-dose cytarabine and autologous stem-cell transplantation in mantle cell lymphoma: Long-term follow-up of the randomized Mantle Cell Lymphoma Younger Trial of the European Mantle Cell Lymphoma Network. J Clin Oncol. 2023;41:479-484. doi: 10.1200/JCO.22.01780

2.         Le Gouill S, Thieblemont C, Oberic L, et al. Rituximab after autologous stem-cell transplantation in mantle-cell lymphoma. N Engl J Med. 2017;377:1250-1260. doi: 10.1056/NEJMoa1701769

3.         Martin P, Cohen JB, Wang M, et al. Treatment outcomes and roles of transplantation and maintenance rituximab in patients with previously untreated mantle cell lymphoma: Results from large real-world cohorts. J Clin Oncol. 2023;41:541-554. doi: 10.1200/JCO.21.02698

4.         Dreyling M, Doorduijn JK, Gine E, et al. Efficacy and safety of ibrutinib combined with standard first-line treatment or as substitute for autologous stem cell transplantation in younger patients with mantle cell lymphoma: Results from the randomized Triangle Trial by the European MCL Network. Blood. 2022;140(Suppl 1):1-3. doi: 10.1182/blood-2022-163018

5.         Wang M, Munoz J, Goy A, et al. KTE-X19 CAR T-Cell therapy in relapsed or refractory mantle-cell lymphoma. N Engl J Med. 2020;382:1331-1342. doi: 10.1056/NEJMoa1914347

6.         Davids MS, Roberts AW, Seymour JF, et al. Phase I first-in-human study of venetoclax in patients with relapsed or refractory non-Hodgkin lymphoma. J Clin Oncol. 2017;35:826-833. doi: 10.1200/JCO.2016.70.4320

7.         Tam CS, Anderson MA, Pott C, et al. Ibrutinib plus venetoclax for the treatment of mantle-cell lymphoma. N Engl J Med. 2018;378:1211-1223. doi: 10.1056/NEJMoa1715519

Mantle cell lymphoma (MCL) is an uncommon subtype of non-Hodgkin lymphoma (NHL) that is clinically heterogeneous, ranging from indolent to aggressive in nature. As with other subtypes of NHL, the treatment landscape is rapidly evolving.

Chemoimmunotherapy remains the standard first-line therapy for younger, fit patients. Although multiple induction regimens are used in this setting, it is typical to use a cytarabine-containing approach. Recently, the long-term analysis of the MCL Younger trial continued to demonstrate improved outcomes with this strategy.¹ This phase 3 study included 497 patients aged ≥ 18 to < 66 years with previously untreated MCL who were randomly assigned to R-CHOP (cyclophosphamide, doxorubicin, prednisone, rituximab, and vincristine; n = 249) or R-DHAP (rituximab, dexamethasone, cytarabine, cisplatin; n = 248). After a median follow-up of 10.6 years, the R-DHAP vs R-CHOP arm continued to have a significantly longer time to treatment failure (hazard ratio [HR] 0.59; P = .038) and overall survival (Mantle Cell Lymphoma International Prognostic Index + Ki-67–adjusted HR 0.60; P = .0066).

Following chemoimmunotherapy, treatment for this patient population typically consists of consolidation with autologous stem cell transplantation (ASCT) and maintenance rituximab.² Recently, the role of ASCT has been called into question.³ Preliminary data from the phase 3 TRIANGLE study demonstrated improvement in outcomes when the Bruton tyrosine kinase (BTK) inhibitor ibrutinib was added to chemoimmunotherapy, regardless of whether patients received ASCT.⁴ Additional studies evaluating the role of transplantation, particularly among patients who are minimal residual disease negative after chemoimmunotherapy, are ongoing (NCT03267433).

Options continue to expand in the relapsed/refractory setting. The chimeric antigen receptor (CAR) T-cell therapy, brexucabtagene autoleucel (brexu-cel), was approved by the US Food and Drug Administration for relapsed/refractory MCL on the basis of the results of the ZUMA-2 study.⁵ Recently, a multicenter, retrospective study demonstrated promising efficacy in the real world as well (Wang et al). This study was performed across 16 medical centers and included 189 patients with relapsed/refractory MCL who underwent leukapheresis for commercial manufacturing of brexu-cel, of which 168 received brexu-cel infusion. Of all patients receiving leukapheresis, 149 (79%) would not have met the eligibility criteria for ZUMA-2. At a median follow-up of 14.3 months after infusion, the best overall and complete response rates were 90% and 82%, respectively. The 6- and 12-month progression-free survival (PFS) rates were 69% (95% CI 61%-75%) and 59% (95% CI 51%-66%), respectively. This approach, however, was associated with significant toxicity, with a nonrelapse mortality rate of 9.1% at 1 year, primarily because of infections. The grade ≥ 3 cytokine release syndrome and neurotoxicity rates were 8% and 32%, respectively. Despite risks, this study confirms the role of CAR T-cell therapy for patients with relapsed/refractory MCL.

Other options in the relapsed setting include BTK and anti-apoptotic protein B-cell lymphoma (BCL-2) inhibitors. Although venetoclax, a BCL-2 inhibitor, has demonstrated activity in MCL in early-phase clinical trials, the role of this drug in clinical practice remains unclear.^6,7 A recent multicenter, retrospective study evaluated the use of venetoclax in 81 adult patients with relapsed/refractory MCL, most of whom were heavily pretreated (median of three prior treatments) and had high-risk features, including high Ki-67 and TP53 alterations, who received venetoclax without (n = 50) or with (n = 31) other agents (Sawalha et al). In this study, venetoclax resulted in a good overall response rate (ORR) but short PFS. At a median follow-up of 16.4 months, patients had a median PFS and overall survival of 3.7 months (95% CI 2.3-5.6) and 12.5 months (95% CI 6.2-28.2), respectively, and an ORR of 40%. Studies of venetoclax in earlier lines of therapy and in combination with other agents are ongoing. There may also be a role for this treatment as a bridge to more definitive therapies, including CAR T-cell therapy or allogeneic stem cell transplantation. Other studies that are evaluating the role of bispecific antibodies and antibody drug conjugates are also underway, suggesting the potential for additional options in this patient population.

Additional References

1.         Hermine O, Jiang L, Walewski J, et al. High-dose cytarabine and autologous stem-cell transplantation in mantle cell lymphoma: Long-term follow-up of the randomized Mantle Cell Lymphoma Younger Trial of the European Mantle Cell Lymphoma Network. J Clin Oncol. 2023;41:479-484. doi: 10.1200/JCO.22.01780

2.         Le Gouill S, Thieblemont C, Oberic L, et al. Rituximab after autologous stem-cell transplantation in mantle-cell lymphoma. N Engl J Med. 2017;377:1250-1260. doi: 10.1056/NEJMoa1701769

3.         Martin P, Cohen JB, Wang M, et al. Treatment outcomes and roles of transplantation and maintenance rituximab in patients with previously untreated mantle cell lymphoma: Results from large real-world cohorts. J Clin Oncol. 2023;41:541-554. doi: 10.1200/JCO.21.02698

4.         Dreyling M, Doorduijn JK, Gine E, et al. Efficacy and safety of ibrutinib combined with standard first-line treatment or as substitute for autologous stem cell transplantation in younger patients with mantle cell lymphoma: Results from the randomized Triangle Trial by the European MCL Network. Blood. 2022;140(Suppl 1):1-3. doi: 10.1182/blood-2022-163018

5.         Wang M, Munoz J, Goy A, et al. KTE-X19 CAR T-Cell therapy in relapsed or refractory mantle-cell lymphoma. N Engl J Med. 2020;382:1331-1342. doi: 10.1056/NEJMoa1914347

6.         Davids MS, Roberts AW, Seymour JF, et al. Phase I first-in-human study of venetoclax in patients with relapsed or refractory non-Hodgkin lymphoma. J Clin Oncol. 2017;35:826-833. doi: 10.1200/JCO.2016.70.4320

7.         Tam CS, Anderson MA, Pott C, et al. Ibrutinib plus venetoclax for the treatment of mantle-cell lymphoma. N Engl J Med. 2018;378:1211-1223. doi: 10.1056/NEJMoa1715519

Mantle cell lymphoma (MCL) is an uncommon subtype of non-Hodgkin lymphoma (NHL) that is clinically heterogeneous, ranging from indolent to aggressive in nature. As with other subtypes of NHL, the treatment landscape is rapidly evolving.

Chemoimmunotherapy remains the standard first-line therapy for younger, fit patients. Although multiple induction regimens are used in this setting, it is typical to use a cytarabine-containing approach. Recently, the long-term analysis of the MCL Younger trial continued to demonstrate improved outcomes with this strategy.¹ This phase 3 study included 497 patients aged ≥ 18 to < 66 years with previously untreated MCL who were randomly assigned to R-CHOP (cyclophosphamide, doxorubicin, prednisone, rituximab, and vincristine; n = 249) or R-DHAP (rituximab, dexamethasone, cytarabine, cisplatin; n = 248). After a median follow-up of 10.6 years, the R-DHAP vs R-CHOP arm continued to have a significantly longer time to treatment failure (hazard ratio [HR] 0.59; P = .038) and overall survival (Mantle Cell Lymphoma International Prognostic Index + Ki-67–adjusted HR 0.60; P = .0066).

Following chemoimmunotherapy, treatment for this patient population typically consists of consolidation with autologous stem cell transplantation (ASCT) and maintenance rituximab.² Recently, the role of ASCT has been called into question.³ Preliminary data from the phase 3 TRIANGLE study demonstrated improvement in outcomes when the Bruton tyrosine kinase (BTK) inhibitor ibrutinib was added to chemoimmunotherapy, regardless of whether patients received ASCT.⁴ Additional studies evaluating the role of transplantation, particularly among patients who are minimal residual disease negative after chemoimmunotherapy, are ongoing (NCT03267433).

Options continue to expand in the relapsed/refractory setting. The chimeric antigen receptor (CAR) T-cell therapy, brexucabtagene autoleucel (brexu-cel), was approved by the US Food and Drug Administration for relapsed/refractory MCL on the basis of the results of the ZUMA-2 study.⁵ Recently, a multicenter, retrospective study demonstrated promising efficacy in the real world as well (Wang et al). This study was performed across 16 medical centers and included 189 patients with relapsed/refractory MCL who underwent leukapheresis for commercial manufacturing of brexu-cel, of which 168 received brexu-cel infusion. Of all patients receiving leukapheresis, 149 (79%) would not have met the eligibility criteria for ZUMA-2. At a median follow-up of 14.3 months after infusion, the best overall and complete response rates were 90% and 82%, respectively. The 6- and 12-month progression-free survival (PFS) rates were 69% (95% CI 61%-75%) and 59% (95% CI 51%-66%), respectively. This approach, however, was associated with significant toxicity, with a nonrelapse mortality rate of 9.1% at 1 year, primarily because of infections. The grade ≥ 3 cytokine release syndrome and neurotoxicity rates were 8% and 32%, respectively. Despite risks, this study confirms the role of CAR T-cell therapy for patients with relapsed/refractory MCL.

Other options in the relapsed setting include BTK and anti-apoptotic protein B-cell lymphoma (BCL-2) inhibitors. Although venetoclax, a BCL-2 inhibitor, has demonstrated activity in MCL in early-phase clinical trials, the role of this drug in clinical practice remains unclear.^6,7 A recent multicenter, retrospective study evaluated the use of venetoclax in 81 adult patients with relapsed/refractory MCL, most of whom were heavily pretreated (median of three prior treatments) and had high-risk features, including high Ki-67 and TP53 alterations, who received venetoclax without (n = 50) or with (n = 31) other agents (Sawalha et al). In this study, venetoclax resulted in a good overall response rate (ORR) but short PFS. At a median follow-up of 16.4 months, patients had a median PFS and overall survival of 3.7 months (95% CI 2.3-5.6) and 12.5 months (95% CI 6.2-28.2), respectively, and an ORR of 40%. Studies of venetoclax in earlier lines of therapy and in combination with other agents are ongoing. There may also be a role for this treatment as a bridge to more definitive therapies, including CAR T-cell therapy or allogeneic stem cell transplantation. Other studies that are evaluating the role of bispecific antibodies and antibody drug conjugates are also underway, suggesting the potential for additional options in this patient population.

Additional References

1.         Hermine O, Jiang L, Walewski J, et al. High-dose cytarabine and autologous stem-cell transplantation in mantle cell lymphoma: Long-term follow-up of the randomized Mantle Cell Lymphoma Younger Trial of the European Mantle Cell Lymphoma Network. J Clin Oncol. 2023;41:479-484. doi: 10.1200/JCO.22.01780

2.         Le Gouill S, Thieblemont C, Oberic L, et al. Rituximab after autologous stem-cell transplantation in mantle-cell lymphoma. N Engl J Med. 2017;377:1250-1260. doi: 10.1056/NEJMoa1701769

3.         Martin P, Cohen JB, Wang M, et al. Treatment outcomes and roles of transplantation and maintenance rituximab in patients with previously untreated mantle cell lymphoma: Results from large real-world cohorts. J Clin Oncol. 2023;41:541-554. doi: 10.1200/JCO.21.02698

4.         Dreyling M, Doorduijn JK, Gine E, et al. Efficacy and safety of ibrutinib combined with standard first-line treatment or as substitute for autologous stem cell transplantation in younger patients with mantle cell lymphoma: Results from the randomized Triangle Trial by the European MCL Network. Blood. 2022;140(Suppl 1):1-3. doi: 10.1182/blood-2022-163018

5.         Wang M, Munoz J, Goy A, et al. KTE-X19 CAR T-Cell therapy in relapsed or refractory mantle-cell lymphoma. N Engl J Med. 2020;382:1331-1342. doi: 10.1056/NEJMoa1914347

6.         Davids MS, Roberts AW, Seymour JF, et al. Phase I first-in-human study of venetoclax in patients with relapsed or refractory non-Hodgkin lymphoma. J Clin Oncol. 2017;35:826-833. doi: 10.1200/JCO.2016.70.4320

7.         Tam CS, Anderson MA, Pott C, et al. Ibrutinib plus venetoclax for the treatment of mantle-cell lymphoma. N Engl J Med. 2018;378:1211-1223. doi: 10.1056/NEJMoa1715519

However, a combined analysis of two other trials (PlanB and SUCCESS C) did not show a benefit with the addition of anthracycline for most patients with human epidermal growth factor receptor 2 (HER2)–negative early breast cancer.²Roy and colleagues performed a retrospective study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, including 1106 women ≥ 66 years of age with node-positive TNBC, of whom 69.3% received adjuvant chemotherapy (N = 767). The use of chemotherapy led to a statistically significant improvement in survival outcomes (3-year cancer-specific survival [CSS] 81.8% vs 71.4%; overall survival 70.7% vs 51.3%). Although the anthracycline/taxane–based therapy did not improve CSS in the overall population vs taxane-based (hazard ratio [HR] 0.94; P = .79), among patients aged ≥ 76 years with four or more positive nodes, there was improvement in CSS with anthracycline/taxane therapy (HR 0.09; P = .02). These data further support the benefits of adjuvant chemotherapy in older patients when indicated; stimulate consideration of nonanthracycline combinations, particularly now with the use of immunotherapy for early TNBC; and highlight the need for inclusion of older individuals in clinical trials.

Treatment strategies to improve efficacy and minimize toxicity are highly desired for patients with early breast cancer (EBC). As an example, for small, node-negative, HER2-positive tumors, adjuvant systemic therapy with 12 weeks of paclitaxel/trastuzumab followed by continuation of trastuzumab to complete 1 full year has demonstrated excellent survival outcomes at over 10 years of follow-up.³ In the WSG-ADAPT-TP phase 2 trial, 375 patients with hormone receptor–positive , HER2-positive EBC were randomized to receive neoadjuvant T-DM1 (trastuzumab emtansine) with or without endocrine therapy or trastuzumab plus endocrine therapy. Similar 5-year invasive disease-free and overall survival rates were seen between the three arms. Patients who achieved a pathologic complete response (pCR) vs non-pCR had improved 5-year invasive disease-free survival (iDFS) rates (92.7% vs 82.7%; unadjusted HR 0.40). Furthermore, among the 117 patients who achieved pCR, the omission of adjuvant chemotherapy did not compromise survival outcomes (5-year iDFS 93% vs 92.1% for those who had vs those who did not have chemotherapy, respectively; unadjusted HR 1.15) (Harbeck et al). De-escalation approaches should ideally focus on the identification of biomarkers of response and resistance, as well as tools that can help predict patient outcomes and allow modification of therapy in real time. An example of this latter concept is the use of ¹⁸F-FDG-PET to identify patients with HER2-positive EBC who were likely to benefit from a chemotherapy-free dual HER2 blockade (trastuzumab/pertuzumab) treatment approach.⁴

Gynecologic surgery has been shown to reduce the risk for breast cancer,⁵ although the specific type of surgery and the impact of hormone replacement therapy add complexity to understanding the risks and outcomes for women. A prospective cohort, the Sister Study, included 50,701 women without a prior diagnosis of breast cancer but with a biological sister who had breast cancer; of these, 13.8% reported having hysterectomy only and 18.1% reported having bilateral oophorectomy with or without hysterectomy. Bilateral oophorectomy was inversely associated with breast cancer incidence (HR 0.91; 95% CI 0.83-1.00), with comparable results for women receiving estrogen only or combination estrogen plus progestin hormone replacement therapy. Contrary to these findings, having a hysterectomy only showed a positive association with breast cancer incidence (HR 1.12; 95% CI 1.02-1.23), with the strongest association among women who used combination estrogen and progestin therapy (HR 1.25; 95% CI 1.01-1.55) (Lovett et al). The impact of other gynecologic surgeries (such as salpingectomy)⁶ and the timing of the initiation of hormone replacement therapy, as well as the duration, should be investigated in future research.

Additional References

1. Blum JL, Flynn PJ, Yothers G, et al. Anthracyclines in early breast cancer: The ABC trials-USOR 06-090, NSABP B-46-I/USOR 07132, and NSABP B-49 (NRG oncology). J Clin Oncol. 2017;35:2647e55. doi: 10.1200/JCO.2016.71.4147

2. de Gregorio A, Janni W, Friedl TW, et al. The impact of anthracyclines in intermediate and high-risk HER2-negative early breast cancer-a pooled analysis of the randomised clinical trials PlanB and SUCCESS C. Br J Cancer. 2022;126:1715-1724. doi: 10.1038/s41416-021-01690-6

3. Tolaney SM, Tarantino P, Graham N, et al. Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer: Final 10-year analysis of the open-label, single-arm, phase 2 APT trial. Lancet Oncol. 2023;24:273-285. doi: 10.1016/S1470-2045(23)00051-7

4. Pérez-García JM, Gebhart G, Ruiz Borrego M, et al; on behalf of PHERGain steering committee and trial investigators. Chemotherapy de-escalation using an ¹⁸F-FDG-PET-based pathological response-adapted strategy in patients with HER2-positive early breast cancer (PHERGain): A multicentre, randomised, open-label, non-comparative, phase 2 trial. Lancet Oncol. 2021;22:858-871. doi: 10.1016/S1470-2045(21)00122-4

5. Chow S, Raine-Bennett T, Samant ND, Postlethwaite DA, Holzapfel M. Breast cancer risk after hysterectomy with and without salpingo-oophorectomy for benign indications. Am J Obstet Gynecol. 2020;223:900.e1-900.e7. doi: 10.1016/j.ajog.2020.06.040

6. ACOG Committee Opinion No. 774: Opportunistic salpingectomy as a strategy for epithelial ovarian cancer prevention. Obstet Gynecol. 2019;133:e279-e284. doi: 10.1097/AOG.0000000000003164

However, a combined analysis of two other trials (PlanB and SUCCESS C) did not show a benefit with the addition of anthracycline for most patients with human epidermal growth factor receptor 2 (HER2)–negative early breast cancer.²Roy and colleagues performed a retrospective study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, including 1106 women ≥ 66 years of age with node-positive TNBC, of whom 69.3% received adjuvant chemotherapy (N = 767). The use of chemotherapy led to a statistically significant improvement in survival outcomes (3-year cancer-specific survival [CSS] 81.8% vs 71.4%; overall survival 70.7% vs 51.3%). Although the anthracycline/taxane–based therapy did not improve CSS in the overall population vs taxane-based (hazard ratio [HR] 0.94; P = .79), among patients aged ≥ 76 years with four or more positive nodes, there was improvement in CSS with anthracycline/taxane therapy (HR 0.09; P = .02). These data further support the benefits of adjuvant chemotherapy in older patients when indicated; stimulate consideration of nonanthracycline combinations, particularly now with the use of immunotherapy for early TNBC; and highlight the need for inclusion of older individuals in clinical trials.

Treatment strategies to improve efficacy and minimize toxicity are highly desired for patients with early breast cancer (EBC). As an example, for small, node-negative, HER2-positive tumors, adjuvant systemic therapy with 12 weeks of paclitaxel/trastuzumab followed by continuation of trastuzumab to complete 1 full year has demonstrated excellent survival outcomes at over 10 years of follow-up.³ In the WSG-ADAPT-TP phase 2 trial, 375 patients with hormone receptor–positive , HER2-positive EBC were randomized to receive neoadjuvant T-DM1 (trastuzumab emtansine) with or without endocrine therapy or trastuzumab plus endocrine therapy. Similar 5-year invasive disease-free and overall survival rates were seen between the three arms. Patients who achieved a pathologic complete response (pCR) vs non-pCR had improved 5-year invasive disease-free survival (iDFS) rates (92.7% vs 82.7%; unadjusted HR 0.40). Furthermore, among the 117 patients who achieved pCR, the omission of adjuvant chemotherapy did not compromise survival outcomes (5-year iDFS 93% vs 92.1% for those who had vs those who did not have chemotherapy, respectively; unadjusted HR 1.15) (Harbeck et al). De-escalation approaches should ideally focus on the identification of biomarkers of response and resistance, as well as tools that can help predict patient outcomes and allow modification of therapy in real time. An example of this latter concept is the use of ¹⁸F-FDG-PET to identify patients with HER2-positive EBC who were likely to benefit from a chemotherapy-free dual HER2 blockade (trastuzumab/pertuzumab) treatment approach.⁴

Gynecologic surgery has been shown to reduce the risk for breast cancer,⁵ although the specific type of surgery and the impact of hormone replacement therapy add complexity to understanding the risks and outcomes for women. A prospective cohort, the Sister Study, included 50,701 women without a prior diagnosis of breast cancer but with a biological sister who had breast cancer; of these, 13.8% reported having hysterectomy only and 18.1% reported having bilateral oophorectomy with or without hysterectomy. Bilateral oophorectomy was inversely associated with breast cancer incidence (HR 0.91; 95% CI 0.83-1.00), with comparable results for women receiving estrogen only or combination estrogen plus progestin hormone replacement therapy. Contrary to these findings, having a hysterectomy only showed a positive association with breast cancer incidence (HR 1.12; 95% CI 1.02-1.23), with the strongest association among women who used combination estrogen and progestin therapy (HR 1.25; 95% CI 1.01-1.55) (Lovett et al). The impact of other gynecologic surgeries (such as salpingectomy)⁶ and the timing of the initiation of hormone replacement therapy, as well as the duration, should be investigated in future research.

Additional References

1. Blum JL, Flynn PJ, Yothers G, et al. Anthracyclines in early breast cancer: The ABC trials-USOR 06-090, NSABP B-46-I/USOR 07132, and NSABP B-49 (NRG oncology). J Clin Oncol. 2017;35:2647e55. doi: 10.1200/JCO.2016.71.4147

2. de Gregorio A, Janni W, Friedl TW, et al. The impact of anthracyclines in intermediate and high-risk HER2-negative early breast cancer-a pooled analysis of the randomised clinical trials PlanB and SUCCESS C. Br J Cancer. 2022;126:1715-1724. doi: 10.1038/s41416-021-01690-6

3. Tolaney SM, Tarantino P, Graham N, et al. Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer: Final 10-year analysis of the open-label, single-arm, phase 2 APT trial. Lancet Oncol. 2023;24:273-285. doi: 10.1016/S1470-2045(23)00051-7

4. Pérez-García JM, Gebhart G, Ruiz Borrego M, et al; on behalf of PHERGain steering committee and trial investigators. Chemotherapy de-escalation using an ¹⁸F-FDG-PET-based pathological response-adapted strategy in patients with HER2-positive early breast cancer (PHERGain): A multicentre, randomised, open-label, non-comparative, phase 2 trial. Lancet Oncol. 2021;22:858-871. doi: 10.1016/S1470-2045(21)00122-4

5. Chow S, Raine-Bennett T, Samant ND, Postlethwaite DA, Holzapfel M. Breast cancer risk after hysterectomy with and without salpingo-oophorectomy for benign indications. Am J Obstet Gynecol. 2020;223:900.e1-900.e7. doi: 10.1016/j.ajog.2020.06.040

6. ACOG Committee Opinion No. 774: Opportunistic salpingectomy as a strategy for epithelial ovarian cancer prevention. Obstet Gynecol. 2019;133:e279-e284. doi: 10.1097/AOG.0000000000003164

However, a combined analysis of two other trials (PlanB and SUCCESS C) did not show a benefit with the addition of anthracycline for most patients with human epidermal growth factor receptor 2 (HER2)–negative early breast cancer.²Roy and colleagues performed a retrospective study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, including 1106 women ≥ 66 years of age with node-positive TNBC, of whom 69.3% received adjuvant chemotherapy (N = 767). The use of chemotherapy led to a statistically significant improvement in survival outcomes (3-year cancer-specific survival [CSS] 81.8% vs 71.4%; overall survival 70.7% vs 51.3%). Although the anthracycline/taxane–based therapy did not improve CSS in the overall population vs taxane-based (hazard ratio [HR] 0.94; P = .79), among patients aged ≥ 76 years with four or more positive nodes, there was improvement in CSS with anthracycline/taxane therapy (HR 0.09; P = .02). These data further support the benefits of adjuvant chemotherapy in older patients when indicated; stimulate consideration of nonanthracycline combinations, particularly now with the use of immunotherapy for early TNBC; and highlight the need for inclusion of older individuals in clinical trials.

Treatment strategies to improve efficacy and minimize toxicity are highly desired for patients with early breast cancer (EBC). As an example, for small, node-negative, HER2-positive tumors, adjuvant systemic therapy with 12 weeks of paclitaxel/trastuzumab followed by continuation of trastuzumab to complete 1 full year has demonstrated excellent survival outcomes at over 10 years of follow-up.³ In the WSG-ADAPT-TP phase 2 trial, 375 patients with hormone receptor–positive , HER2-positive EBC were randomized to receive neoadjuvant T-DM1 (trastuzumab emtansine) with or without endocrine therapy or trastuzumab plus endocrine therapy. Similar 5-year invasive disease-free and overall survival rates were seen between the three arms. Patients who achieved a pathologic complete response (pCR) vs non-pCR had improved 5-year invasive disease-free survival (iDFS) rates (92.7% vs 82.7%; unadjusted HR 0.40). Furthermore, among the 117 patients who achieved pCR, the omission of adjuvant chemotherapy did not compromise survival outcomes (5-year iDFS 93% vs 92.1% for those who had vs those who did not have chemotherapy, respectively; unadjusted HR 1.15) (Harbeck et al). De-escalation approaches should ideally focus on the identification of biomarkers of response and resistance, as well as tools that can help predict patient outcomes and allow modification of therapy in real time. An example of this latter concept is the use of ¹⁸F-FDG-PET to identify patients with HER2-positive EBC who were likely to benefit from a chemotherapy-free dual HER2 blockade (trastuzumab/pertuzumab) treatment approach.⁴

Gynecologic surgery has been shown to reduce the risk for breast cancer,⁵ although the specific type of surgery and the impact of hormone replacement therapy add complexity to understanding the risks and outcomes for women. A prospective cohort, the Sister Study, included 50,701 women without a prior diagnosis of breast cancer but with a biological sister who had breast cancer; of these, 13.8% reported having hysterectomy only and 18.1% reported having bilateral oophorectomy with or without hysterectomy. Bilateral oophorectomy was inversely associated with breast cancer incidence (HR 0.91; 95% CI 0.83-1.00), with comparable results for women receiving estrogen only or combination estrogen plus progestin hormone replacement therapy. Contrary to these findings, having a hysterectomy only showed a positive association with breast cancer incidence (HR 1.12; 95% CI 1.02-1.23), with the strongest association among women who used combination estrogen and progestin therapy (HR 1.25; 95% CI 1.01-1.55) (Lovett et al). The impact of other gynecologic surgeries (such as salpingectomy)⁶ and the timing of the initiation of hormone replacement therapy, as well as the duration, should be investigated in future research.

Additional References

1. Blum JL, Flynn PJ, Yothers G, et al. Anthracyclines in early breast cancer: The ABC trials-USOR 06-090, NSABP B-46-I/USOR 07132, and NSABP B-49 (NRG oncology). J Clin Oncol. 2017;35:2647e55. doi: 10.1200/JCO.2016.71.4147

2. de Gregorio A, Janni W, Friedl TW, et al. The impact of anthracyclines in intermediate and high-risk HER2-negative early breast cancer-a pooled analysis of the randomised clinical trials PlanB and SUCCESS C. Br J Cancer. 2022;126:1715-1724. doi: 10.1038/s41416-021-01690-6

3. Tolaney SM, Tarantino P, Graham N, et al. Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer: Final 10-year analysis of the open-label, single-arm, phase 2 APT trial. Lancet Oncol. 2023;24:273-285. doi: 10.1016/S1470-2045(23)00051-7

4. Pérez-García JM, Gebhart G, Ruiz Borrego M, et al; on behalf of PHERGain steering committee and trial investigators. Chemotherapy de-escalation using an ¹⁸F-FDG-PET-based pathological response-adapted strategy in patients with HER2-positive early breast cancer (PHERGain): A multicentre, randomised, open-label, non-comparative, phase 2 trial. Lancet Oncol. 2021;22:858-871. doi: 10.1016/S1470-2045(21)00122-4

5. Chow S, Raine-Bennett T, Samant ND, Postlethwaite DA, Holzapfel M. Breast cancer risk after hysterectomy with and without salpingo-oophorectomy for benign indications. Am J Obstet Gynecol. 2020;223:900.e1-900.e7. doi: 10.1016/j.ajog.2020.06.040

6. ACOG Committee Opinion No. 774: Opportunistic salpingectomy as a strategy for epithelial ovarian cancer prevention. Obstet Gynecol. 2019;133:e279-e284. doi: 10.1097/AOG.0000000000003164

Good news! There's not a lot to say about this. Dupilumab is so easy. No blood work, no immunosuppression. Dupilumab is highly effective and very safe. It's safe enough for children as young as 6 months! It's so effective that if it is not working, I question my diagnosis (Could it be contact dermatitis or mycosis fungoides instead?) and whether the patient is taking the medication properly.

Boesjes and colleagues describe in Acta Dermato-Venereologica the Dutch experience with upadacitinib in patients who have not been successfully treated with dupilumab or baricitinib. Presumably, such patients, because treatment with dupilumab or baricitinib or both was unsuccessful, have very resistant atopic dermatitis (either due to strong genetic propensity or perhaps because they don't take their medications). Despite having such refractory disease, most patients did well on the treatment with rapid disease improvement. Upadacitinib didn't work for everyone, though. About 30% of the patients discontinued upadacitinib treatment due to ineffectiveness, adverse events, or both (8.5%, 14.9%, and 6.4%, respectively).

How much of that ineffectiveness was due to poor adherence to taking the treatment was not assessed. Upadacitinib is extraordinarily effective for atopic dermatitis. I didn't think I would ever see a drug more effective than dupilumab for atopic dermatitis, but a low dose of upadacitinib (15 mg/day) seems about twice as effective as dupilumab for complete clearing of atopic dermatitis. The higher dose of 30 mg may be 3.5 times as effective as dupiliumab at getting atopic dermatitis completely clear.¹

I dislike the word significant. Significant is ambiguous. It could mean that an observed association would not be likely to occur by chance, or it could mean that an observed association is clinically meaningful. Smith and colleagues in "Association between electronic cigarette use and atopic dermatitis among United States adults" reported finding a "significant" association between e-cigarette use and atopic dermatitis. A total of 23% of 2119 e-cigarette users had atopic dermatitis vs 17.1% of 26,444 nonusers. Clearly, the observed association was statistically significant (the 6% difference was not likely to occur due to chance alone). Is the finding clinically meaningful? I don't think it would affect our practice in any way.

The authors made the point that the study doesn't tell us whether e-cigarette use causes atopic dermatitis or if atopic dermatitis causes people to smoke. I wonder if just being younger (or some other factor) might make people more likely to use e-cigarettes and more likely to have atopic dermatitis (assuming atopic dermatitis gradually subsides over time, a dogma that may not be true).

Kabashima and colleagues report on the efficacy of the interleukin (IL)–31 antagonist nemolizumab. IL-31 mediates itch and having a new drug to block IL-31 may be a great treatment for our itchy patients. In this study, patients who had greater itch reduction had greater improvement in eczema and in quality of life. I'm quite sure that reducing itch improves patients' quality of life. But when it comes to the itch and the inflammation, I'm not sure which comes first. Does controlling the itch make the inflammation better? Maybe. Does controlling inflammation make itch better? Certainly.

For atopic patients with inflammation, controlling that inflammation seems to me to be the best approach, and we don't need more new treatments to accomplish that. For those patients who have a lot of itch and little inflammation, an IL-31 antagonist may be a revolutionary addition to our treatment options.

Additional References

1. Blauvelt A, Teixeira HD, Simpson EL, et al. Efficacy and safety of upadacitinib vs dupilumab in adults with moderate-to-severe atopic dermatitis: a randomized clinical trial. JAMA Dermatol. 2021;157:1047-1055. doi: 10.1001/jamadermatol.2021.3023. Erratum in: JAMA Dermatol. 2022;158:219. doi: 10.1001/jamadermatol.2021.5451

Good news! There's not a lot to say about this. Dupilumab is so easy. No blood work, no immunosuppression. Dupilumab is highly effective and very safe. It's safe enough for children as young as 6 months! It's so effective that if it is not working, I question my diagnosis (Could it be contact dermatitis or mycosis fungoides instead?) and whether the patient is taking the medication properly.

Boesjes and colleagues describe in Acta Dermato-Venereologica the Dutch experience with upadacitinib in patients who have not been successfully treated with dupilumab or baricitinib. Presumably, such patients, because treatment with dupilumab or baricitinib or both was unsuccessful, have very resistant atopic dermatitis (either due to strong genetic propensity or perhaps because they don't take their medications). Despite having such refractory disease, most patients did well on the treatment with rapid disease improvement. Upadacitinib didn't work for everyone, though. About 30% of the patients discontinued upadacitinib treatment due to ineffectiveness, adverse events, or both (8.5%, 14.9%, and 6.4%, respectively).

How much of that ineffectiveness was due to poor adherence to taking the treatment was not assessed. Upadacitinib is extraordinarily effective for atopic dermatitis. I didn't think I would ever see a drug more effective than dupilumab for atopic dermatitis, but a low dose of upadacitinib (15 mg/day) seems about twice as effective as dupilumab for complete clearing of atopic dermatitis. The higher dose of 30 mg may be 3.5 times as effective as dupiliumab at getting atopic dermatitis completely clear.¹

I dislike the word significant. Significant is ambiguous. It could mean that an observed association would not be likely to occur by chance, or it could mean that an observed association is clinically meaningful. Smith and colleagues in "Association between electronic cigarette use and atopic dermatitis among United States adults" reported finding a "significant" association between e-cigarette use and atopic dermatitis. A total of 23% of 2119 e-cigarette users had atopic dermatitis vs 17.1% of 26,444 nonusers. Clearly, the observed association was statistically significant (the 6% difference was not likely to occur due to chance alone). Is the finding clinically meaningful? I don't think it would affect our practice in any way.

The authors made the point that the study doesn't tell us whether e-cigarette use causes atopic dermatitis or if atopic dermatitis causes people to smoke. I wonder if just being younger (or some other factor) might make people more likely to use e-cigarettes and more likely to have atopic dermatitis (assuming atopic dermatitis gradually subsides over time, a dogma that may not be true).

Kabashima and colleagues report on the efficacy of the interleukin (IL)–31 antagonist nemolizumab. IL-31 mediates itch and having a new drug to block IL-31 may be a great treatment for our itchy patients. In this study, patients who had greater itch reduction had greater improvement in eczema and in quality of life. I'm quite sure that reducing itch improves patients' quality of life. But when it comes to the itch and the inflammation, I'm not sure which comes first. Does controlling the itch make the inflammation better? Maybe. Does controlling inflammation make itch better? Certainly.

For atopic patients with inflammation, controlling that inflammation seems to me to be the best approach, and we don't need more new treatments to accomplish that. For those patients who have a lot of itch and little inflammation, an IL-31 antagonist may be a revolutionary addition to our treatment options.

Additional References

1. Blauvelt A, Teixeira HD, Simpson EL, et al. Efficacy and safety of upadacitinib vs dupilumab in adults with moderate-to-severe atopic dermatitis: a randomized clinical trial. JAMA Dermatol. 2021;157:1047-1055. doi: 10.1001/jamadermatol.2021.3023. Erratum in: JAMA Dermatol. 2022;158:219. doi: 10.1001/jamadermatol.2021.5451

Good news! There's not a lot to say about this. Dupilumab is so easy. No blood work, no immunosuppression. Dupilumab is highly effective and very safe. It's safe enough for children as young as 6 months! It's so effective that if it is not working, I question my diagnosis (Could it be contact dermatitis or mycosis fungoides instead?) and whether the patient is taking the medication properly.

Boesjes and colleagues describe in Acta Dermato-Venereologica the Dutch experience with upadacitinib in patients who have not been successfully treated with dupilumab or baricitinib. Presumably, such patients, because treatment with dupilumab or baricitinib or both was unsuccessful, have very resistant atopic dermatitis (either due to strong genetic propensity or perhaps because they don't take their medications). Despite having such refractory disease, most patients did well on the treatment with rapid disease improvement. Upadacitinib didn't work for everyone, though. About 30% of the patients discontinued upadacitinib treatment due to ineffectiveness, adverse events, or both (8.5%, 14.9%, and 6.4%, respectively).

How much of that ineffectiveness was due to poor adherence to taking the treatment was not assessed. Upadacitinib is extraordinarily effective for atopic dermatitis. I didn't think I would ever see a drug more effective than dupilumab for atopic dermatitis, but a low dose of upadacitinib (15 mg/day) seems about twice as effective as dupilumab for complete clearing of atopic dermatitis. The higher dose of 30 mg may be 3.5 times as effective as dupiliumab at getting atopic dermatitis completely clear.¹

I dislike the word significant. Significant is ambiguous. It could mean that an observed association would not be likely to occur by chance, or it could mean that an observed association is clinically meaningful. Smith and colleagues in "Association between electronic cigarette use and atopic dermatitis among United States adults" reported finding a "significant" association between e-cigarette use and atopic dermatitis. A total of 23% of 2119 e-cigarette users had atopic dermatitis vs 17.1% of 26,444 nonusers. Clearly, the observed association was statistically significant (the 6% difference was not likely to occur due to chance alone). Is the finding clinically meaningful? I don't think it would affect our practice in any way.

The authors made the point that the study doesn't tell us whether e-cigarette use causes atopic dermatitis or if atopic dermatitis causes people to smoke. I wonder if just being younger (or some other factor) might make people more likely to use e-cigarettes and more likely to have atopic dermatitis (assuming atopic dermatitis gradually subsides over time, a dogma that may not be true).

Kabashima and colleagues report on the efficacy of the interleukin (IL)–31 antagonist nemolizumab. IL-31 mediates itch and having a new drug to block IL-31 may be a great treatment for our itchy patients. In this study, patients who had greater itch reduction had greater improvement in eczema and in quality of life. I'm quite sure that reducing itch improves patients' quality of life. But when it comes to the itch and the inflammation, I'm not sure which comes first. Does controlling the itch make the inflammation better? Maybe. Does controlling inflammation make itch better? Certainly.

For atopic patients with inflammation, controlling that inflammation seems to me to be the best approach, and we don't need more new treatments to accomplish that. For those patients who have a lot of itch and little inflammation, an IL-31 antagonist may be a revolutionary addition to our treatment options.

Additional References

1. Blauvelt A, Teixeira HD, Simpson EL, et al. Efficacy and safety of upadacitinib vs dupilumab in adults with moderate-to-severe atopic dermatitis: a randomized clinical trial. JAMA Dermatol. 2021;157:1047-1055. doi: 10.1001/jamadermatol.2021.3023. Erratum in: JAMA Dermatol. 2022;158:219. doi: 10.1001/jamadermatol.2021.5451

With regard to advanced targeted therapies, there is concern about the side effects of Janus kinase (JAK) inhibitors, especially in patients with comorbidities. To address safety concerns with upadacitinib, a selective JAK1 inhibitor, Burmester and colleagues conducted an integrated safety analysis of 12 phase 3 trials that included 6991 patients (PsA n = 907; rheumatoid arthritis [RA] n = 3209; ankylosing spondylitis n = 182; and atopic dermatitis n = 2693) who received upadacitinib (15 or 30 mg once daily). Some trials included active comparators; therefore, safety among 1008 patients (RA n = 579; PsA n = 429) who received 40-mg adalimumab every other week and 314 patients with RA who received methotrexate were compared with those treated with upadacitinib. Overall, patients with PsA receiving 15-mg upadacitinib once daily had acceptable rates of treatment-emergent adverse events (TEAE; 244.8/100 patient-years [PY]), serious TEAE (11.1/100 PY), TEAE leading to discontinuation (5.4/100 PY), and death (0.8/100 PY). Patients with PsA treated with upadacitinib had higher rates of herpes zoster, nonmelanoma skin cancer, and elevations in creatine phosphokinase when compared with patients treated with adalimumab. Although these results are reassuring to clinicians treating PsA, continued surveillance regarding the risks for venous thrombosis, cardiovascular events, and cancer are required.

In a post hoc analysis of 10 clinical trials that included patients with PsA (n = 783) and psoriasis (n = 3663) who received tofacitinib, Kristensen and colleagues reported that the risk for major adverse cardiac events was higher among patients with PsA and a high 10-year atherosclerotic cardiovascular disease (ASCVD) risk vs patients with a low ASCVD risk. The incidence of cancer was highest in patients with PsA and an intermediate 10-year ASCVD risk. Although these studies are reassuring, the assessment and risk stratification of adverse events with JAK inhibitors and therapies in PsA will require longer-term comparative clinical trials as well as an evaluation of observational data from disease registries.

Comorbidities also have an impact on treatment persistence in PsA. Tillett and colleagues conducted a retrospective study including 9057 patients with plaque psoriasis alone or with concomitant PsA who received either ustekinumab or conventional systemic disease-modifying antirheumatic drugs. They demonstrated that among patients receiving ustekinumab, those with concomitant PsA had a higher comorbidity burden, including diabetes, hypertension, and obesity, and a shorter time to ustekinumab discontinuation when compared with those with psoriasis alone. Secondary failure of advanced therapies is increasingly noted in the management of psoriatic disease. Female sex, depression, previous exposure to biologics, and the presence of comorbidities are important risk factors. Comprehensive management of psoriatic disease should include appropriate management of comorbidities for better long-term treatment persistence and outcomes.

With regard to advanced targeted therapies, there is concern about the side effects of Janus kinase (JAK) inhibitors, especially in patients with comorbidities. To address safety concerns with upadacitinib, a selective JAK1 inhibitor, Burmester and colleagues conducted an integrated safety analysis of 12 phase 3 trials that included 6991 patients (PsA n = 907; rheumatoid arthritis [RA] n = 3209; ankylosing spondylitis n = 182; and atopic dermatitis n = 2693) who received upadacitinib (15 or 30 mg once daily). Some trials included active comparators; therefore, safety among 1008 patients (RA n = 579; PsA n = 429) who received 40-mg adalimumab every other week and 314 patients with RA who received methotrexate were compared with those treated with upadacitinib. Overall, patients with PsA receiving 15-mg upadacitinib once daily had acceptable rates of treatment-emergent adverse events (TEAE; 244.8/100 patient-years [PY]), serious TEAE (11.1/100 PY), TEAE leading to discontinuation (5.4/100 PY), and death (0.8/100 PY). Patients with PsA treated with upadacitinib had higher rates of herpes zoster, nonmelanoma skin cancer, and elevations in creatine phosphokinase when compared with patients treated with adalimumab. Although these results are reassuring to clinicians treating PsA, continued surveillance regarding the risks for venous thrombosis, cardiovascular events, and cancer are required.

In a post hoc analysis of 10 clinical trials that included patients with PsA (n = 783) and psoriasis (n = 3663) who received tofacitinib, Kristensen and colleagues reported that the risk for major adverse cardiac events was higher among patients with PsA and a high 10-year atherosclerotic cardiovascular disease (ASCVD) risk vs patients with a low ASCVD risk. The incidence of cancer was highest in patients with PsA and an intermediate 10-year ASCVD risk. Although these studies are reassuring, the assessment and risk stratification of adverse events with JAK inhibitors and therapies in PsA will require longer-term comparative clinical trials as well as an evaluation of observational data from disease registries.

Comorbidities also have an impact on treatment persistence in PsA. Tillett and colleagues conducted a retrospective study including 9057 patients with plaque psoriasis alone or with concomitant PsA who received either ustekinumab or conventional systemic disease-modifying antirheumatic drugs. They demonstrated that among patients receiving ustekinumab, those with concomitant PsA had a higher comorbidity burden, including diabetes, hypertension, and obesity, and a shorter time to ustekinumab discontinuation when compared with those with psoriasis alone. Secondary failure of advanced therapies is increasingly noted in the management of psoriatic disease. Female sex, depression, previous exposure to biologics, and the presence of comorbidities are important risk factors. Comprehensive management of psoriatic disease should include appropriate management of comorbidities for better long-term treatment persistence and outcomes.

With regard to advanced targeted therapies, there is concern about the side effects of Janus kinase (JAK) inhibitors, especially in patients with comorbidities. To address safety concerns with upadacitinib, a selective JAK1 inhibitor, Burmester and colleagues conducted an integrated safety analysis of 12 phase 3 trials that included 6991 patients (PsA n = 907; rheumatoid arthritis [RA] n = 3209; ankylosing spondylitis n = 182; and atopic dermatitis n = 2693) who received upadacitinib (15 or 30 mg once daily). Some trials included active comparators; therefore, safety among 1008 patients (RA n = 579; PsA n = 429) who received 40-mg adalimumab every other week and 314 patients with RA who received methotrexate were compared with those treated with upadacitinib. Overall, patients with PsA receiving 15-mg upadacitinib once daily had acceptable rates of treatment-emergent adverse events (TEAE; 244.8/100 patient-years [PY]), serious TEAE (11.1/100 PY), TEAE leading to discontinuation (5.4/100 PY), and death (0.8/100 PY). Patients with PsA treated with upadacitinib had higher rates of herpes zoster, nonmelanoma skin cancer, and elevations in creatine phosphokinase when compared with patients treated with adalimumab. Although these results are reassuring to clinicians treating PsA, continued surveillance regarding the risks for venous thrombosis, cardiovascular events, and cancer are required.

In a post hoc analysis of 10 clinical trials that included patients with PsA (n = 783) and psoriasis (n = 3663) who received tofacitinib, Kristensen and colleagues reported that the risk for major adverse cardiac events was higher among patients with PsA and a high 10-year atherosclerotic cardiovascular disease (ASCVD) risk vs patients with a low ASCVD risk. The incidence of cancer was highest in patients with PsA and an intermediate 10-year ASCVD risk. Although these studies are reassuring, the assessment and risk stratification of adverse events with JAK inhibitors and therapies in PsA will require longer-term comparative clinical trials as well as an evaluation of observational data from disease registries.

Comorbidities also have an impact on treatment persistence in PsA. Tillett and colleagues conducted a retrospective study including 9057 patients with plaque psoriasis alone or with concomitant PsA who received either ustekinumab or conventional systemic disease-modifying antirheumatic drugs. They demonstrated that among patients receiving ustekinumab, those with concomitant PsA had a higher comorbidity burden, including diabetes, hypertension, and obesity, and a shorter time to ustekinumab discontinuation when compared with those with psoriasis alone. Secondary failure of advanced therapies is increasingly noted in the management of psoriatic disease. Female sex, depression, previous exposure to biologics, and the presence of comorbidities are important risk factors. Comprehensive management of psoriatic disease should include appropriate management of comorbidities for better long-term treatment persistence and outcomes.

Two recent studies examined interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA). Albrecht and colleagues examined the prevalence of ILD in German patients with RA using a nationwide claims database from 2007 to 2020. Using diagnosis codes for seropositive and seronegative RA (along with disease-modifying antirheumatic drug prescriptions) as well as ILD, they found the prevalence of ILD to be relatively stable from 1.6% to 2.2%, and that incidence was stable (reported as 0.13%-0.21% per year, rather than per patient-year) over the course of the study. There is likely some misclassification with the primary reliance on diagnosis codes (of the included patients with RA only 44% were seropositive). They also excluded drug-induced ILD by diagnosis code, which may not be sufficient. Overall, the prevalence of ILD seems on the low end of what might be expected and may reflect a need for earlier evaluation to detect subclinical ILD.

Kronzer and colleagues performed a case-control study of 84 patients with incident RA-ILD compared with 233 patients with RA without ILD to evaluate the risk associated with specific anticitrullinated protein antibodies (ACPA) for the development of ILD. Compared with the clinical risk factors of smoking, disease activity, obesity, and glucocorticoid use, six "fine-specificity" ACPA were better able to predict ILD risk, with immunoglobulin (Ig) A2 to citrullinated histone 4 associated with an odds ratio (OR) of 0.08, and the others (IgA2 to citrullinated histone 2A, IgA2 to native cyclic histone 2A, IgA2 to native histone 2A, IgG to cyclic citrullinated filaggrin, and IgG to native cyclic filaggrin) were associated with OR of 2.5-5.5 for ILD. In combination with clinical characteristics, the authors developed a risk score with 93% specificity for RA-ILD that should be validated in other populations.

Suh and colleagues examined the association of RA with another less well-studied organ complication, end-stage renal disease (ESRD), using a large national insurance database. Once again, the accuracy of diagnosis is not fully clear using International Classification of Diseases, Tenth Edition (ICD-10), codes for classification. Overall, people with RA had a higher risk for ESRD than did people without RA, regardless of sex or smoking status. Because no immediate mechanistic connection between RA and ESRD is evident, it is possible that part of the increased risk is due to medications used in RA treatment, such as nonsteroidal anti-inflammatory drugs, but this hypothesis remains to be tested.

Finally, a footnote to the success of the treat-to-target strategy (T2T) in RA comes in a study by Ramiro and colleagues of the RA-BIODAM cohort, which, along with other studies, has shown the success of T2T in achieving and maintaining long-term clinical remission in RA. The effect of T2T on radiographic progression, however, is less clear. In this study, over 500 patients were followed for 2 years and a comparison between the T2T strategy and radiographic damage was made. The T2T strategy consisted of intensification of treatment if the Disease Activity Score (DAS-44) did not achieve a goal of < 1.6. This was compared with the radiographic damage (based on the change in Sharp-van der Heijde score[SvdH]) over a 6-month period. Overall, the change in progression was not different among patients who were treated with a stricter adherence to T2T (ie, a higher proportion of T2T) compared with those who were not, suggesting that a looser application of T2T will not necessarily cause a worsening of radiographic progression. It is possible, given the intervals of assessment in this study, that a longer follow-up after T2T is necessary to detect progression, or, given that patients were not randomly assigned, patients who were more strictly treated with T2T were already at higher risk for radiographic progression. However, this study is also helpful in understanding how insights from controlled trials may play out in usual clinical practice.

Two recent studies examined interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA). Albrecht and colleagues examined the prevalence of ILD in German patients with RA using a nationwide claims database from 2007 to 2020. Using diagnosis codes for seropositive and seronegative RA (along with disease-modifying antirheumatic drug prescriptions) as well as ILD, they found the prevalence of ILD to be relatively stable from 1.6% to 2.2%, and that incidence was stable (reported as 0.13%-0.21% per year, rather than per patient-year) over the course of the study. There is likely some misclassification with the primary reliance on diagnosis codes (of the included patients with RA only 44% were seropositive). They also excluded drug-induced ILD by diagnosis code, which may not be sufficient. Overall, the prevalence of ILD seems on the low end of what might be expected and may reflect a need for earlier evaluation to detect subclinical ILD.

Kronzer and colleagues performed a case-control study of 84 patients with incident RA-ILD compared with 233 patients with RA without ILD to evaluate the risk associated with specific anticitrullinated protein antibodies (ACPA) for the development of ILD. Compared with the clinical risk factors of smoking, disease activity, obesity, and glucocorticoid use, six "fine-specificity" ACPA were better able to predict ILD risk, with immunoglobulin (Ig) A2 to citrullinated histone 4 associated with an odds ratio (OR) of 0.08, and the others (IgA2 to citrullinated histone 2A, IgA2 to native cyclic histone 2A, IgA2 to native histone 2A, IgG to cyclic citrullinated filaggrin, and IgG to native cyclic filaggrin) were associated with OR of 2.5-5.5 for ILD. In combination with clinical characteristics, the authors developed a risk score with 93% specificity for RA-ILD that should be validated in other populations.

Suh and colleagues examined the association of RA with another less well-studied organ complication, end-stage renal disease (ESRD), using a large national insurance database. Once again, the accuracy of diagnosis is not fully clear using International Classification of Diseases, Tenth Edition (ICD-10), codes for classification. Overall, people with RA had a higher risk for ESRD than did people without RA, regardless of sex or smoking status. Because no immediate mechanistic connection between RA and ESRD is evident, it is possible that part of the increased risk is due to medications used in RA treatment, such as nonsteroidal anti-inflammatory drugs, but this hypothesis remains to be tested.

Finally, a footnote to the success of the treat-to-target strategy (T2T) in RA comes in a study by Ramiro and colleagues of the RA-BIODAM cohort, which, along with other studies, has shown the success of T2T in achieving and maintaining long-term clinical remission in RA. The effect of T2T on radiographic progression, however, is less clear. In this study, over 500 patients were followed for 2 years and a comparison between the T2T strategy and radiographic damage was made. The T2T strategy consisted of intensification of treatment if the Disease Activity Score (DAS-44) did not achieve a goal of < 1.6. This was compared with the radiographic damage (based on the change in Sharp-van der Heijde score[SvdH]) over a 6-month period. Overall, the change in progression was not different among patients who were treated with a stricter adherence to T2T (ie, a higher proportion of T2T) compared with those who were not, suggesting that a looser application of T2T will not necessarily cause a worsening of radiographic progression. It is possible, given the intervals of assessment in this study, that a longer follow-up after T2T is necessary to detect progression, or, given that patients were not randomly assigned, patients who were more strictly treated with T2T were already at higher risk for radiographic progression. However, this study is also helpful in understanding how insights from controlled trials may play out in usual clinical practice.

Two recent studies examined interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA). Albrecht and colleagues examined the prevalence of ILD in German patients with RA using a nationwide claims database from 2007 to 2020. Using diagnosis codes for seropositive and seronegative RA (along with disease-modifying antirheumatic drug prescriptions) as well as ILD, they found the prevalence of ILD to be relatively stable from 1.6% to 2.2%, and that incidence was stable (reported as 0.13%-0.21% per year, rather than per patient-year) over the course of the study. There is likely some misclassification with the primary reliance on diagnosis codes (of the included patients with RA only 44% were seropositive). They also excluded drug-induced ILD by diagnosis code, which may not be sufficient. Overall, the prevalence of ILD seems on the low end of what might be expected and may reflect a need for earlier evaluation to detect subclinical ILD.

Kronzer and colleagues performed a case-control study of 84 patients with incident RA-ILD compared with 233 patients with RA without ILD to evaluate the risk associated with specific anticitrullinated protein antibodies (ACPA) for the development of ILD. Compared with the clinical risk factors of smoking, disease activity, obesity, and glucocorticoid use, six "fine-specificity" ACPA were better able to predict ILD risk, with immunoglobulin (Ig) A2 to citrullinated histone 4 associated with an odds ratio (OR) of 0.08, and the others (IgA2 to citrullinated histone 2A, IgA2 to native cyclic histone 2A, IgA2 to native histone 2A, IgG to cyclic citrullinated filaggrin, and IgG to native cyclic filaggrin) were associated with OR of 2.5-5.5 for ILD. In combination with clinical characteristics, the authors developed a risk score with 93% specificity for RA-ILD that should be validated in other populations.

Suh and colleagues examined the association of RA with another less well-studied organ complication, end-stage renal disease (ESRD), using a large national insurance database. Once again, the accuracy of diagnosis is not fully clear using International Classification of Diseases, Tenth Edition (ICD-10), codes for classification. Overall, people with RA had a higher risk for ESRD than did people without RA, regardless of sex or smoking status. Because no immediate mechanistic connection between RA and ESRD is evident, it is possible that part of the increased risk is due to medications used in RA treatment, such as nonsteroidal anti-inflammatory drugs, but this hypothesis remains to be tested.

Finally, a footnote to the success of the treat-to-target strategy (T2T) in RA comes in a study by Ramiro and colleagues of the RA-BIODAM cohort, which, along with other studies, has shown the success of T2T in achieving and maintaining long-term clinical remission in RA. The effect of T2T on radiographic progression, however, is less clear. In this study, over 500 patients were followed for 2 years and a comparison between the T2T strategy and radiographic damage was made. The T2T strategy consisted of intensification of treatment if the Disease Activity Score (DAS-44) did not achieve a goal of < 1.6. This was compared with the radiographic damage (based on the change in Sharp-van der Heijde score[SvdH]) over a 6-month period. Overall, the change in progression was not different among patients who were treated with a stricter adherence to T2T (ie, a higher proportion of T2T) compared with those who were not, suggesting that a looser application of T2T will not necessarily cause a worsening of radiographic progression. It is possible, given the intervals of assessment in this study, that a longer follow-up after T2T is necessary to detect progression, or, given that patients were not randomly assigned, patients who were more strictly treated with T2T were already at higher risk for radiographic progression. However, this study is also helpful in understanding how insights from controlled trials may play out in usual clinical practice.

One therapy that has transformed the management of this disease is anti-CD19 chimeric antigen receptor (CAR) T-cell therapy. Currently there are three FDA-approved options for patients with relapsed/refractory large B-cell lymphoma (LBCL) who have received at least two prior lines of therapy.^[1-3] More recently, axicabtagene ciloleucel (axi-cel) and lisocabtagene maraleucel (liso-cel) have also been approved for second-line therapy on the basis of results of the ZUMA-7 and TRANSFORM studies, respectively.^[4,5]The primary analysis of the TRANSFORM study, which included patients with primary refractory or early relapse of large B-cell lymphoma, is now available. In this study, 184 patients were randomly assigned to receive liso-cel or three cycles of the standard of care (high-dose chemotherapy and autologous stem cell transplantation). After a 17.5-month median follow-up, the liso-cel vs standard-of-care group had significantly improved median event-free survival (hazard ratio [HR] 0.356; 95% CI 0.243-0.522), median progression-free survival (HR 0.400; P < .0001), and complete response rate (74% vs 43%; P < .0001), along with low rates of grade 3 cytokine release syndrome (1%) and neurologic events (4%). This confirms the role of liso-cel in the second-line setting for high-risk patients.

Another promising treatment approach across lymphoma subtypes, including DLBCL, are CD20/CD3 bispecific monoclonal antibodies. The results of the phase 2 trial of glofitamab for patients with relapsed/refractory DLBCL were published recently. This study included 155 patients with relapsed/refractory DLBCL after at least two prior lines of therapy. Approximately one third of patients had received prior CAR T-cell therapy. Patients were treated for a fixed duration of 12 cycles. At a median follow-up of 12.6 months, 39% (95% CI 32%-48%) and 52% (95% CI 43%-60%) of patients achieved complete and objective responses, respectively. Seventy-eight percent of patients with a complete response continued to be in remission at 12 months. Grade 3 or higher cytokine release syndrome was rare and occurred in less than 5% of patients.

Bispecific antibodies have many advantages, including off-the-shelf access and favorable toxicity profiles. Longer follow-up, however, will be required to determine the durability of response beyond 1 year. As bispecific antibodies become available, many questions will emerge, including how best to sequence with CAR T-cell therapy and whether to combine them with other regimens. Additional studies of bispecific antibodies in combination with chemoimmunotherapy and other treatment approaches are underway.

Additional References

1.         Neelapu SS, Locke FL, Bartlett NL, et al. Axicabtagene ciloleucel CAR T-cell therapy in refractory large B-cell lymphoma. N Engl J Med. 2017;377:2531-2544. Doi:10.1056/NEJMoa1707447

2.         Schuster SJ, Bishop MR, Tam CS, et al. Tisagenlecleucel in adult relapsed or refractory diffuse large B-cell lymphoma. N Engl J Med. 2019;380:45-56. Doi:10.1056/NEJMoa1804980

3.         Abramson JS, Palomba ML, Gordon LI, et al. Lisocabtagene maraleucel for patients with relapsed or refractory large B-cell lymphomas (TRANSCEND NHL 001): A multicentre seamless design study. Lancet. 2020;396:839-852. Doi:10.1016/S0140-6736(20)31366-0

4.         Locke FL, Miklos DB, Jacobson CA, et al. Axicabtagene ciloleucel as second-line therapy for large B-cell lymphoma. N Engl J Med. 2022;386:640-654. Doi:10.1056/NEJMoa2116133

5.         Kamdar M, Solomon SR, Arnason J, et al. Lisocabtagene maraleucel versus standard of care with salvage chemotherapy followed by autologous stem cell transplantation as second-line treatment in patients with relapsed or refractory large B-cell lymphoma (TRANSFORM): Results from an interim analysis of an open-label, randomised, phase 3 trial. Lancet. 2022;399:2294-2308. Doi:10.1016/S0140-6736(22)00662-6

One therapy that has transformed the management of this disease is anti-CD19 chimeric antigen receptor (CAR) T-cell therapy. Currently there are three FDA-approved options for patients with relapsed/refractory large B-cell lymphoma (LBCL) who have received at least two prior lines of therapy.^[1-3] More recently, axicabtagene ciloleucel (axi-cel) and lisocabtagene maraleucel (liso-cel) have also been approved for second-line therapy on the basis of results of the ZUMA-7 and TRANSFORM studies, respectively.^[4,5]The primary analysis of the TRANSFORM study, which included patients with primary refractory or early relapse of large B-cell lymphoma, is now available. In this study, 184 patients were randomly assigned to receive liso-cel or three cycles of the standard of care (high-dose chemotherapy and autologous stem cell transplantation). After a 17.5-month median follow-up, the liso-cel vs standard-of-care group had significantly improved median event-free survival (hazard ratio [HR] 0.356; 95% CI 0.243-0.522), median progression-free survival (HR 0.400; P < .0001), and complete response rate (74% vs 43%; P < .0001), along with low rates of grade 3 cytokine release syndrome (1%) and neurologic events (4%). This confirms the role of liso-cel in the second-line setting for high-risk patients.

Another promising treatment approach across lymphoma subtypes, including DLBCL, are CD20/CD3 bispecific monoclonal antibodies. The results of the phase 2 trial of glofitamab for patients with relapsed/refractory DLBCL were published recently. This study included 155 patients with relapsed/refractory DLBCL after at least two prior lines of therapy. Approximately one third of patients had received prior CAR T-cell therapy. Patients were treated for a fixed duration of 12 cycles. At a median follow-up of 12.6 months, 39% (95% CI 32%-48%) and 52% (95% CI 43%-60%) of patients achieved complete and objective responses, respectively. Seventy-eight percent of patients with a complete response continued to be in remission at 12 months. Grade 3 or higher cytokine release syndrome was rare and occurred in less than 5% of patients.

Bispecific antibodies have many advantages, including off-the-shelf access and favorable toxicity profiles. Longer follow-up, however, will be required to determine the durability of response beyond 1 year. As bispecific antibodies become available, many questions will emerge, including how best to sequence with CAR T-cell therapy and whether to combine them with other regimens. Additional studies of bispecific antibodies in combination with chemoimmunotherapy and other treatment approaches are underway.

Additional References

1.         Neelapu SS, Locke FL, Bartlett NL, et al. Axicabtagene ciloleucel CAR T-cell therapy in refractory large B-cell lymphoma. N Engl J Med. 2017;377:2531-2544. Doi:10.1056/NEJMoa1707447

2.         Schuster SJ, Bishop MR, Tam CS, et al. Tisagenlecleucel in adult relapsed or refractory diffuse large B-cell lymphoma. N Engl J Med. 2019;380:45-56. Doi:10.1056/NEJMoa1804980

3.         Abramson JS, Palomba ML, Gordon LI, et al. Lisocabtagene maraleucel for patients with relapsed or refractory large B-cell lymphomas (TRANSCEND NHL 001): A multicentre seamless design study. Lancet. 2020;396:839-852. Doi:10.1016/S0140-6736(20)31366-0

4.         Locke FL, Miklos DB, Jacobson CA, et al. Axicabtagene ciloleucel as second-line therapy for large B-cell lymphoma. N Engl J Med. 2022;386:640-654. Doi:10.1056/NEJMoa2116133

5.         Kamdar M, Solomon SR, Arnason J, et al. Lisocabtagene maraleucel versus standard of care with salvage chemotherapy followed by autologous stem cell transplantation as second-line treatment in patients with relapsed or refractory large B-cell lymphoma (TRANSFORM): Results from an interim analysis of an open-label, randomised, phase 3 trial. Lancet. 2022;399:2294-2308. Doi:10.1016/S0140-6736(22)00662-6

One therapy that has transformed the management of this disease is anti-CD19 chimeric antigen receptor (CAR) T-cell therapy. Currently there are three FDA-approved options for patients with relapsed/refractory large B-cell lymphoma (LBCL) who have received at least two prior lines of therapy.^[1-3] More recently, axicabtagene ciloleucel (axi-cel) and lisocabtagene maraleucel (liso-cel) have also been approved for second-line therapy on the basis of results of the ZUMA-7 and TRANSFORM studies, respectively.^[4,5]The primary analysis of the TRANSFORM study, which included patients with primary refractory or early relapse of large B-cell lymphoma, is now available. In this study, 184 patients were randomly assigned to receive liso-cel or three cycles of the standard of care (high-dose chemotherapy and autologous stem cell transplantation). After a 17.5-month median follow-up, the liso-cel vs standard-of-care group had significantly improved median event-free survival (hazard ratio [HR] 0.356; 95% CI 0.243-0.522), median progression-free survival (HR 0.400; P < .0001), and complete response rate (74% vs 43%; P < .0001), along with low rates of grade 3 cytokine release syndrome (1%) and neurologic events (4%). This confirms the role of liso-cel in the second-line setting for high-risk patients.

Another promising treatment approach across lymphoma subtypes, including DLBCL, are CD20/CD3 bispecific monoclonal antibodies. The results of the phase 2 trial of glofitamab for patients with relapsed/refractory DLBCL were published recently. This study included 155 patients with relapsed/refractory DLBCL after at least two prior lines of therapy. Approximately one third of patients had received prior CAR T-cell therapy. Patients were treated for a fixed duration of 12 cycles. At a median follow-up of 12.6 months, 39% (95% CI 32%-48%) and 52% (95% CI 43%-60%) of patients achieved complete and objective responses, respectively. Seventy-eight percent of patients with a complete response continued to be in remission at 12 months. Grade 3 or higher cytokine release syndrome was rare and occurred in less than 5% of patients.

Bispecific antibodies have many advantages, including off-the-shelf access and favorable toxicity profiles. Longer follow-up, however, will be required to determine the durability of response beyond 1 year. As bispecific antibodies become available, many questions will emerge, including how best to sequence with CAR T-cell therapy and whether to combine them with other regimens. Additional studies of bispecific antibodies in combination with chemoimmunotherapy and other treatment approaches are underway.

Additional References

1.         Neelapu SS, Locke FL, Bartlett NL, et al. Axicabtagene ciloleucel CAR T-cell therapy in refractory large B-cell lymphoma. N Engl J Med. 2017;377:2531-2544. Doi:10.1056/NEJMoa1707447

2.         Schuster SJ, Bishop MR, Tam CS, et al. Tisagenlecleucel in adult relapsed or refractory diffuse large B-cell lymphoma. N Engl J Med. 2019;380:45-56. Doi:10.1056/NEJMoa1804980

3.         Abramson JS, Palomba ML, Gordon LI, et al. Lisocabtagene maraleucel for patients with relapsed or refractory large B-cell lymphomas (TRANSCEND NHL 001): A multicentre seamless design study. Lancet. 2020;396:839-852. Doi:10.1016/S0140-6736(20)31366-0

4.         Locke FL, Miklos DB, Jacobson CA, et al. Axicabtagene ciloleucel as second-line therapy for large B-cell lymphoma. N Engl J Med. 2022;386:640-654. Doi:10.1056/NEJMoa2116133

5.         Kamdar M, Solomon SR, Arnason J, et al. Lisocabtagene maraleucel versus standard of care with salvage chemotherapy followed by autologous stem cell transplantation as second-line treatment in patients with relapsed or refractory large B-cell lymphoma (TRANSFORM): Results from an interim analysis of an open-label, randomised, phase 3 trial. Lancet. 2022;399:2294-2308. Doi:10.1016/S0140-6736(22)00662-6