Age, Recent Treatment, Appear to Influence Severity of COVID-19 in Patients With CLL
Age, Recent Treatment Appear to Influence Severity of COVID-19 in Patients With CLL
Long-Term Results of Ibrutinib/Umbralisib Show Efficacy in CLL and MCL
Long-Term Results of Ibrutinib/Umbralisib Show Efficacy in CLL and MCL
This article was originally published by Targeted Oncology
Matthew S. Davids, MD, associate director of the Center for Chronic Lymphocytic Leukemia, director, Clinical Research for the Lymphoma Program at the Dana-Farber Cancer Institute, and associate professor of Medicine at Harvard Medical School, discusses the long-term follow-up of a phase 1/1b trial (NCT02268851) for patients with relapsed/refractory chronic lymphocytic leukemia (CLL) or mantle cell lymphoma (MCL) receiving ibrutinib (Imbruvica) and umbralisib.
The initial results were presented early in 2019 with about 2 years of follow-up, showing high rates of response in patients with CLL and MCL, according to Davids. There was good tolerability observed for these patients, and the investigators were able to identify the recommended phase 2 dose for umbralisib of 800 mg combined with the standard dose of ibrutinib.
The challenge with the initial report was that the follow-up for these patients was short, Davids says. The goal of the update at the 2020 European Hematology Association Congress was to present about 4 years of follow-up of the progression-free survival (PFS) and overall survival (OS) of the high-risk patients. The investigators also looked at the rates of complete remission, which increased over time.
For patients with MCL, the median PFS was around 11 months, and the median OS was about 2 and a half years. Davids thinks that this didn’t look much different than ibrutinib monotherapy, and it is hard to tell if there is a difference between monotherapy and this combination.
Davids says the investigators saw the bigger difference in the patients with CLL compared to historical control studies. There was about an 80% 4-year PFS in the high-risk CLL population and a 4-year OS of 90%. There are still many patients on the ibrutinib and umbralisib combination. The data set highlights the efficacy and safety of dual B-cell receptor blockade and warrants further study, he believes.
CLL Advocates NZ Newsletter Issue 1
CLL Advocates NZ Newsletter Issue 1
Welcome to our first CLL Advocates newsletter. Like many organisations, we weren’t able to accomplish very much over the lockdown period. We did, however, manage a Trustees’ teleconference to shape up our strategy for the next 12 months. One of the proposals made at that meeting was a monthly newsletter, so here is the first edition.
A huge number of lay and medical articles have been written about the COVID pandemic, and, as you may have seen on our website, we’ve published a number relevant to people living with CLL. See them here. One of particular interest was a consensus statement by Australasian haematologists on management of blood cancers in the COVID pandemic (published in May’s Internal Medicine Journal). It noted that, with a mean age of diagnosis of about 70 years, CLL patients are already likely to be in a high-risk group simply because of age. Advice specifically directed to CLL patients was:
- to delay planned therapy where possible
- to consider using oral agents over IV medications so as to avoid exposure to higher risk environments such as hospital chemotherapy units, for treatment of both initial therapy, and for relapsed/refractory disease (see our recent letter to Pharmac on this matter).
New Zealand has done extraordinarily well at this stage to contain the virus, though it should be noted that vaccination, if successfully developed, may present further challenges for CLL patients.
The CLLANZ Trustees’ meeting agreed that information/education initiatives on CLL should be high on our priority list. In this regard, a review of the current management of CLL by Dr Gillian Corbett, haematologist and trustee, has been published on our website. A detailed CLL patient information booklet is also now close to sign-off and will be published shortly.
In October this year we will be staging a half day or evening combined meeting/seminar on CLL in NZ with the Leukaemia & Blood Cancer (LBC) group, with leading NZ CLL specialists. This will be ‘in person’ in Auckland and also online on Zoom so that people from around the country can join in the discussion and if desired put questions to the speakers. Details will follow soon.
To ensure we reach as many people as possible who have an interest in CLL, we encourage you to become a ‘friend’ of CLL Advocates NZ – by signing up to our newsletter here and/or joining our private Facebook group. You can apply to join the group here.
More details of anticipated activities will follow in subsequent newsletters.
Meanwhile, now that we have passed the winter solstice, and are becoming adjusted to the new ‘normal’, stay well, physically, mentally and spiritually. And please remember that as well as our advocacy role, we want to be a source of knowledge and support for New Zealanders living with CLL, and their families and supporters. To help us achieve this we would welcome and appreciate your feedback, and your thoughts on how we can best achieve our mission.
With best wishes
Neil Graham FRACP, FRCP
Executive Director
CLL Advocates NZ
Three-Drug Combo Promising Against High-Risk CLL
Three-Drug Combo Promising Against High-Risk CLL
For patients with high-risk chronic lymphocytic leukemia (CLL), first-line therapy with a triple combination of targeted agents showed encouraging response rates in the phase 2 CLL2-GIVe trial.
Among 41 patients with untreated CLL bearing deleterious TP53 mutations and/or the 17p chromosomal deletion who received the GIVe regimen consisting of obinutuzumab (Gazyva), ibrutinib (Imbruvica), and venetoclax (Venclexta), the complete response rate at final restaging was 58. 5%, and 33 patients with a confirmed response were negative for minimal residual disease after a median follow-up of 18
Chemotherapy-Free Regimen Consisting of 3 Novel Agents for Previously Untreated, Poor Prognosis CLL
Chemotherapy-Free Regimen Consisting of 3 Novel Agents for Previously Untreated, Poor Prognosis CLL
Nearly 60% of evaluable patients with previously untreated, chronic lymphocytic leukemia (CLL) characterized by chromosomal deletion of 17p (del[17p]) and/or a deleterious TP53 mutation treated with obinutuzumab, ibrutinib, and venetoclax triplet therapy achieved either complete remission (CR) or a CR with incomplete recovery of the bone marrow, according to results of a single-arm, phase 2 study presented during the Virtual Edition of the 25th European Hematology Association (EHA) Annual Congress.
While less than 10% of patients diagnosed with CLL have disease characterized by del(17p), this biomarker is present in up to half of patients with refractory disease.2 Hence, there is an unmet need for efficacious and safe treatment regimens for this subgroup of patients. Furthermore, compounding this need is the finding that TP53 mutations, another biomarker of poor prognosis, have been reported to be present in approximately 90% of patients with disease characterized by del(17p) although only about 40% of those with TP53-mutant CLL also have del(17p).An unmutated IGHV gene is another risk factor for poor prognosis in the setting of CLL.2
Dr. Flinn on the Role of BTK Inhibitors in CLL
Dr. Flinn on the Role of BTK Inhibitors in CLL
This story was originally published on OneLive
Ian W. Flinn, MD, PhD, discusses the role of BTK inhibitors in chronic lymphocytic leukemia.
Ian W. Flinn, MD, PhD, director of the Blood Cancer Research Program, Sarah Cannon Research Institute, discusses the role of BTK inhibitors in chronic lymphocytic leukemia (CLL).
BTK inhibitors such as ibrutinib (Imbruvica), acalabrutinib (Calquence), and zanubrutinib (Brukinsa) have been transformative in the treatment of patients with B-cell malignancies such as CLL, mantle cell lymphoma, marginal zone lymphoma, and Waldenström’s macroglobulinemia, says Flinn.
In CLL specifically, BTK inhibitors have become a prominent frontline standard of care, adds Flinn.
Though, it is important to acknowledge that the toxicities that are associated with ibrutinib, including arthralgias, atrial fibrillation, and, though rare, significant bleeding, often lead to treatment discontinuation in patients with CLL.
'CLL flares’ reported after stopping ibrutinib
'CLL flares’ reported after stopping ibrutinib
Patients with ibrutinib-resistant CLL should remain on the BTK inhibitor until immediately before starting their next therapy, Australian haematologists have advised. In a Commentary article in Leukemia & Lymphoma, Dr Chloe Tang and Associate Professor Constantine Tam wrote that ‘CLL flares’ – accelerated CLL progression after ceasing ibrutinib – can be difficult to distinguish from …
Durable disease control achieved with BTKi salvage therapy in patients with CLL
Durable disease control achieved with BTKi salvage therapy in patients with CLL
Patients with chronic lymphocytic leukaemia (CLL) who progress on venetoclax can achieve durable disease control with Bruton tyrosine kinase inhibitor (BTKi) salvage therapy, new Australian research reveals. The study included 23 patients with refractory/relapsed CLL who received a BTKi (ibrutinib [n=21], zanubrutinib [n=2]) after ceasing the BCL2 inhibitor venetoclax due to progressive disease. After initiating …
To continue reading click here.
A current overview of medications in the treatment of CLL in New Zealand
A current overview of medications in the treatment of CLL in New Zealand
A talk presented to the CLL Advocates NZ Board of Trustees on 7 May 2020 by Dr Gillian Corbett MBChB, FRACPath, MRCP, FRACP, Trustee, CLL Advocates NZ https://clladvocates.nz/about-us/trustees/
Not all CLL patients need treatment. Treatment is offered for progressive disease, increasing lymphadenopathy, anaemia, and/or low platelets, as well as rapidly increasing lymphocyte count.
Patients with mutated heavy genes (about 55%) generally carry a better prognosis than those with unmutated heavy genes. This testing is unfortunately unavailable in NZ.
First line treatment
In New Zealand, FCR (fludarabine, cyclophosphamide, rituximab) is standard treatment for younger patients with CLL, up to around 70-75 years. Fludarabine and cyclophosphamide are generally given orally, once per month for up to 6 courses, and rituximab is given as an intravenous infusion once a month. This treatment is very successful for patients with mutated heavy chain genes, and some may potentially be cured. However those with unmutated heavy chain genes do not respond so well and frequently relapse early. A study has shown that such patients respond well to ibrutinib with a better outcome than FCR. However ibrutinib is not funded to treat CLL in New Zealand.
For older patients (70-85 years) the funded first line treatment is bendamustine and rituximab. Each is given by infusion once per month for up to 6 months. This treatment has been shown to be not so effective for younger patients, for whom FCR is preferred, but is better tolerated by older patients
For older patients or those unfit for bendamustine and rituximab, chlorambucil and obinutuzumab is the funded treatment. Obinutuzumab is a more potent antibody than rituximab and has been shown to be more effective in combination with chlorambucil in these patients.
Venetoclax is funded as first line treatment for patients with del17p chromosomal change. These patients do not generally respond well to the other funded treatments. It targets BCL2 which results in an increased rate of CLL cell death. It is given orally and is generally well tolerated but in some patients with bulky disease it may cause tumour cell lysis which can result in kidney damage. Such patients may require hospitalisation for intravenous fluid and supportive care.
Second line treatment
Patients who relapse within 3 years of previous treatment are eligible for venetoclax and rituximab. The venetoclax is to be used for up to 24 months. It is given orally.
Research
There are studies overseas of combining ibrutinib and venetoclax treatment with a view to achieving negative minimal residual disease and possibly cure of CLL. The results of these studies are awaited.
Ibrutinib is a Bruton’s tyrosine kinase (BTK) inhibitor which interferes with CLL cell growth. It is effective in the majority of de novo and relapsed patients with CLL. It is not known to cure CLL. It is generally well tolerated. Other BTK inhibitors that are more targeted are being trialled eg acalabrutinib and zanubrutinib. Tauranga and Waikato Hospitals are part of an international clinical trial comparing ibrutinib to zanubrutinib in relapsed CLL.
Other areas of research are in the development of immune therapies eg CAR-T cells to target CLL cells.
Study Findings Support Long-Term Efficacy and Safety of Acalabrutinib in R/R CLL
Study Findings Support Long-Term Efficacy and Safety of Acalabrutinib in R/R CLL
Long-term follow-up of a phase 1/2 study demonstrated durable efficacy and safety of acalabrutinib monotherapy in patients with relapsed/refractory chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL), according to results published in Blood.1
Acalabrutinib, an oral selective Bruton tyrosine kinase (BTK) inhibitor, was approved in November 2019 by the US Food and Drug Administration (FDA) at a dose of 100 mg twice daily for the treatment of adult patients with CLL/SLL.2
This analysis included updated results from the initial phase 1/2 study of acalabrutinib in an expanded cohort of 134 adult patients with relapsed/refractory CLL/SLL with a median age of 66 years (ClinicalTrial.gov Identifier: NCT02029443) followed for a median of 41 months. While patients initially received acalabrutinib at a dose of either 200 mg once daily or 100 mg twice daily, only the latter dose of acalabrutinib was administered following a study amendment in May 2015 based on results of pharmacodynamics studies.
At data cutoff, more than half of study patients were still receiving acalabrutinib, with 21% of patients discontinuing acalabrutinib therapy due to progressive disease.
Overall response rate (ORR), including patients achieving a complete response, a partial response. or a partial response with lymphocytosis (PRL) was 94%, with PRL as best response in 6% of patients. Of note, ORR was 90% or higher in the subgroups of patients with disease characterized by del(17)(p13.1), del(11)(q22.3), unmutated immunoglobulin heavy variable (IGHV) genes, and complex karyotype characterized by 3 or more abnormalities. In addition, median duration of response (DOR) was not reached, with 45-month DOR estimated at 63% for those with PRL or better.
Median progression-free survival (PFS) for the overall study population was not reached at the time of the analysis, with 45-month PFS estimated at 62%. In the subgroups of patients with disease characterized by del(17)(p13.1), unmutated/mutated IGHV, complex karyotype, and del(11)(q22.3), median PFS was 36 months, not reached, 33 months, and not reached, respectively.
Regarding safety, grade 3 or higher adverse events occurred in 66% of patients, including neutropenia, pneumonia, hypertension, anemia, and diarrhea in 14%, 11%, 7%, 7%, and 5% of patients, respectively.
Eleven percent of patients discontinued acalabrutinib as a result of one or more adverse events. Adverse event-related death was reported in 7.5% of patients, with half of these attributed to pneumonia.
Atrial fibrillation of any grade occurred in 7% patients, with approximately 3% experiencing atrial fibrillation of at least grade 3. Major bleeding classified as grade 3 or higher, serious, or involving the CNS, was reported in 5% percent of patients.
“Notably, acalabrutinib with follow-up beyond 4 years has shown a decreased frequency of [adverse events] over time and no long-term safety issues to date,” the study authors noted.
In their concluding remarks, they further commented that “this updated and expanded study confirms the efficacy, durability of response, and long-term safety of acalabrutinib, justifying its further investigation in previously untreated and treated patients with CLL/SLL.”
References
- Byrd JC, Wierda WG, Schuh A, et al. Acalabrutinib monotherapy in patients with relapsed/refractory chronic lymphocytic leukemia: updated phase 2 results. Blood. 2020;135:1204-1213.
- Acalabrutinib (Calquence®) [package insert]. 2019. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2019.
Originally published on Cancer Therapy Advisor