MDACC has, for the first time, given their experience of TKI
, T9 m% U/ k, y9 u* n& Udiscontinuation. The doctors at MDACC look at 26 patients who+ O: p9 V" `7 h$ U3 ~
discontinued therapy from 2003-2012 for various reasons. These reasons
1 q A! p$ S' {) t) linclude long time in CMR, adverse side-effects, pregnancy and financial
3 z9 H% z% |7 e. ^# Sconstraints. Please note that 17 patients discontinued therapy in CMR7 O$ C' O! P5 Z) f
and the rest in MMR. Of the patients in CMR who discontinued therapy,
; K# a/ u0 `1 l- H4 E; X47% had molecular relapse. Those in CMR who discontinued and had taken6 U) Q( a0 R' v2 x! P
prior Interferon to a TKI, 50% relapsed. Also note that of these 26
* `9 Z6 J' _ Opatients, most had been treated with high dose Gleevec.* ~2 U- o, V. e8 Z
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"All patients discontinued therapy in CML-CP, all in CCyR, of them, 17
' P. q' ?( \" K: F' p& y: X, _ K( P(65%) had undetectable transcripts, 2 (8%) had MR4.5, and 7 (27%) MMR.
5 y! B7 E4 r! s0 bThe median duration of CMR before TKI cessation was 62 mos, (0- 118).+ k& N) O: o' C; C) m) f% _% I" ^
The median duration of total TKI therapy was 101 mos (3- 135).". A$ v b9 W& T5 G$ H' Y4 D
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Therefore, the median time in CMR before discontinuation was about 5
. T1 W' Q$ J. dyears. The median follow-up is only 11 months. The median time for
$ [3 I: _' q# B# Xmolecular relapse of 8 patients who had been in CMR was 4 months and$ w( ]- d- Y/ _3 A
they relapsed with median PCR value of 0.01 on the International Scale./ O l5 U/ x8 M' S+ W
8 i& m: O$ X) l( e. ^# }* ?0 z! e# h
Of the 7 patients who discontinued when in MMR, 4 remained in MMR at a
+ o u1 p6 O( o: b; Ymedian follow-up of 21 months, 1 remained in CCR, 1 in active disease
1 ^' ^# f0 s+ h1 jand 1 transformed to accelerated phase off drugs. Therefore, from this
8 v* C" r# r- ]# u. `8 idata, scarce as it is, there is a risk of transformation to advanced$ K7 i0 y1 |* f ] Q1 X; L% V
disease if one discontinues drugs in MMR.
3 G- ^, D7 h8 R* S/ D; l: y
% Y' h7 K* h& G2 ?. g. I6 E2 patients were PCRU (4.5 log machine) and these patients relapsed
/ I/ I* t( Y, H" I0 k, b0 sinto MMR when drugs were discontinued.0 A3 u# Y8 x+ Z1 n: ~/ A( Q
& d* p( p. A4 }) H' G
Seven pts with relapse were treated again with TKI, 3 with nilotinib,
6 I+ p! j' @+ r% x2 with dasatinib, and one each with imatinib and bosutinib (the latter. n, {4 j3 q; Q" Y( T
in AP). After a median of 13 months on therapy (range 4-52) all patients O4 X* N. D" m( v& J
improved their response, 5 with CMR and 2 MMR (including the pt that had0 \7 y9 o1 f$ _3 j+ p* Q' T) n7 a# y
transformed to AP). They do not say why all patients were not retreated
]3 w& M+ S0 V+ A: k$ xwith imatinib and had to take Nilotinib and Dasatinib. Also, note that& s- [# I5 j9 y" l
one did not regain CMR at the 13th month mark though it is good news
: p6 i6 q$ T5 K6 s6 [9 f( zthat 5 did. It may take some time to regain CMR for some who have gone
7 P# O, Q$ H* K" z8 K8 z$ b9 moff drugs and relapsed. However, from our own list experiences, some1 Y) O3 P+ h" T
had regained CMR fast when they retook the TKI.7 M# T/ D: } R- g
) v- e9 b4 c# O5 w8 i" k
The doctors conclude that treatment discontinuation is experimental
- I) A& y7 i: m1 Oand cannot be recommended at this stage as a standard procedure.
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Best Wishes,$ U" u6 a: P( O k# ~
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Anjana. Q3 M0 R, p/ h1 h$ m7 j
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6 \) {1 t" M3 h5 [& K# O
3783 Patient (Pt)-Driven Discontinuation of Tyrosine Kinase Inhibitor7 }4 I# L4 m0 Y- I# _% A) e5 V
Theray in Chronic Phase Chronic Myeloid Leukemia (CML) - Single5 O. K& k# B% U$ e9 t( c% S
Institution Experience8 H" Q# ?! k# T, }6 f/ X# |' ]
Program: Oral and Poster Abstracts9 Q) L) e4 u0 }4 j, d
Session: 632. Chronic Myeloid Leukemia - Therapy: Poster III
. f5 _; ?/ m& N! x( e ^8 C; X% p; t7 i3 g9 N; j! y7 c9 M
Monday, December 10, 2012, 6:00 PM-8:00 PM
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Hall B1-B2, Level 1, Building B (Georgia World Congress Center)
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Ohad Benjamini, MD1*, Hagop M. Kantarjian, MD1*, Mary Beth Rios, RN1,$ w" |) I; s. \0 }
Elias Jabbour, MD2*, Susan O'Brien, M.D.1, Preetesh Jain, MD, DM, PhD1*,3 y2 l7 ~3 _" r6 W8 `9 x
Stefan Faderl, MD1, Guillermo Garcia-Manero, MD1*, Farhad Ravandi, MD1,
$ H( i9 i7 I, I* n8 C! J4 x) n- MGautam Borthakur, M.D.1, Alfonso Quint醩-Cardama, MD1* and Jorge E.
- D$ M$ R# [. k4 w- ZCortes, MD1 _3 d, L8 E E2 ~! M
" N( S, X" k) K) d+ F) ?$ ?
1Department of Leukemia, The University of Texas MD Anderson Cancer
D6 b4 ~3 [# q9 l+ F p" xCenter, Houston, TX5 ]: A9 N6 g+ Y: Y* N
2Department of Leukemia, The University of Texas M.D. Anderson Cancer5 f N. o; w: m3 Y" I
Center, Houston, TX
% X |' R. g2 }0 E {
# `0 v9 O' a+ z. P) oIntroduction: Some recent studies have reported on the outcome of CML
! p- C n' ` S( B( mpts who discontinued thyrosin kinase inhibitors (TKI) after achieving) G1 n* z5 u" {0 a. j& h* J6 z
sustained undetectable bcr-abl transcript level. Most patients who stop6 o5 h. S. K8 c1 L' `- a. X
TKI have experienced molecular relapse. Most patients respond after
2 }8 R2 y, `4 H( a( o; f6 T! W/ Mresuming TKIs regaining undetectable bcr-abl transcript levels. These
$ z8 V8 T x5 E9 pseries have prospectively planned treatment discontinuation and included9 e' L' @+ m7 `7 l5 S4 D- I, X
only pts that have sustained complete molecular response (CMR) for at# U2 h/ r( d/ H, p1 ~
least 2 yrs. However, in many instances pts may want to discontinue TKIs
: ]. j8 A0 o) J" Pnot in CMR. Various reasons may lead patients to discontinue TKI
. T' q; q2 U$ ]( c( E) Jtreatment unexpectedly, among them severe adverse effects, pregnancy or; ^& w2 K0 s# i* ~4 y* F
economic constraints. This single institution experience reflects the
4 I5 f8 g6 N6 @; m& dheterogeneous nature of pt-driven TKI discontinuation.+ O" k; O/ T+ R* }
+ r: x. S; U( h: P" O) l
Aim: To characterize the outcome and profile of CML pts who chose to1 H* S9 X% f# z
discontinue TKI therapy in a single center regardless of their initial) i$ i7 Q# W7 h3 H- M+ ^7 b& z) `
response to TKI therapy.
5 x- r6 q- ]" B" Q6 P! |; D8 J- V: \8 @* y7 S2 d) ~. r9 g; G5 p
Methods:We retrospectively analyzed MDACC data on all patients with CML
! s3 K! Q2 K8 e0 {3 Cthat were treated with TKIs in our institution and discontinued therapy.7 `+ x6 u1 I4 ], n9 v% k
! z: J( c6 U" H/ o7 tResults: A total of 26 patients with CML-CP managed at MDACC
- E! h9 a) ?! g3 Y' G) jdiscontinued TKI between 2003 and 2012. The total median follow up time
0 E. v/ ^' \! ^5 [3 m7 @4 u- U: ~2 rsince diagnosis was more than 120 months (mos) (range, 45 mos to 304
- C: J8 E( U: O6 q2 w- b6 `6 vmos). The median age at diagnosis was 48 yrs (range, 28-73); 15 pts were- W2 C8 r$ k/ _) I
female. All pts had been diagnosed and treated in chronic phase.1 k1 Q% l# e. P$ z& [& }
Interferon was initial therapy in 11 pts (42%) and 15 pts received TKI
* Z3 v6 p s7 X2 _4 h) j) |$ Was initial therapy (4 received imatinib 400mg/day, 10 imatinib6 F% R- L4 d3 P0 U" |
600-800mg/day, and 1 bosutinib.) Of the 11 pts initially treated with
! d5 j4 }+ a' B3 UIFN, 7 then received imatinib 400mg and 4 imatinib 800mg upon IFN- M, [" p" }+ ~5 l
failure. Pts treated frontline with TKI started therapy within a median* d P l) O0 q& k+ y+ q( P
of 0.8 mos from diagnosis (range 0 to 4) and those with previous+ w% @. V( B" c# @, R
interferon (n=11) after a median of 60 mos from diagnosis (31 to 1640 Z- J+ {3 B3 a
mos). Before TKI discontinuation 21pts (81%) were receiving their first1 N$ ~. r4 g; Z& A7 j( n9 ]
TKI and 5 (19%) were receiving 2nd (4) or 3rd line (1) TKI. Complete
! k! k- {# {9 Vcytogenetic response (CCyR) had been achieved in all 26 pts at a median9 J& Q3 y7 l+ U' t
of 3.5 mos (3-93); Major molecular response (MMR) in all at a median of/ w& \0 T6 }) |/ Y8 ~' b
9 mos (3-73) and CMR in 17 (65%) at a median of 22 mos (9-120). All
) {- [; m) E1 O8 F4 A9 z" kpatients discontinued therapy in CML-CP, all in CCyR, of them, 17 (65%)) v, P0 G# v: \" \ Z* ?( A
had undetectable transcripts, 2 (8%) had MR4.5, and 7 (27%) MMR. The
5 _8 V0 `' C6 R$ G% K$ |9 u9 k4 Amedian duration of CMR before TKI cessation was 62 mos, (0- 118). The, R) {- i, Y! w) L
median duration of total TKI therapy was 101 mos (3- 135).
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Fourteen pts (54%) discontinued TKI due to adverse events, 2 pts
0 {* L& i& {" N/ `+ U4 Jdiscontinued to become pregnant, 5 decided to stop after long CMR, and 5
u( X* U" f% D, ^2 I) J! K! Z/ |pts discontinued for financial reasons. After TKI discontinuation
* ^5 I2 d) |& p$ Tpatients were followed for a median of 11 mos (5-131). Among pts with
# u7 \" m4 r4 f3 CCMR at discontinuation, molecular relapse occurred in 8 (47%) pts at a2 {5 U& C7 i3 [# ~. r
median of 4 mos (1-11) from discontinuation with median transcript level8 B1 D! `3 V. Q% _& M M
at relapse of 0.07 (IS) (range, 0.004-2.17). Six pts with initial INF
6 m; c+ L2 B2 k# r. p$ |therapy had CMR at time of TKI discontinuation, 50% of them relapsed.
% x7 H) f& u. t0 g8 SAmong 7 pts who discontinued therapy in MMR, after a median follow-up
! A' D l4 t+ J. n, J" F9 h+ M: gfrom discontinuation of 21.6 months (range, 4.6-106), 4 remained at MMR,
' B2 G. h) I5 y6 tone has minor CyR and one CCyR without retreatment at last follow up
+ B% M( N5 H( j$ P" I2 w4 Kafter 78 and 105 months from TKI discontinuation, and one transformed to4 T) _0 F) [. N5 e3 P& _
accelerated phase (AP). The 2 pts with MR4.5at discontinuation relapsed' [1 R/ l& S$ h( }0 \2 J
to MMR. Three pts had a transient molecular recurrence with spontaneous
J4 Z8 e" |4 Xre-gain of CMR. Seven pts with relapse were treated again with TKI, 3
* R3 ~, Z& `0 p3 x; f7 B5 d }with nilotinib, 2 with dasatinib, and one each with imatinib and
: K: W. H" r! x: D$ H2 L; l6 ybosutinib (the later in AP). After a median of 13 months on therapy
2 ^" d) e' D8 A, @- y) y0 D(range 4-52) all patients improved their response, 5 with CMR and 2 MMR
, ~5 F# |9 c6 M- q* s(including the pt that had transformed to AP). There were no deaths or1 Y( x$ v5 y$ A; {
transformations to blastic phase of CML. At last follow up 14 (54%) pts4 w+ r9 |/ }2 h
were in CMR, 5 (19%) in MMR,5 (19%) in CCyR and 1 each in minor CyR and- c+ X. _6 ^. m+ b( w
PCyR.
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. h9 t2 A0 L" I1 L/ tConclusion: Pt-driven TKI discontinuation in CML-CP leads to molecular( V- p# m; M# P4 N' a
relapse in nearly half of the pts who discontinue therapy in CMR. Some, N. C) A; v) f
pts who discontinue in MMR may have sustained MMR. Treatment
2 }, |# O4 _! e. V4 sdiscontinuation should be considered experimental and cannot be
) h1 m2 N6 s5 w. f; d: grecommended to pts as a standard approach.! \/ y& n' K& D) }
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Disclosures: Ravandi: BMS: Honoraria, Research Funding. |