Clinical Trials Offer Opportunities to Change Practice to Improve Prevention and Treatment of Blood Disorders
New insights help inform evidence-based decisions for care, improve outcomes
(WASHINGTON, Dec. 4, 2020) – Four studies being presented during the 62nd American Society of Hematology (ASH) Annual Meeting and Exposition present opportunities to improve care for patients with a variety of blood disorders. Together, the studies provide support for new clinical approaches such as alternate treatment delivery methods, updated uses for existing therapies, and earlier referrals to specialty care.
“These are very practical trials with real-world implications,” said press briefing moderator Lisa Hicks, MD, of St. Michael’s Hospital and the University of Toronto. “They address important questions relevant to everyday practice in the clinic.”
The first study supports administering the monoclonal antibody daratumumab for multiple myeloma via a quick injection instead of an intravenous infusion, an approach that could save significant time for patients and clinics.
The second study found that, despite being routinely used in practice, the clot stabilizer tranexamic acid does not prevent bleeding when used prophylactically for patients undergoing treatment for blood cancers, although it leaves open the possibility that the drug may be an effective treatment for these patients when bleeding occurs.
The third study reports the drug ruxolitinib can offer relief for patients with chronic graft-versus-host disease (GVHD) after a stem cell transplant, suggesting ruxolitinib is a viable second-line treatment for patients whose symptoms are not fully resolved with corticosteroids.
Finally, the fourth study supports referring older patients with myelodysplastic syndromes to transplant centers for allogeneic hematopoietic cell transplantation, an important shift from current practice that could offer many more patients the potential for a cure.
This press briefing will take place on Friday, December 4, at 9:30 a.m. Pacific time on the ASH annual meeting virtual platform.
Study Bolsters Case for Delivering Daratumumab Subcutaneously for Multiple Myeloma
412: Apollo: Phase 3 Randomized Study of Subcutaneous Daratumumab Plus Pomalidomide and Dexamethasone (D-Pd) Versus Pomalidomide and Dexamethasone (Pd) Alone in Patients (Pts) with Relapsed/Refractory Multiple Myeloma (RRMM)
A new study suggests the monoclonal antibody daratumumab has similar benefits when delivered via subcutaneous injection as it does when delivered intravenously to individuals with multiple myeloma which persists or recurs after first-line treatments. Patients given subcutaneous daratumumab along with the immunomodulator pomalidomide and the anti-inflammatory steroid dexamethasone were 37% less likely to die or have their disease worsen compared to patients who received pomalidomide and dexamethasone alone in the phase III trial.
“This is an effective combination with a predictable safety profile that allows for the use of subcutaneous daratumumab along with oral pomalidomide and dexamethasone for patients who have received at least one prior line of therapy that included lenalidomide and a proteasome inhibitor,” said senior study author Meletios A. Dimopoulos, MD, of National and Kapodistrian University of Athens in Athens, Greece. “Subcutaneous daratumumab is much easier for the patient and reduces the time they need to spend at the outpatient chemotherapy unit.”
The combination of intravenous daratumumab and pomalidomide with dexamethasone has been widely adopted in the U.S. as a second-line therapy for patients whose multiple myeloma does not respond durably to lenalidomide and proteasome inhibitors. However, delivering daratumumab intravenously typically requires patients to spend a full day at the clinic for each infusion. Administering the therapy via a five-minute subcutaneous injection can substantially reduce the burden for patients and clinics, Dr. Dimopoulos said.
The researchers enrolled 304 patients in 12 European countries. Half were randomly assigned to receive daratumumab plus pomalidomide with dexamethasone and half only received pomalidomide with dexamethasone. Patients underwent 28-day treatment cycles until their disease worsened or they experienced unacceptable side effects.
About one-third of patients died during the trial’s median follow-up period of about 17 months. The study met its primary endpoint, showing a significantly higher rate of progression-free survival at 12 months among patients receiving the combination therapy. Participants receiving the daratumumab-pomalidomide combination were treated for a median of nearly 12 months, substantially longer than the median treatment duration of less than seven months among those receiving pomalidomide alone.
Patients receiving daratumumab experienced adverse events at a rate consistent with previous studies, raising no new safety concerns. Dr. Dimopoulos said the findings suggest the combination therapy can be a good option for patients who have not experienced lasting benefits from lenalidomide and proteasome inhibitors, particularly those whose cancer is resistant to lenalidomide. He noted that the study suggested a slight trend toward increased survival in the daratumumab arm, but additional follow-up is necessary to assess any survival benefit.
Meletios A. Dimopoulos, MD, National and Kapodistrian University of Athens, will present this study in an oral presentation on Sunday, December 6, at 12:00 noon Pacific time on the ASH annual meeting virtual platform.
Tranexamic Acid Not Found to Prevent Bleeding in Patients with Blood Cancers
2: Effects of Tranexamic Acid Prophylaxis on Bleeding Outcomes in Hematologic Malignancy: The A-TREAT Trial
The clot stabilizer tranexamic acid performed no better than placebo when administered prophylactically to prevent bleeding in patients with blood cancers who also received routine prophylactic platelet transfusions. Researchers cautioned that the study’s focus is different from other situations in which tranexamic acid has been found effective, such as its use in treating bleeding related to childbirth, surgery, or inherited blood disorders.
“Clearly patients with low platelet counts and blood cancers have a different kind of bleeding than the bleeding experienced by patients who have suffered some kind of trauma or surgery,” said senior study author Terry B. Gernsheimer, MD, of the University of Washington School of Medicine. “Their bleeding likely is due to endothelial damage – damage to the lining of blood vessels – that tranexamic acid would not treat. To prevent bleeding in these patients, we may need to look at ways to speed the healing of the endothelium that occurs with chemotherapy, radiation, and graft-versus-host disease in patients receiving a transplant.”
Between 48% and 70% of patients undergoing treatment for blood cancers experience bleeding complications of World Health Organization grade 2 or higher. Though not life-threatening, grade 2 bleeding – for example, a nosebleed lasting more than 30 minutes – can be concerning. Bleeding of grade 3 or 4 can be life-threatening and warrant blood transfusions. Most patients undergoing treatment for blood cancers are routinely given platelet transfusions to prevent bleeding, but many continue to experience bleeding episodes, nevertheless.
Tranexamic acid works by slowing the process by which blood clots naturally break down. To determine whether tranexamic acid could help to further reduce bleeding in these patients, the researchers enrolled 327 patients undergoing treatment for blood cancers at three U.S. medical centers. Half were randomly assigned to receive tranexamic acid and half received a placebo, administered either orally or intravenously three times a day until they recovered their platelet count, or for up to 30 days. Researchers regularly followed up with participants to assess bleeding events both in and outside of the hospital.
The results revealed no significant differences among the study groups in terms of the number of bleeding events, the number of red blood cell transfusions, or the number of platelet transfusions patients required during the treatment period and for up to 14 days afterward. Patients receiving tranexamic acid had a significantly higher rate of occlusions in their central venous line (a catheter placed in a large vein commonly used for delivering cancer drugs) which required clearing with a clot-dissolving drug, but there was no difference in the occurrence of clots in patients’ veins or arteries.
Dr. Gernsheimer noted that other studies could help elucidate whether the drug may be helpful for specific subgroups of patients with blood cancers or as a treatment for bleeding, rather than as a preventive measure in these patients. It may also be useful to prevent or treat bleeding in patients with other causes of low platelet counts.
Terry B. Gernsheimer, MD, University of Washington School of Medicine, will present this study in a plenary presentation on Sunday, December 6, 2020 at 7:00 a.m. Pacific time on the ASH annual meeting virtual platform.
Researchers Report First Successful Second-Line Treatment for Chronic Graft-Versus-Host Disease
77: Ruxolitinib (RUX) Vs Best Available Therapy (BAT) in Patients with Steroid- Refractory/Steroid-Dependent Chronic Graft-Vs-Host Disease (cGVHD): Primary Findings from the Phase 3, Randomized REACH3 Study
The drug ruxolitinib brought relief from the debilitating effects of chronic graft-versus-host disease (GVHD) at twice the rate of the best available therapy in a phase III trial. The findings represent a major step forward for patients with chronic GVHD that is not resolved by taking corticosteroids, said researchers. There is currently no approved second-line therapy for chronic forms of the disease.
“This is the first multicenter randomized controlled trial for chronic, steroid-refractory or steroid-dependent GVHD that is positive,” said senior study author Robert Zeiser, PhD, of University Medical Center, Freiburg Im Breisgau, Germany. “It shows a significant advantage for ruxolitinib. It is likely that this trial will lead to approval for this indication and change the guidelines for the treatment of this disease.”
GVHD is a complication of allogeneic hematopoietic (stem) cell transplantation, a therapy used to treat blood cancers. It occurs when T cells (the graft) received from a donor through the transplant see the patient’s healthy cells and tissue (the host) as foreign and start to attack them. Roughly half of patients undergoing a stem cell transplant develop GVHD. About half of these patients are able to resolve their symptoms with a temporary course of corticosteroids, a class of drugs that lower inflammation in the body. The remaining patients either do not respond to steroids, cannot take them, or must take them continuously to stave off symptoms.
Ruxolitinib is designed to block a molecular signal involved in triggering inflammation. A previous trial, REACH2, found that ruxolitinib offered benefits for patients with acute GVHD, a severe form of GVHD with a mortality rate of 80%. The new trial, REACH3, aimed to determine whether the drug could bring similar benefits for the much larger number of patients affected by chronic GVHD. While chronic GVHD is not nearly as deadly as acute GVHD, its symptoms, which include weight loss, skin stiffness, and multiple disabilities, can severely and permanently affect patients’ quality of life.
Researchers enrolled 329 patients with moderate-to-severe chronic GVHD. Half were randomly assigned to receive ruxolitinib for six 28-day cycles. The other half received one of nine alternative treatments, representing the best available therapy, at the discretion of their physician. At the end of the six treatment cycles, researchers assessed symptoms of 125 patients who had completed the full course of treatment to which they were assigned.
The trial met its primary endpoint, showing a clear and substantial improvement in the overall response to treatment among patients taking ruxolitinib. Of the 125 patients assessed, 50% of those receiving ruxolitinib had at least some reduction in symptoms, compared to only 25% among those receiving best available therapy. Seven percent of those taking ruxolitinib saw their symptoms resolve completely, compared to only 3% among those receiving best available therapy.
Participants in both arms of the study experienced similar rates of adverse events, which aligned with the health challenges commonly faced by patients with chronic GVHD, suggesting ruxolitinib has an acceptable safety profile in these patients, according to Dr. Zeiser.
Robert Zeiser, PhD, University Medical Center, Freiburg Im Breisgau, Germany, will present this study in an oral presentation on Saturday, December 5, at 8:00 a.m. Pacific time on the ASH annual meeting virtual platform.
Curative Transplant Improves Survival for Older Adults with Myelodysplastic Syndrome
75: A Multi-Center Biologic Assignment Trial Comparing Reduced Intensity Allogeneic Hematopoietic Cell Transplantation to Hypomethylating Therapy or Best Supportive Care in Patients Aged 50-75 with Advanced Myelodysplastic Syndrome: Blood and Marrow Transplant Clinical Trials Network Study 1102
Allogeneic hematopoietic cell transplantation nearly doubled the rate of survival among patients 50 to 75 years old with myelodysplastic syndrome (MDS) in a trial conducted by the Blood and Marrow Transplant Clinical Trials Network. Despite being the only known cure for MDS, this therapy is typically only offered to younger patients because its benefits for older adults have not previously been proven. Researchers say the study offers the most definitive evidence to date that this type of stem cell transplantation significantly improves the outlook for older adults who would otherwise face a high likelihood of dying.
“Transplantation has been underutilized, historically, in this patient group,” said senior study author Corey Cutler, MD, MPH, of Dana-Farber Cancer Institute. “Based on our findings, all patients should at least be referred to a transplant center so that those who are eligible and who have a suitable donor can undergo transplant and have better survival. It is important to refer these patients early so that the transplant center can work on finding an optimal donor right from the get-go.”
Allogeneic hematopoietic (stem) cell transplantation is a process to replace a recipient’s stem cells and immune system with cells from a healthy donor. It is the only known method to cure patients with MDS. The Centers for Medicare and Medicaid Services (CMS) covers transplantation for MDS as part of a Coverage with Evidence Development program. CMS approved the design of the trial and is expected to consider the findings when determining future payment policies.
Researchers from the Blood and Marrow Transplant Clinical Trials Network enrolled 384 patients treated for MDS at 34 U.S. medical centers. Patients were referred to transplant centers, which searched for suitable stem cell donors. The 260 patients who were matched with a donor within 90 days were assigned to receive a stem cell transplant; the other 124 patients with no suitable donor received standard supportive care. Participants were followed for roughly three years from their date of enrollment.
Overall survival was much higher in patients assigned to receive a stem cell transplant (47.9%) compared to those who were not (26.6%) at three years from treatment assignment. Leukemia-free survival was also higher in those assigned to receive a transplant (35.8%) than those who were not (20.6%). The researchers observed no significant differences among subgroups and no differences in quality of life between the two study arms.
Dr. Cutler noted that starting the transplantation process as early as possible can increase a patient’s chance of finding a suitable donor and successfully proceeding with a transplant.
This study was co-funded by the National, Heart, Lung and Blood Institute (NHLBI) and the National Cancer Institute (NCI), both part of the National Institutes of Health.
Corey Cutler, MD, MPH, Dana-Farber Cancer Institute, will present this study in an oral presentation on Saturday, December 5, at 7:30 a.m. Pacific time on the ASH annual meeting virtual platform.
Additional press briefings will take place throughout the meeting on health disparities, genome editing and cellular therapy, COVID-19, and late-breaking abstracts. For the complete annual meeting program and abstracts, visit www.hematology.org/annual-meeting. Follow ASH and #ASH20 on Twitter, Instagram, LinkedIn, and Facebook for the most up-to-date information about the 2020 ASH Annual Meeting.
The American Society of Hematology (ASH) (www.hematology.org) is the world’s largest professional society of hematologists dedicated to furthering the understanding, diagnosis, treatment, and prevention of disorders affecting the blood. For more than 60 years, the Society has led the development of hematology as a discipline by promoting research, patient care, education, training, and advocacy in hematology. ASH publishes Blood (www.bloodjournal.org), the most cited peer-reviewed publication in the field, and Blood Advances (www.bloodadvances.org), an online, peer-reviewed open-access journal.
Leah Enser, ASH, [email protected]
Brianne Cannon, FleishmanHillard, [email protected]