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Erschienen in: Current Hematologic Malignancy Reports 2/2020

27.02.2020 | Chronic Lymphocytic Leukemias (N Jain, Section Editor)

Is There a Role for Chemotherapy in the Era of Targeted Therapies?

verfasst von: Jason C. Lee, Nicole Lamanna

Erschienen in: Current Hematologic Malignancy Reports | Ausgabe 2/2020

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Abstract

Purpose of Review

The treatment landscape of chronic lymphocytic leukemia has been rapidly evolving over the past few years. The prior standard of care, chemoimmunotherapy, is being replaced by targeted agents, and the utility of chemotherapy has come under question. In this review, we examine recent data comparing chemoimmunotherapy to targeted agents, how these data impact clinical management, and whether there are potential future roles for cytotoxic chemotherapy.

Recent Findings

Clinical trials have shown improved clinical outcomes with targeted agents compared to traditional chemoimmunotherapy. Based on these data, the current treatment paradigm primarily favors targeted agents over chemoimmunotherapy, with a few exceptions. However, targeted agents have notable limitations, and thus, there may be a future role of cytotoxic chemotherapy when administered in combination with targeted agents.

Summary

Although targeted agents have nearly replaced chemoimmunotherapy in the treatment of chronic lymphocytic leukemia, novel combinations utilizing chemotherapy are being developed that may lead to better outcomes.
Literatur
4.
Zurück zum Zitat Effects of chlorambucil and therapeutic decision in initial forms of chronic lymphocytic leukemia (stage A): results of a randomized clinical trial on 612 patients. The French Cooperative Group on Chronic Lymphocytic Leukemia. Blood. 1990;75(7):1414–21. Effects of chlorambucil and therapeutic decision in initial forms of chronic lymphocytic leukemia (stage A): results of a randomized clinical trial on 612 patients. The French Cooperative Group on Chronic Lymphocytic Leukemia. Blood. 1990;75(7):1414–21.
6.
7.
Zurück zum Zitat Binet JL. A new prognostic classification of chronic lymphocytic leukemia derived from a multivariate survival analysis. Cancer. 1981;48(1):198–206.CrossRefPubMed Binet JL. A new prognostic classification of chronic lymphocytic leukemia derived from a multivariate survival analysis. Cancer. 1981;48(1):198–206.CrossRefPubMed
10.
Zurück zum Zitat Damle RN. Ig V gene mutation status and CD38 expression as novel prognostic indicators in chronic lymphocytic leukemia. Blood. 1999;94(6):1840–7.CrossRefPubMed Damle RN. Ig V gene mutation status and CD38 expression as novel prognostic indicators in chronic lymphocytic leukemia. Blood. 1999;94(6):1840–7.CrossRefPubMed
11.
Zurück zum Zitat Hamblin TJ. Unmutated Ig V(H) genes are associated with a more aggressive form of chronic lymphocytic leukemia. Blood. 1999;94(6):1848–54.CrossRefPubMed Hamblin TJ. Unmutated Ig V(H) genes are associated with a more aggressive form of chronic lymphocytic leukemia. Blood. 1999;94(6):1848–54.CrossRefPubMed
12.
Zurück zum Zitat Kröber A. V(H) mutation status, CD38 expression level, genomic aberrations, and survival in chronic lymphocytic leukemia. Blood. 2002;100(4):1410–6.CrossRefPubMed Kröber A. V(H) mutation status, CD38 expression level, genomic aberrations, and survival in chronic lymphocytic leukemia. Blood. 2002;100(4):1410–6.CrossRefPubMed
15.
Zurück zum Zitat The International CLL-IPI working group. An international prognostic index for patients with chronic lymphocytic leukaemia (CLL-IPI): a meta-analysis of individual patient data. Lancet Oncol. 2016;17(6):779–90.CrossRef The International CLL-IPI working group. An international prognostic index for patients with chronic lymphocytic leukaemia (CLL-IPI): a meta-analysis of individual patient data. Lancet Oncol. 2016;17(6):779–90.CrossRef
22.
Zurück zum Zitat Thompson PA, Tam CS, O'Brien SM, Wierda WG, Stingo F, Plunkett W, et al. Fludarabine, cyclophosphamide, and rituximab treatment achieves long-term disease-free survival in IGHV-mutated chronic lymphocytic leukemia. Blood. 2016;127(3):303–9. https://doi.org/10.1182/blood-2015-09-667675An important reference showing frontline FCR's ability to possibly induce cures in a subset of IgHV-mutated CLL patients. CrossRefPubMedPubMedCentral Thompson PA, Tam CS, O'Brien SM, Wierda WG, Stingo F, Plunkett W, et al. Fludarabine, cyclophosphamide, and rituximab treatment achieves long-term disease-free survival in IGHV-mutated chronic lymphocytic leukemia. Blood. 2016;127(3):303–9. https://​doi.​org/​10.​1182/​blood-2015-09-667675An important reference showing frontline FCR's ability to possibly induce cures in a subset of IgHV-mutated CLL patients. CrossRefPubMedPubMedCentral
24.
Zurück zum Zitat Eichhorst B, Fink AM, Bahlo J, Busch R, Kovacs G, Maurer C, et al. First-line chemoimmunotherapy with bendamustine and rituximab versus fludarabine, cyclophosphamide, and rituximab in patients with advanced chronic lymphocytic leukaemia (CLL10): an international, open-label, randomised, phase 3, non-inferiority trial. Lancet Oncol. 2016;17(7):928–42. https://doi.org/10.1016/s1470-2045(16)30051-1.CrossRefPubMed Eichhorst B, Fink AM, Bahlo J, Busch R, Kovacs G, Maurer C, et al. First-line chemoimmunotherapy with bendamustine and rituximab versus fludarabine, cyclophosphamide, and rituximab in patients with advanced chronic lymphocytic leukaemia (CLL10): an international, open-label, randomised, phase 3, non-inferiority trial. Lancet Oncol. 2016;17(7):928–42. https://​doi.​org/​10.​1016/​s1470-2045(16)30051-1.CrossRefPubMed
27.
Zurück zum Zitat Kovacs G, Robrecht S, Fink AM, Bahlo J, Cramer P, von Tresckow J, et al. Minimal residual disease assessment improves prediction of outcome in patients with chronic lymphocytic leukemia (CLL) who achieve partial response: comprehensive analysis of two Phase III studies of the German CLL Study Group. J Clin Oncol. 2016;34(31):3758–65. https://doi.org/10.1200/jco.2016.67.1305This study analyzed two large Phase III trials (CLL8 and CLL10) to show the strong independent correlation of attaining MRD negativity with better long-term clinical outcomes. CrossRefPubMed Kovacs G, Robrecht S, Fink AM, Bahlo J, Cramer P, von Tresckow J, et al. Minimal residual disease assessment improves prediction of outcome in patients with chronic lymphocytic leukemia (CLL) who achieve partial response: comprehensive analysis of two Phase III studies of the German CLL Study Group. J Clin Oncol. 2016;34(31):3758–65. https://​doi.​org/​10.​1200/​jco.​2016.​67.​1305This study analyzed two large Phase III trials (CLL8 and CLL10) to show the strong independent correlation of attaining MRD negativity with better long-term clinical outcomes. CrossRefPubMed
28.
Zurück zum Zitat Bottcher S, Ritgen M, Fischer K, Stilgenbauer S, Busch RM, Fingerle-Rowson G, et al. Minimal residual disease quantification is an independent predictor of progression-free and overall survival in chronic lymphocytic leukemia: a multivariate analysis from the randomized GCLLSG CLL8 trial. J Clin Oncol. 2012;30(9):980–8. https://doi.org/10.1200/jco.2011.36.9348.CrossRefPubMed Bottcher S, Ritgen M, Fischer K, Stilgenbauer S, Busch RM, Fingerle-Rowson G, et al. Minimal residual disease quantification is an independent predictor of progression-free and overall survival in chronic lymphocytic leukemia: a multivariate analysis from the randomized GCLLSG CLL8 trial. J Clin Oncol. 2012;30(9):980–8. https://​doi.​org/​10.​1200/​jco.​2011.​36.​9348.CrossRefPubMed
31.
Zurück zum Zitat Lamanna N, Jurcic JG, Noy A, Maslak P, Gencarelli AN, Panageas KS, et al. Sequential therapy with fludarabine, high-dose cyclophosphamide, and rituximab in previously untreated patients with chronic lymphocytic leukemia produces high-quality responses: molecular remissions predict for durable complete responses. J Clin Oncol. 2009;27(4):491–7. https://doi.org/10.1200/jco.2008.16.4459.CrossRefPubMed Lamanna N, Jurcic JG, Noy A, Maslak P, Gencarelli AN, Panageas KS, et al. Sequential therapy with fludarabine, high-dose cyclophosphamide, and rituximab in previously untreated patients with chronic lymphocytic leukemia produces high-quality responses: molecular remissions predict for durable complete responses. J Clin Oncol. 2009;27(4):491–7. https://​doi.​org/​10.​1200/​jco.​2008.​16.​4459.CrossRefPubMed
32.
Zurück zum Zitat Fischer K, Cramer P, Busch R, Bottcher S, Bahlo J, Schubert J, et al. Bendamustine in combination with rituximab for previously untreated patients with chronic lymphocytic leukemia: a multicenter phase II trial of the German chronic lymphocytic leukemia study group. J Clin Oncol. 2012;30(26):3209–16. https://doi.org/10.1200/jco.2011.39.2688.CrossRefPubMed Fischer K, Cramer P, Busch R, Bottcher S, Bahlo J, Schubert J, et al. Bendamustine in combination with rituximab for previously untreated patients with chronic lymphocytic leukemia: a multicenter phase II trial of the German chronic lymphocytic leukemia study group. J Clin Oncol. 2012;30(26):3209–16. https://​doi.​org/​10.​1200/​jco.​2011.​39.​2688.CrossRefPubMed
33.
Zurück zum Zitat Fischer K, Cramer P, Busch R, Stilgenbauer S, Bahlo J, Schweighofer CD, et al. Bendamustine combined with rituximab in patients with relapsed and/or refractory chronic lymphocytic leukemia: a multicenter phase II trial of the German chronic lymphocytic leukemia study group. J Clin Oncol. 2011;29(26):3559–66. https://doi.org/10.1200/jco.2010.33.8061.CrossRefPubMed Fischer K, Cramer P, Busch R, Stilgenbauer S, Bahlo J, Schweighofer CD, et al. Bendamustine combined with rituximab in patients with relapsed and/or refractory chronic lymphocytic leukemia: a multicenter phase II trial of the German chronic lymphocytic leukemia study group. J Clin Oncol. 2011;29(26):3559–66. https://​doi.​org/​10.​1200/​jco.​2010.​33.​8061.CrossRefPubMed
35.
Zurück zum Zitat Goede V, Fischer K, Engelke A, Schlag R, Lepretre S, Montero LF, et al. Obinutuzumab as frontline treatment of chronic lymphocytic leukemia: updated results of the CLL11 study. Leukemia. 2015;29(7):1602–4.CrossRefPubMed Goede V, Fischer K, Engelke A, Schlag R, Lepretre S, Montero LF, et al. Obinutuzumab as frontline treatment of chronic lymphocytic leukemia: updated results of the CLL11 study. Leukemia. 2015;29(7):1602–4.CrossRefPubMed
36.
39.
Zurück zum Zitat Woyach JA, Ruppert AS, Heerema NA, Zhao W, Booth AM, Ding W, et al. Ibrutinib regimens versus chemoimmunotherapy in older patients with untreated CLL. N Engl J Med. 2018;379(26):2517–28. https://doi.org/10.1056/NEJMoa1812836This reference shows the results of the Alliance A041202 Phase III trial, which displayed the superiority of ibrutinib containing regimens over BR chemoimmunotherapy for the frontline treatment of older and/or frail patients with CLL. CrossRefPubMedPubMedCentral Woyach JA, Ruppert AS, Heerema NA, Zhao W, Booth AM, Ding W, et al. Ibrutinib regimens versus chemoimmunotherapy in older patients with untreated CLL. N Engl J Med. 2018;379(26):2517–28. https://​doi.​org/​10.​1056/​NEJMoa1812836This reference shows the results of the Alliance A041202 Phase III trial, which displayed the superiority of ibrutinib containing regimens over BR chemoimmunotherapy for the frontline treatment of older and/or frail patients with CLL. CrossRefPubMedPubMedCentral
40.
41.
Zurück zum Zitat Shanafelt TD, Wang XV, Kay NE, Hanson CA, O'Brien S, Barrientos J, et al. Ibrutinib-rituximab or chemoimmunotherapy for chronic lymphocytic leukemia. N Engl J Med. 2019;381(5):432–43. https://doi.org/10.1056/NEJMoa1817073This reference shows analysis from the ECOG-ACRIN E1912 Phase III trial, which compared ibrutinib + rituximab to FCR in the frontline setting for young fit CLL patients. CrossRefPubMedPubMedCentral Shanafelt TD, Wang XV, Kay NE, Hanson CA, O'Brien S, Barrientos J, et al. Ibrutinib-rituximab or chemoimmunotherapy for chronic lymphocytic leukemia. N Engl J Med. 2019;381(5):432–43. https://​doi.​org/​10.​1056/​NEJMoa1817073This reference shows analysis from the ECOG-ACRIN E1912 Phase III trial, which compared ibrutinib + rituximab to FCR in the frontline setting for young fit CLL patients. CrossRefPubMedPubMedCentral
42.
Zurück zum Zitat Fischer K, Al-Sawaf O, Bahlo J, Fink AM, Tandon M, Dixon M, et al. Venetoclax and obinutuzumab in Patients with CLL and coexisting conditions. N Engl J Med. 2019;380(23):2225–36. https://doi.org/10.1056/NEJMoa1815281This reference shows data from the Phase III CLL14 trial, which led to the first FDA approval of a venetoclax-containing, fixed-duration regimen (venetoclax + obinutuzumab) in the frontline treatment of CLL.CrossRefPubMed Fischer K, Al-Sawaf O, Bahlo J, Fink AM, Tandon M, Dixon M, et al. Venetoclax and obinutuzumab in Patients with CLL and coexisting conditions. N Engl J Med. 2019;380(23):2225–36. https://​doi.​org/​10.​1056/​NEJMoa1815281This reference shows data from the Phase III CLL14 trial, which led to the first FDA approval of a venetoclax-containing, fixed-duration regimen (venetoclax + obinutuzumab) in the frontline treatment of CLL.CrossRefPubMed
45.
Zurück zum Zitat Munir T, Brown JR, O'Brien S, Barrientos JC, Barr PM, Reddy NM, et al. Final analysis from RESONATE: up to 6 years of follow-up on ibrutinib in patients with previously treated chronic lymphocytic leukemia or small lymphocytic lymphoma. Am J Hematol. 2019;94(12):1353–63. https://doi.org/10.1002/ajh.25638This reference shows the long-term efficacy of ibrutinib in the treatment of relapsed/refractory CLL.CrossRefPubMedPubMedCentral Munir T, Brown JR, O'Brien S, Barrientos JC, Barr PM, Reddy NM, et al. Final analysis from RESONATE: up to 6 years of follow-up on ibrutinib in patients with previously treated chronic lymphocytic leukemia or small lymphocytic lymphoma. Am J Hematol. 2019;94(12):1353–63. https://​doi.​org/​10.​1002/​ajh.​25638This reference shows the long-term efficacy of ibrutinib in the treatment of relapsed/refractory CLL.CrossRefPubMedPubMedCentral
46.
Zurück zum Zitat Chanan-Khan A, Cramer P, Demirkan F, Fraser G, Silva RS, Grosicki S, et al. Ibrutinib combined with bendamustine and rituximab compared with placebo, bendamustine, and rituximab for previously treated chronic lymphocytic leukaemia or small lymphocytic lymphoma (HELIOS): a randomised, double-blind, phase 3 study. Lancet Oncol. 2016;17(2):200–11. https://doi.org/10.1016/s1470-2045(15)00465-9.CrossRefPubMed Chanan-Khan A, Cramer P, Demirkan F, Fraser G, Silva RS, Grosicki S, et al. Ibrutinib combined with bendamustine and rituximab compared with placebo, bendamustine, and rituximab for previously treated chronic lymphocytic leukaemia or small lymphocytic lymphoma (HELIOS): a randomised, double-blind, phase 3 study. Lancet Oncol. 2016;17(2):200–11. https://​doi.​org/​10.​1016/​s1470-2045(15)00465-9.CrossRefPubMed
51.
53.
Zurück zum Zitat Kater AP, Seymour JF, Hillmen P, Eichhorst B, Langerak AW, Owen C, et al. Fixed duration of venetoclax-rituximab in relapsed/refractory chronic lymphocytic leukemia eradicates minimal residual disease and prolongs survival: post-treatment follow-up of the MURANO Phase III Study. J Clin Oncol. 2019;37(4):269–77. https://doi.org/10.1200/jco.18.01580This reference shows updated follow-up of the Phase III MURANO trial, displaying the ability of venetoclax + rituximab to induce durable MRD-negative remissions after a 2-year fixed duration of treatment in relapsed/refractory CLL.CrossRefPubMed Kater AP, Seymour JF, Hillmen P, Eichhorst B, Langerak AW, Owen C, et al. Fixed duration of venetoclax-rituximab in relapsed/refractory chronic lymphocytic leukemia eradicates minimal residual disease and prolongs survival: post-treatment follow-up of the MURANO Phase III Study. J Clin Oncol. 2019;37(4):269–77. https://​doi.​org/​10.​1200/​jco.​18.​01580This reference shows updated follow-up of the Phase III MURANO trial, displaying the ability of venetoclax + rituximab to induce durable MRD-negative remissions after a 2-year fixed duration of treatment in relapsed/refractory CLL.CrossRefPubMed
54.
Zurück zum Zitat Burger JA, Barr PM, Robak T, Owen C, Ghia P, Tedeschi A, et al. Long-term efficacy and safety of first-line ibrutinib treatment for patients with CLL/SLL: 5 years of follow-up from the phase 3 RESONATE-2 study. Leukemia. 2019. https://doi.org/10.1038/s41375-019-0602-xThis reference shows the long-term efficacy of ibrutinib in the frontline treatment of CLL. Burger JA, Barr PM, Robak T, Owen C, Ghia P, Tedeschi A, et al. Long-term efficacy and safety of first-line ibrutinib treatment for patients with CLL/SLL: 5 years of follow-up from the phase 3 RESONATE-2 study. Leukemia. 2019. https://​doi.​org/​10.​1038/​s41375-019-0602-xThis reference shows the long-term efficacy of ibrutinib in the frontline treatment of CLL.
64.
Zurück zum Zitat Sharman JP, Coutre SE, Furman RR, Cheson BD, Pagel JM, Hillmen P, et al. Final results of a randomized, phase III study of rituximab with or without Idelalisib followed by open-label Idelalisib in patients with relapsed chronic lymphocytic leukemia. J Clin Oncol. 2019;37(16):1391–402. https://doi.org/10.1200/jco.18.01460.CrossRefPubMed Sharman JP, Coutre SE, Furman RR, Cheson BD, Pagel JM, Hillmen P, et al. Final results of a randomized, phase III study of rituximab with or without Idelalisib followed by open-label Idelalisib in patients with relapsed chronic lymphocytic leukemia. J Clin Oncol. 2019;37(16):1391–402. https://​doi.​org/​10.​1200/​jco.​18.​01460.CrossRefPubMed
67.
73.
Zurück zum Zitat Cuneo A, Barosi G, Danesi R, Fagiuoli S, Ghia P, Marzano A, et al. Management of adverse events associated with idelalisib treatment in chronic lymphocytic leukemia and follicular lymphoma: a multidisciplinary position paper. Hematol Oncol. 2019;37(1):3–14. https://doi.org/10.1002/hon.2540.CrossRefPubMed Cuneo A, Barosi G, Danesi R, Fagiuoli S, Ghia P, Marzano A, et al. Management of adverse events associated with idelalisib treatment in chronic lymphocytic leukemia and follicular lymphoma: a multidisciplinary position paper. Hematol Oncol. 2019;37(1):3–14. https://​doi.​org/​10.​1002/​hon.​2540.CrossRefPubMed
80.
Zurück zum Zitat Jain N, Thompson PA, Burgery JA, Ferrajoli A, Takahashi K, Estrov ZE et al. Ibrutinib, Fludarabine, cyclophosphamide, and obinutuzumab (iFCG) for first-line treatment of IGHV-mutated CLL and without Del (17p)/mutated TP53. American Society of Hematology annual meeting; Dec 8 2019; Orlando, Florida: American Society of Hematology. Jain N, Thompson PA, Burgery JA, Ferrajoli A, Takahashi K, Estrov ZE et al. Ibrutinib, Fludarabine, cyclophosphamide, and obinutuzumab (iFCG) for first-line treatment of IGHV-mutated CLL and without Del (17p)/mutated TP53. American Society of Hematology annual meeting; Dec 8 2019; Orlando, Florida: American Society of Hematology.
81.
Zurück zum Zitat Davids MS, Brander DM, Kim HT, Tyekucheva S, Bsat J, Savell A, et al. Ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial treatment for younger patients with chronic lymphocytic leukaemia: a single-arm, multicentre, phase 2 trial. Lancet Haematol. 2019;6(8):e419–e28. https://doi.org/10.1016/s2352-3026(19)30104-8This Phase II study shows the ability of a combination of FCR + ibrutinib to induce high response rates and MRD negativity rates in a relatively unselected, young, treatment-naïve CLL population.CrossRefPubMedPubMedCentral Davids MS, Brander DM, Kim HT, Tyekucheva S, Bsat J, Savell A, et al. Ibrutinib plus fludarabine, cyclophosphamide, and rituximab as initial treatment for younger patients with chronic lymphocytic leukaemia: a single-arm, multicentre, phase 2 trial. Lancet Haematol. 2019;6(8):e419–e28. https://​doi.​org/​10.​1016/​s2352-3026(19)30104-8This Phase II study shows the ability of a combination of FCR + ibrutinib to induce high response rates and MRD negativity rates in a relatively unselected, young, treatment-naïve CLL population.CrossRefPubMedPubMedCentral
82.
Zurück zum Zitat Cramer P, von Tresckow J, Bahlo J, Robrecht S, Langerbeins P, Al-Sawaf O, et al. Bendamustine followed by obinutuzumab and venetoclax in chronic lymphocytic leukaemia (CLL2-BAG): primary endpoint analysis of a multicentre, open-label, phase 2 trial. Lancet Oncol. 2018;19(9):1215–28. https://doi.org/10.1016/s1470-2045(18)30414-5This Phase II study shows the possible ability of chemotherapy (e.g. bendamustine) to be utilized as an effective and rapid debulking agent prior to initiation of venetoclax-containing regimens in the frontline treatment of CLL.CrossRefPubMed Cramer P, von Tresckow J, Bahlo J, Robrecht S, Langerbeins P, Al-Sawaf O, et al. Bendamustine followed by obinutuzumab and venetoclax in chronic lymphocytic leukaemia (CLL2-BAG): primary endpoint analysis of a multicentre, open-label, phase 2 trial. Lancet Oncol. 2018;19(9):1215–28. https://​doi.​org/​10.​1016/​s1470-2045(18)30414-5This Phase II study shows the possible ability of chemotherapy (e.g. bendamustine) to be utilized as an effective and rapid debulking agent prior to initiation of venetoclax-containing regimens in the frontline treatment of CLL.CrossRefPubMed
Metadaten
Titel
Is There a Role for Chemotherapy in the Era of Targeted Therapies?
verfasst von
Jason C. Lee
Nicole Lamanna
Publikationsdatum
27.02.2020
Verlag
Springer US
Erschienen in
Current Hematologic Malignancy Reports / Ausgabe 2/2020
Print ISSN: 1558-8211
Elektronische ISSN: 1558-822X
DOI
https://doi.org/10.1007/s11899-020-00563-8

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