5 Key Takeaways From ASH 2017

Surabhi Dangi-Garimella, PhD

One of the largest meetings for blood-based diseases was held in Atlanta, Georgia, December 9-12. Discussions at the 59th Annual Meeting and Exposition of the American Society of Hematology included progress reports on genetically modified immunotherapy treatments, a new treatment paradigm for advanced Hodgkin lymphoma, possibility of treatment-free remission in chronic myelogenous leukemia, and challenges with hospice utilization for patients with leukemia.

1. Outpatient administration and off-the shelf products possible for CAR T
A much-anticipated session on the second day of the meeting provided long-term updates on trials evaluating 2 chimeric antigen receptor-T (CAR T) treatments: tisagenlecleucel or CTL019 (Kymriah) for the treatment of adult relapsed/refractory diffuse large B-cell lymphoma (DLBCL) and axicabtagene ciloleucel (Yescarta) evaluated in patients with refractory aggressive non-Hodgkin lymphoma. The best overall response rate (ORR) with tisagenlecleucel, in 81 evaluable patients who participated in the JULIET trial, was 53%, with 40% complete response (CR) and 14% partial response. ORR held true across the various subgroups that were analyzed. A 15.4-month follow-up in the ZUMA-1 trial yielded an ORR of 82% and a CR rate of 54% after a single infusion of axicabtagene ciloleucel.

Stephen Schuster, MD, of the Perelman School of Medicine, told The American Journal of Managed Care® (AJMC®) in an interview that the remission in their long-term follow-up studies lasted several years and that none of the respondents had relapsed at 29 months.

2. ECHELON-1 results may shift the treatment paradigm in Hodgkin lymphoma
Phase 3 results from the ECHELON-1 study showed superior modified progression-free survival after adding the modified anti-CD30 antibody, brentuximab, to doxorubicin, vinblastine, and dacarbazine (A+AVD) in patients with advanced Hodgkin lymphoma (HL). This presents a significant change in the standard frontline regimen of doxorubicin, bleomycin, vinblastine, and dacarbazine, which has not been modified for over 40 years since it was first described, according to presenting author Joseph M. Connors, MD, medical oncologist from the BC Cancer Agency, University of British Columbia. “This establishes A+AVD as a new frontline option for patients with advanced-stage HL,” Connors concluded.

3. Transfusions may pose a barrier to hospice utilization in leukemia
Researchers from Brown University, Rhode Island Hospital, and Duke Cancer Institute used claims information from the linked Surveillance, Epidemiology, and End Results-Medicare database to identify Medicare beneficiaries 65 years and older with acute and chronic leukemias to query whether transfusion dependence (TD) is a barrier to hospice utilization among older patients with leukemia who are enrolled in Medicare. The authors found that TD was associated with a slightly higher likelihood of hospice enrollment, a 52% shorter time on hospice, and less frequent outpatient hospice referral in chronic leukemia but not in acute leukemia.

“We found that those who are dependent on transfusions before hospice referral only used hospice for about 6 days. Those who do hospice care will tell you that using hospice care for just a few hours, or a few days, or even maybe a week or 2 is really not enough to derive the maximal benefits for patients and families when we know that it is really high-quality care for those who are at the end of life who need that care in terms of improving how they feel and their ability to stay at home when their time is short,” study author Thomas LeBlanc, MD, told AJMC®.

4. Different outcomes in children versus AYAs with ALL
Adolescent and young adults (AYAs) with acute lymphoblastic leukemia (ALL) in specific have poor survival compared with children, according to Julie A. Wolfson, MD, of the University of Alabama at Birmingham School of Medicine. “In our study, we had comparable survival to what's been shown nationally before, which is about 70% to 80%, depending on their age; in AYAs, it's more 35% to 45%, depending on the age, as well,” Wolfson told AJMC® in an interview.

According to Wolfson, relapse was more common among AYAs if they were of a nonwhite race and if they were not enrolled in a clinical trial.

5. Preventing cardiotoxicity and taking patients off treatment in CML
Francois-Xavier Mahon, MD, PhD, University of Bordeaux, told the audience attending his session that the emerging goal of leukemia management is treatment cessation. “The question is why should we stop treatment [with tyrosine kinase inhibitors (TKIs)]?” Mahon asked. The reasons include off-target effects, cardiovascular toxicity, and growth effects in children. An important criterion is identifying the good responders, he said, adding that instead of completely halting treatment, dose reduction should be an option in these patients.

During the same session, Javid Moslehi, MD, of Vanderbilt School of Medicine, Nashville, Tennesse, discussed the cardiotoxic effects of TKIs, and emphasized the importance of educating both patients and providers of these risks.
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