What happens to intolerant, relapsed or refractory chronic myeloid leukemia patients without access to clinical trials?

ABSTRACT Objective: To assess clinical outcomes of intolerant, relapsed or refractory patients who could not be treated with new tyrosine kinase inhibitors or experimental therapies. Methods: A retrospective cohort of 90 chronic myeloid leukemia patients in all phases of the disease treated with imatinib mesylate as their first TKI therapy, and with dasatinib or nilotinib as the next line of therapy. We evaluated clinical outcomes of these patients, with special focus on the group that needed more than two therapy lines. Results: Thirty-nine percent of patients were refractory or intolerant to imatinib. An 8-year overall survival rate of the patients who went through three or more lines of treatment was significantly lower, compared to those who were able to maintain imatinib as their first-line therapy (83% and 22%, respectively p < 0.01). Decreased overall survival was associated with advanced-phase disease (p < 0.01), failure to achieve major molecular response in first-line treatment (p < 0.01) and interruption of first-line treatment due to any reason (p = 0.023). Failure in achieving complete cytogenetic response and major molecular response and treatment interruption were associated with the progression to the third-line treatment. Conclusion: The critical outcome observed in relapsed, intolerant or refractory chronic phase CML patients reflects the unmet need for this group of patients without an alternative therapy, such as new drugs or experimental therapies in clinical trials. Broader access to newer treatment possibilities is a crucial asset to improve survival among CML patients, especially those refractory or intolerant to first-line therapies.

Prognostic impact of MYD88 mutation, proliferative index and cell origin in diffuse large B cell lymphoma

Abstract Background Diffuse large B-cell lymphoma, among non-Hodgkin lymphomas, is one of the most frequent subtypes. Clinical laboratory data and post-treatment outcomes are scarce in the Brazilian population. Objective The main objective of this retrospective study was to assess the impact of tumor markers, including the Myeloid differentiation primary response 88 (MYD88) mutation. Method Eighty-three patients were included and treated with R-CHOP or R-CHOP-like regimens. Results Median age was 64-years old and 58% were female patients. The median follow-up was 42 months. The progression free survival (PFS) at this time was 63% and overall survival (OS), 66%. In the patients with tumors expressing Myc proto-oncogene protein (MYC) and B-cell lymphoma 2 (BCL2), assessed by immunohistochemistry (IHC), known as dual protein expressers, median post-progression survival was 31 (15-45) months. An increased proliferative index were associated with a high rate of progression (hazard ratio 2.31 [95% confidence interval [1.05-5.12]; p = 0.04). The cell of origin (COO), identified by IHC, was not able to predict PFS (p = 0.76). The MYD88 L265P mutation was present in 10.8% (9/83) of patients and did not show a prognostic correlation. Conclusion In conclusion, the MYD88 mutation, although an important tool for diagnosis and a possible target drug, presented at a low frequency and was not a prognostic marker in this population.

Obinutuzumabe no tratamento de pacientes com leucemia linfoide crônica, não elegíveis à dose completa de fludarabina: análise de impacto orçamentário baseado no tempo para a próxima terapia / Obinutuzumab for the treatment of unfit patients with chronic lymphocytic leukemia: budget impact analysis based on time to next treatment

Objetivo: Comparar o impacto orçamentário de obinutuzumabe + clorambucila (GClb), rituximabe + clorambucila (RClb), ofatumumabe + clorambucila (OClb) ou clorambucila (Clb) na primeira linha de tratamento (1L) e suas respectivas opções de segunda linha (2L) recomendadas por consenso brasileiro e internacional para adultos com leucemia linfoide crônica (LLC) não tratados previamente e inelegíveis à dose completa de fludarabina (slow-go). Métodos: A análise foi conduzida a partir do desfecho de tempo para próxima terapia (TPPT) na perspectiva do Sistema de Saúde Suplementar (SSS). Apenas custos de aquisição de medicamentos foram considerados, incluindo posologia de bulas registradas. Regimes de tratamento de 2L considerados foram RClb ou ibrutinibe. As curvas de TPPT foram obtidas do estudo CLL11 e COMPLEMENT 1. Resultados: Em horizonte temporal de cinco anos, GClb demonstrou benefício econômico, quando comparado com RClb, OClb e Clb, sendo o potencial de savings por paciente de R$ 80 mil, R$ 149 mil e R$ 284 mil, respectivamente. Adicionalmente, em cinco anos, verificou-se que a adoção de GClb na 1L para pacientes com LLC pode promover economia de R$32 milhões para SSS quando comparado com RClb e Clb, uma vez que seu intervalo livre de tratamento é mais longo do que o das tecnologias comparadas, o que posterga o início do tratamento de 2L. Conclusões: Apesar de o preço unitário de obinutuzumabe e o custo de tratamento inicial de GClb serem superiores aos de RClb, OClb e Clb, o tratamento de 1L com GClb pode promover benefícios econômicos em longo prazo, consequentes dos resultados clínicos favoráveis da associação de GClb no tratamento da LLC.

Objective: To compare the budget impact of obinutuzumab + chlorambucil (GClb), rituximab + chlorambucil (RClb), ofatumumabe + chlorambucil (OClb) or chlorambucil (Clb) in first line treatment (1L) and their respective therapeutic options in second line (2L), recommended by a Brazilian and international consensus for adults with chronic lymphocytic leukemia (CLL), with no previous treatment and classified as ineligible to full dose fludarabine treatment (slow-go). Methods: The analysis was conducted based on the outcome time to next treatment (TPPT) under the perspective of the Brazilian Private Healthcare System (SSS). Only drug acquisition costs were considered, including dosage from registered labels. RClb and ibrutinib were considered as 2L treatment regimens. The TPPT curves were obtained from the CLL11 and COMPLEMENT 1 studies. Results: Considering a five-year time horizon, GClb demonstrated economic benefit when compared to RClb, OClb and Clb, with potential savings per patient of R$ 80 thousand, R$ 149 thousand and R$ 284 thousand, respectively. Additionally, in five years, the adoption of GClb as 1L for patients with CLL can promote an economy of R$ 32 million to the SSS when compared to RClb and Clb, since the GClb treatment free interval is longer than the compared technologies, which delays the beginning of the more costly 2L treatment. Conclusions: Although the unitary obinutuzumab price and the cost of initial GClb treatment are greater than RClb, OClb and Clb, 1L treatment with GClb can promote economic benefits in the long term, resulting from the favorable clinical results of GClb association in CLL treatment.