Real-world studies on B-cell malignancies

Randomized controlled trials remain the preferred way of evaluating new treatments. However, in studies on malignancies, trial data may not always be sufficient to address the requirements of health care providers and regulatory agencies regarding recommendations as patients are strictly selected through inclusion- and exclusion criteria. Carefully collected data from consecutive, unselected patients from a well-defined area, without missing cases, will reveal the actual results in routine medical care. These real-world results often differ from results in clinical trials and may provide important additional information to data from clinical trials and serve as control for early non-randomized clinical studies of novel drugs. It is important to find optimal ways to use new high-cost cancer drugs not just for healthcare authorities but for the wider society. The aim of this thesis was to compile reliable real-world data in certain subgroups of patients with chronic lymphocytic leukemia (CLL) and diffuse large B-cell lymphoma (DLBCL), the two most common subgroups of lymphoid malignancies. The first study investigated the effectiveness and safety of 2nd line treatment in consecutive relapsed or refractory (R/R) CLL patients treated between 2003 and 2013 in the Stockholm region. In-depth analysis of each patient file was performed retrospectively. Despite access to new therapies no significant improvement in survival over time was demonstrated. These results highlighted the need for next generation targeted therapies in this patient group and constituted a relevant context for interpretation of and comparison with data obtained in clinical trials of new drugs. The second study was a nationwide study on consecutive CLL patients receiving 1st line therapy between 2007 and 2013. Baseline characteristics, treatment, outcome and toxicity were retrospectively extracted from each patient’s medical file. After a median follow-up of almost 5 years, median progression free survival (PFS) and overall survival (OS) were 24 and 58 months respectively, both significantly associated with type of treatment, del(17p), performance status, gender and age. Overall, there was no significant improvement in OS during the time period studied and importantly regional differences in outcome was observed. The study constitutes a large and unique material providing a context to evaluate the findings obtained in clinical trials of new drugs. The third study was an adjusted comparison between the Bruton tyrosine kinase inhibitor ibrutinib versus previous standard of care treatments in two cohorts of patients with R/R CLL. With multivariate regression modelling to adjust for differences in baseline prognostic factors, PFS and OS were significantly longer with ibrutinib than with previous standard of care regimens. The study describes a statistical approach to provide a preliminary comparison between treatments used in clinical routine and new drugs until comparisons from randomized clinical trials are available.In In the fourth study outcome of 1st line treatment in consecutive patients aged 80 years or older, diagnosed with DLBCL between 2000 and 2015 in the Stockholm region was evaluated. Retrospective data were collected from each individual patient file. Patients ≥ 85 years responded to and tolerated chemoimmunotherapy equally well as patients aged 80-84 years, highlighting that even very elderly patients benefit from active therapy provided that dose-adaption of chemotherapeutic drugs are performed

Real-world results of ibrutinib in patients with relapsed or refractory chronic lymphocytic leukemia: data from 95 consecutive patients treated in a compassionate use program. A study from the Swedish Chronic Lymphocytic Leukemia Group

Ibrutinib, a Brutons tyrosine kinase inhibitor is approved for relapsed/refractory and del(17p)/TP53 mutated chronic lymphocytic leukemia. Discrepancies between clinical trials and routine healthcare are commonly observed in oncology. Herein we report real-world results for 95 poor prognosis Swedish patients treated with ibrutinib in a compassionate use program. Ninety-five consecutive patients (93 chronic lymphocytic leukemia, 2 small lymphocytic leukemia) were included in the study between May 2014 and May 2015. The median age was 69 years. 63% had del(17p)/TP53 mutation, 65% had Rai stage III/IV, 28% had lymphadenopathy amp;gt;= 10cm. Patients received ibrutinib 420 mg once daily until progression. At a median follow-up of 10.2 months, the overall response rate was 84% (consistent among subgroups) and 77% remained progression-free. Progression-free survival and overall survival were significantly shorter in patients with del(17p)/TP53 mutation (P=0.017 and P=0.027, log-rank test); no other factor was significant in Cox proportional regression hazards model. Ibrutinib was well tolerated. Hematomas occurred in 46% of patients without any major bleeding. Seven patients had Richters transformation. This real-world analysis on consecutive chronic lymphocytic leukemia patients from a well-defined geographical region shows the efficacy and safety of ibrutinib to be similar to that of pivotal trials. Yet, del(17p)/TP53 mutation remains a therapeutic challenge. Since not more than half of our patients would have qualified for the pivotal ibrutinib trial (RESONATE), our study emphasizes that real-world results should be carefully considered in future with regards to new agents and new indications in chronic lymphocytic leukemia.Funding Agencies|Swedish Cancer Society [15 0894]; Cancer Society in Stockholm [144142, 151313]; King Gustav V Jubilee Fund [144193]; Cancer and Allergy Foundation [150 420, 150 431]; StratCan Karolinska Institutet [2201]; AFA Insurance [130054]; Stockholm County Council, Sweden [20150070]</p

Complications after proton radiotherapy in children, focusing on severe late complications : a complete Swedish cohort 2008–2019

Background: Proton radiotherapy (RT) is an attractive tool to deliver local therapy with minimal dose to uninvolved tissue, however, not suitable for all patients. The aim was to explore complications, especially severe late complications (grades 3–4), following proton RT delivered to a complete Swedish cohort of paediatric patients aged &lt;18 years treated 2008–2019. Material and Methods: Data was downloaded from a national registry. Complications with a possible causation with RT are reported. Proton treatments until July 2015 was performed with a fixed horizontal 172 MeV beam (The Svedberg Laboratory (TSL), Uppsala) in a sitting position and thereafter with gantry-based pencil-beam scanning technique (Skandion Clinic, Uppsala) in a supine position. Results: 219 courses of proton RT (77 at TSL and 142 at Skandion) were delivered to 212 patients (mean age 9.2 years) with various tumour types (CNS tumours 58%, sarcomas 26%, germ cell tumours 7%). Twenty-five patients had severe acute complications (skin, mucous membrane, pharynx/oesophagus, larynx, upper gastrointestinal canal, lower gastrointestinal canal, eyes, ears). Fifteen patients had severe late complications; with increased proportion over time: 4% at 1-year follow-up (FU), 5% at 3-year, 11% at 5-year. Organs affected were skin (1 patient), subcutaneous tissue (4), salivary glands (1), upper GI (1), bone (7), joints (2), CNS (2), PNS (1), eyes (1) and ears (5). Twenty-one of the 28 patients with 10-year FU had at least one late complication grades 1–4 and fourteen of them had more than one (2–5 each). Conclusion: The most important result of our study is the relatively low proportion of severe late complications, comparable with other proton studies on various tumours. Furthermore, the numbers of late complications are lower than our own data set on a mixed population of photon and proton treated paediatric patients, assuring the safety of using proton therapy also in the clinical practice

Long-term real-world results of ibrutinib therapy in patients with relapsed or refractory chronic lymphocytic leukemia : 30-month follow up of the Swedish compassionate use cohort

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First-line therapy in chronic lymphocytic leukemia: a Swedish nation-wide real-world study on 1053 consecutive patients treated between 2007 and 2013

The aim of this study was to investigate long-term outcome following first-line therapy in consecutive chronic lymphocytic leukemia (CLL) patients in a well-defined geographic area: Sweden. All patients diagnosed with CLL (2007-2013) (n=3672) were identified from national registries, screening of patient files identified all (100%) treated first line (n=1053) and for those, an in-depth analysis was performed. End points were overall response rate, progression-free survival (PFS), overall survival (OS), and safety. Median age was 71 years; 53% had Rai stage III-IV and 97% had performance status grade 0-2. Fluorescence in situ hybridization (FISH) was performed in 57% of patients: 15% had del(17p). Chlorambucil + prednisone was used in 39% (5% also received rituximab). Fludarabine+cyclophosphamide+rituximab or fludarabine+cyclophosphamide was used in 43% and bendamustine + rituximab in 6%. Overall response rate was 64%; chlorambucil 43%, fludarabine+cyclophosphamide+rituximab 84%, fludarabine+cyclophosphamide 75% and bendamustine + rituximab 75%. Median PFS and OS was 24 and 58 months, respectively, both were significantly associated (multivariate analysis) with type of treatment, del(17p), performance status, gender, age and geographical region (OS only). Chlorambucil-treated patients had a median PFS and OS of only 9 and 33 months, respectively. Chlorambucil usage declined gradually throughout the study period, but one-third of patients still received chlorambucil + rituximab in 2013. Infections amp;gt;= grade III were significantly associated with treatment; chlorambucil 19% versus fludarabine+cyclophosphamide+rituximab 30%. Richter transformation occurred in 5.5% of the patients, equally distributed across therapies. This is the largest retrospective, real-world cohort of consecutive first-line treated CLL patients with a complete follow up. In elderly patients, an unmet need for more effective, well-tolerated therapies was identified.Funding Agencies|AFA Insurance [130054]; SLL/ALF [20150070]; Blodcancerfonden 2016; Dr Ake Olsson Foundation [2-791/2016]; SLL/KI Hogre klinisk forskare 2018/2019 [K2894-2016]; Svenska Lakaresallskapet [SLS-406961]; Gilead Sciences Nordic Fellowship Programme 2015; Swedish Cancer Society [150930, 160534]</p

Complications after proton radiotherapy in children, focusing on severe late complications. A complete Swedish cohort 2008–2019

Proton radiotherapy (RT) is an attractive tool to deliver local therapy with minimal dose to uninvolved tissue, however, not suitable for all patients. The aim was to explore complications, especially severe late complications (grades 3–4), following proton RT delivered to a complete Swedish cohort of paediatric patients aged Data was downloaded from a national registry. Complications with a possible causation with RT are reported. Proton treatments until July 2015 was performed with a fixed horizontal 172 MeV beam (The Svedberg Laboratory (TSL), Uppsala) in a sitting position and thereafter with gantry-based pencil-beam scanning technique (Skandion Clinic, Uppsala) in a supine position. 219 courses of proton RT (77 at TSL and 142 at Skandion) were delivered to 212 patients (mean age 9.2 years) with various tumour types (CNS tumours 58%, sarcomas 26%, germ cell tumours 7%). Twenty-five patients had severe acute complications (skin, mucous membrane, pharynx/oesophagus, larynx, upper gastrointestinal canal, lower gastrointestinal canal, eyes, ears). Fifteen patients had severe late complications; with increased proportion over time: 4% at 1-year follow-up (FU), 5% at 3-year, 11% at 5-year. Organs affected were skin (1 patient), subcutaneous tissue (4), salivary glands (1), upper GI (1), bone (7), joints (2), CNS (2), PNS (1), eyes (1) and ears (5). Twenty-one of the 28 patients with 10-year FU had at least one late complication grades 1–4 and fourteen of them had more than one (2–5 each). The most important result of our study is the relatively low proportion of severe late complications, comparable with other proton studies on various tumours. Furthermore, the numbers of late complications are lower than our own data set on a mixed population of photon and proton treated paediatric patients, assuring the safety of using proton therapy also in the clinical practice.</p