To review and update the European LeukemiaNet (ELN) recommendations for the management of chronic myeloid leukemia with imatinib and second-generation tyrosine kinase inhibitors (TKIs), including ...monitoring, response definition, and first- and second-line therapy.
These recommendations are based on a critical and comprehensive review of the relevant papers up to February 2009 and the results of four consensus conferences held by the panel of experts appointed by ELN in 2008.
Cytogenetic monitoring was required at 3, 6, 12, and 18 months. Molecular monitoring was required every 3 months. On the basis of the degree and the timing of hematologic, cytogenetic, and molecular results, the response to first-line imatinib was defined as optimal, suboptimal, or failure, and the response to second-generation TKIs was defined as suboptimal or failure.
Initial treatment was confirmed as imatinib 400 mg daily. Imatinib should be continued indefinitely in optimal responders. Suboptimal responders may continue on imatinb, at the same or higher dose, or may be eligible for investigational therapy with second-generation TKIs. In instances of imatinib failure, second-generation TKIs are recommended, followed by allogeneic hematopoietic stem-cell transplantation only in instances of failure and, sometimes, suboptimal response, depending on transplantation risk.
We analyzed the cost-effectiveness of treating incident chronic myeloid leukemia in chronic phase (CML-CP) with generic imatinib when it becomes available in United States in 2016. In the year ...following generic entry, imatinib's price is expected to drop 70% to 90%. We hypothesized that initiating treatment with generic imatinib in these patients and then switching to the other tyrosine-kinase inhibitors (TKIs), dasatinib or nilotinib, because of intolerance or lack of effectiveness ("imatinib-first") would be cost-effective compared with the current standard of care: "physicians' choice" of initiating treatment with any one of the three TKIs.
We constructed Markov models to compare the five-year cost-effectiveness of imatinib-first vs physician's choice from a US commercial payer perspective, assuming 3% annual discounting ($US 2013). The models' clinical endpoint was five-year overall survival taken from a systematic review of clinical trial results. Per-person spending on incident CML-CP treatment overall care components was estimated using Truven's MarketScan claims data. The main outcome of the models was cost per quality-adjusted life-year (QALY). We interpreted outcomes based on a willingness-to-pay threshold of $100 000/QALY. A panel of European LeukemiaNet experts oversaw the study's conduct.
Both strategies met the threshold. Imatinib-first ($277 401, 3.87 QALYs) offered patients a 0.10 decrement in QALYs at a savings of $88 343 over five years to payers compared with physician's choice ($365 744, 3.97 QALYs). The imatinib-first incremental cost-effectiveness ratio was approximately $883 730/QALY. The results were robust to multiple sensitivity analyses.
When imatinib loses patent protection and its price declines, its use will be the cost-effective initial treatment strategy for CML-CP.
Imatinib mesylate (IM), 400 mg daily, is the standard treatment of Philadelphia-positive (Ph+) chronic myeloid leukemia (CML). Preclinical data and results of single-arm studies raised the suggestion ...that better results could be achieved with a higher dose. To investigate whether the systematic use of a higher dose of IM could lead to better results, 216 patients with Ph+ CML at high risk (HR) according to the Sokal index were randomly assigned to receive IM 800 mg or 400 mg daily, as front-line therapy, for at least 1 year. The CCgR rate at 1 year was 64% and 58% for the high-dose arm and for the standard-dose arm, respectively (P = .435). No differences were detectable in the CgR at 3 and 6 months, in the molecular response rate at any time, as well as in the rate of other events. Twenty-four (94%) of 25 patients who could tolerate the full 800-mg dose achieved a CCgR, and only 4 (23%) of 17 patients who could tolerate less than 350 mg achieved a CCgR. This study does not support the extensive use of high-dose IM (800 mg daily) front-line in all CML HR patients. This trial was registered at www.clinicaltrials.gov as #NCT00514488.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The treatment policy of chronic myeloid leukemia (CML), particularly with tyrosine kinase inhibitors, has been influenced by several recent studies that were well designed and rapidly performed, but ...their interpretation is of some concern because different end points and methodologies were used. To understand and compare the results of the previous and future studies and to translate their conclusion into clinical practice, there is a need for common definitions and methods for analyses of CML studies. A panel of experts was appointed by the European LeukemiaNet with the aim of developing a set of definitions and recommendations to be used in design, analyses, and reporting of phase 3 clinical trials in this disease. This paper summarizes the consensus of the panel on events and major end points of interest in CML. It also focuses on specific issues concerning the intention-to-treat principle and longitudinal data analyses in the context of long-term follow-up. The panel proposes that future clinical trials follow these recommendations.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Treatment of chronic myeloid leukemia (CML) with interferon-alpha (IFN-α) was introduced in the early 1980s. Several clinical trials showed a survival advantage for patients treated with IFN-α ...compared to conventional chemotherapy. Some patients achieved longstanding complete cytogenetic remissions (i.e. >2 log tumor mass reduction). IFN-α was then recommended as first line medical treatment until 2001. The mechanism of this anti-leukemic effect is not clear, although IFN-α has many effects of potential relevance on stem cells and immunology. There is no evidence of benefit for high dose (in practice a maximally tolerated dose) compared with lower dose IFN-α. When IFN-α is combined with other drugs, we advice lower dose IFN to minimize toxicity and increase treatment adherence and duration. IFN-α combined with Ara-C moderately improves treatment outcome. Imatinib, a tyrosine kinase inhibitor, is now first line treatment for CML, but two large randomized studies show improved outcome when pegylated IFN-α is added to the treatment with imatinib. One explanation for this might be that IFN-α, contrary to imatinib, stimulates the quiescent stem cells to proliferate and thereby potentially increases sensitivity to imatinib. Although imatinib and other tyrosine kinase inhibitors are very efficient, they are rarely curative. IFN-α could be included in curatively aimed combination treatment protocols and thus still be an important element in CML treatment.
•Multiplex platforms for protein quantification were compared.•Plasma from patients with chronic myeloid leukemia was used for the comparison.•The absolute protein concentration measured by different ...platforms varied.•Relative protein concentration was better correlated between some platforms.
When introducing multiplex platforms to measure protein content in precious clinical material there is an increased risk of cross reactivity, loss of sensitivity as well as accuracy. In this paper, four multiplex platforms and one singleplex platform were compared by running pre- and post-treatment plasma samples from CML patients. We found a variation of absolute protein concentrations between platforms. For some of the analytes and platforms, relative differences between pre- and post-treatment samples correlated. We conclude that absolute concentrations measured by different platforms should be compared with caution and comparing relative differences could be more accurate.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
We analyzed and compared the cost-effectiveness of 2 strategies for treating CML patients – using imatinib first in all (altering therapy as needed in a stepwise approach) or by physician’s choice, ...starting either imatinib or one of the approved second-generation tyrosine kinase inhibitors (TKIs) dasatinib or nilotinib. Currently, each TKI is patent-protected and commands about one-third of front-line CML treatment. Life-long treatment is recommended. Imatinib is losing patent exclusivity and facing generic competition presently in the US (in early 2016) and in EU member countries; its price is expected to drop 70-90% within two years following generic entry.
We constructed a Markov model simulating outcomes over 5 years when imatinib 400 mg is used first for all incident chronic phase CML patients, or alternatively by physician choice using any of the 3 TKIs first. The model assumes the commercial payer or health system perspective. In the stepwise approach, if imatinib fails, patients are switched to dasatinib or nilotinib in equal proportions. Patients are assumed to switch drugs if they were intolerant or failed standard efficacy endpoints: complete cytogenetic response (CCyR) or major molecular response (MMR) as defined in the ELN recommendations (Baccarani et al. Blood 2013). The model adjusts the price of imatinib over time as generic competition begins within each market: 100% of the branded price for first 6-months; 60-80% for the second 6-months; 10-30% thereafter.
For each drug, tolerance, efficacy and probabilities of treatment choice, failure, and switching were drawn from published clinical trials (principally IRIS, ENESTnd, DASISON, and second-line phase II and transplant studies) and used Sokal or Euro risk group data where available. Quality-adjusted life years (QALYs) were based on CML-specific health utilities (Szabo et al, 2010). For the US model, direct medical costs per patient were drawn from Marketscan (2001-2007) and included US annual drug prices: imatinib ($76,800), dasatinib and nilotinib ($102,000). Additional costs included patient monitoring, hospitalization, and allogeneic transplantation, if required. Costs and QALYs were discounted at 3% ($US; 2013 values). Univariate and multivariate sensitivity analyses tested parameters with the greatest impact on results. We also considered cost savings in years 4 and 5 from TKI discontinuation in a fraction of patients achieving MR4.5 in years 2 and 3. Results were interpreted from a willingness-to-pay (WTP) of $100,000/QALY.
Compared to physician choice starting any TKI regimen ($172,076; 3.36 QALYs) over the first 5 years, stepwise therapy costs less and offers clinically-equivalent utility ($147,091; 3.25 QALYs) when generic imatinib is available. Thus, stepwise therapy is estimated to have an incremental cost-effectiveness ratio (ICER) of $227,136/QALY. The ICER was favorable for stepwise therapy for each Sokal risk group.
The results are robust to changes based on univariate analyses of the most sensitive parameters (imatinib-associated probability of CCyR/MMR, price drops, and the health utility of suboptimal response or treatment failure). A Bayesian multivariate probabilistic sensitivity analysis using 10,000 Monte Carlo simulations suggested that stepwise therapy is cost-effective in 73.3% of simulations (point estimates above the diagonal WTP line in Figure 1). Limitations include efficacy data drawn from prospective trials; thus, results may not apply to patients with co-morbidities, older age, or lack of access to appropriate specialty care.
We conclude that when imatinib loses patent protection in 2016 in the US and its price declines, it will be the cost-effective initial treatment strategy for chronic phase CML compared to dasatinib and nilotinib. Our model and results demonstrate that system-level cost-effectiveness can be estimated based on country-specific (1) CML incidence and prevalence, (2) CML treatment patterns and associated costs across all medical inputs, including drugs, (3) expected date for loss of patent exclusivity, and (4) pricing policies for generic drugs and formulary placement decisions. Comparative cost-effectiveness data for the US, UK, and other selected EU countries will be presented.
Display omitted
Larson:Ariad: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Pfizer: Consultancy. Apperley:Ariad: Research Funding; Bristol Myers Squibb: Research Funding; Novartis: Research Funding; Pfizer: Research Funding. Baccarani:Ariad: Consultancy, Honoraria; Bristol Myers Squibb: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria. Eigendorff:Bristol Myers Squibb: Research Funding; Novartis: Research Funding. Martinelli:Ariad: Research Funding; Bristol Myers Squibb: Research Funding; Novartis: Research Funding; Pfizer: Research Funding. Mueller:Ariad: Research Funding; Bristol Myers Squibb: Research Funding; Novartis: Research Funding; Pfizer: Research Funding. Niederwieser:Novartis: Research Funding. Saussele:Bristol Myers Squibb: Research Funding; Novartis: Research Funding; Pfizer: Research Funding. Silver:Novartis: Research Funding. Hehlmann:Novartis: Research Funding; Bristol Myers Squibb: Research Funding.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
National and regional population-based registries are, provided diagnostic accuracy and full coverage of the target population, indispensible tools for epidemiological research. Chronic myeloid ...leukaemia (CML) registries with more comprehensive reporting may also provide complementary data on treatment outcome to those obtained from clinical trials. Reports from several European CML registries consistently show a crude annual incidence of 0.7–1.0/100,000, a median age at diagnosis of 57–60 years and a male/female ratio of 1.2–1.7. The incidence of CML has been stable over time. Worldwide, variations in the reported incidence of CML may be due to methodological issues, but a true difference between different geographical areas and/or ethnical subgroups cannot be excluded. The prevalence of CML is not well known but has been estimated to be 10–12/100,000 inhabitants with a steady increase due to the dramatic improvement in survival of these patients. In recent population-based studies, CML patients have an overall survival that is comparable to that shown in large clinical trials, though relative survival in patients >70 years is still decreased. The importance of socio-economic factors and health-care setting for outcome and the possible increased risk of secondary cancer in CML are areas of ongoing research.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
In patients with chronic myeloid leukemia (CML), first-line imatinib treatment leads to 8-year overall survival (OS) probabilities above 80%. Many patients die of reasons unrelated to CML. This work ...tackled the reassessment of prognosis under particular consideration of the probabilities of dying of CML. Analyses were based on 2290 patients with chronic phase CML treated with imatinib in six clinical trials. 'Death due to CML' was defined by death after disease progression. At 8 years, OS was 89%. Of 208 deceased patients, 44% died of CML. Higher age, more peripheral blasts, bigger spleen and low platelet counts were significantly associated with increased probabilities of dying of CML and determined a new long-term survival score with three prognostic groups. Compared with the low-risk group, the patients of the intermediate- and the high-risk group had significantly higher probabilities of dying of CML. The score was successfully validated in an independent sample of 1120 patients. In both samples, the new score differentiated probabilities of dying of CML better than the Sokal, Euro and the European Treatment and Outcome Study (EUTOS) score. The new score identified 61% low-risk patients with excellent long-term outcome and 12% high-risk patients. The new score supports the prospective assessment of long-term antileukemic efficacy and risk-adapted treatment.
Full text
Available for:
EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
The outcome of chronic myeloid leukemia (CML) has been profoundly changed by the introduction of tyrosine kinase inhibitors into therapy, but the prognosis of patients with CML is still evaluated ...using prognostic scores developed in the chemotherapy and interferon era. The present work describes a new prognostic score that is superior to the Sokal and Euro scores both in its prognostic ability and in its simplicity. The predictive power of the score was developed and tested on a group of patients selected from a registry of 2060 patients enrolled in studies of first-line treatment with imatinib-based regimes. The EUTOS score using the percentage of basophils and spleen size best discriminated between high-risk and low-risk groups of patients, with a positive predictive value of not reaching a CCgR of 34%. Five-year progression-free survival was significantly better in the low- than in the high-risk group (90% vs 82%, P = .006). These results were confirmed in the validation sample. The score can be used to identify CML patients with significantly lower probabilities of responding to therapy and survival, thus alerting physicians to those patients who require closer observation and early intervention.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
PDF
