The impact of post-remission granulocyte colony-stimulating factor use in the phase 3 studies of venetoclax combination treatments in patients with newly diagnosed acute myeloid leukemia

IF 10.1 1区 医学 Q1 HEMATOLOGY American Journal of Hematology Pub Date : 2024-11-01 DOI:10.1002/ajh.27515
Courtney D. DiNardo, Keith W. Pratz, Panayiotis Panayiotidis, Xudong Wei, Vladimir Vorobyev, Árpád Illés, Inho Kim, Vladimir Ivanov, Grace Ku, Catherine L. Miller, Meng Zhang, Fernando Tatsch, Jalaja Potluri, Xenia Schmidt, Christian Récher
{"title":"The impact of post-remission granulocyte colony-stimulating factor use in the phase 3 studies of venetoclax combination treatments in patients with newly diagnosed acute myeloid leukemia","authors":"Courtney D. DiNardo, Keith W. Pratz, Panayiotis Panayiotidis, Xudong Wei, Vladimir Vorobyev, Árpád Illés, Inho Kim, Vladimir Ivanov, Grace Ku, Catherine L. Miller, Meng Zhang, Fernando Tatsch, Jalaja Potluri, Xenia Schmidt, Christian Récher","doi":"10.1002/ajh.27515","DOIUrl":null,"url":null,"abstract":"<p>Based on results from the randomized, placebo-controlled phase 3 VIALE-A (NCT02993523) and VIALE-C (NCT03069352) trials,<span><sup>1-4</sup></span> venetoclax in combination with hypomethylating agents or low-dose cytarabine (LDAC) has become standard of care in patients with newly diagnosed acute myeloid leukemia (AML) who are ineligible for intensive chemotherapy. Cytopenias are common adverse events with venetoclax and are primarily managed with protocol-mandated dose modifications, including dose interruptions and cycle delays.<span><sup>2, 5</sup></span> Neutropenia and febrile neutropenia may be mitigated with granulocyte-colony stimulating factor (G-CSF)<span><sup>4, 6</sup></span>; however, limited evidence exists on G-CSF use and impact on safety and efficacy in patients receiving low-intensity therapies. The present analysis assessed outcomes by G-CSF use post-remission (i.e., following blast clearance) among patients with newly diagnosed, intensive-chemotherapy–ineligible AML who received venetoclax-azacitidine or venetoclax-LDAC in the VIALE-A and VIALE-C trials, respectively.</p>\n<p>VIALE-A and VIALE-C study designs have been previously described.<span><sup>1, 3</sup></span> Both trials enrolled patients aged ≥18 years with newly diagnosed AML who were ineligible for induction chemotherapy (aged ≥75 years or with comorbid conditions precluding intensive chemotherapy treatment). In VIALE-A, patients received venetoclax-azacitidine or placebo-azacitidine; in VIALE-C, patients received venetoclax-LDAC or placebo-LDAC. Both trial protocols allowed G-CSF use with administration for cytopenia management as per institutional practice. In this exploratory post hoc analysis, patients treated with venetoclax combinations who had achieved a best response of complete remission (CR)/CR with incomplete hematologic recovery (CRi) were assessed for outcomes by G-CSF use, including overall survival (OS), duration of CR/CRi (DOR), and safety. G-CSF use was analyzed from the time of remission achievement (post-remission), defined as blast clearance (&lt;5% bone marrow blasts) for this analysis. Clinical data cutoff was December 1, 2021 for VIALE-A and February 15, 2021 for VIALE-C.<span><sup>2, 3</sup></span> The analysis populations included patients who achieved best response of CR/CRi, unless otherwise specified.<span><sup>1, 3</sup></span> Data presentation is descriptive in nature, and formal statistical comparisons were not performed due to the post hoc nature of this analysis. Additional details are in the Data S1.</p>\n<p>Approximately half of patients treated with venetoclax combinations in VIALE-A and VIALE-C received G-CSF post-remission. In VIALE-A, 50% (95/191) of CR/CRi responders in the venetoclax-azacitidine arm and 26% (11/42) in the placebo-azacitidine arm received G-CSF post-remission (Tables S1 and S2). In VIALE-C, 46% (32/69) of CR/CRi responders in the venetoclax-LDAC arm and 22% (2/9) in the placebo-LDAC arm received G-CSF post-remission (Tables S3 and S4). In both trials, baseline characteristics, including baseline grade ≥3 neutropenia, were generally similar between patients who received G-CSF and those who did not (Tables S5 and S6). In VIALE-A, the median time to first G-CSF use after remission was 36 days (range, 2–483) in the venetoclax-azacitidine arm, and 45/95 patients (47%) received G-CSF in ≥50% of treatment cycles; similar results were observed in the placebo arm (Table S2). Patients received concomitant G-CSF for a median of five treatment cycles in both arms (Table S2). Time to G-CSF use and treatment cycles for VIALE-C are in Table S3.</p>\n<p>In the venetoclax-azacitidine arm of VIALE-A, 89% of CR/CRi responders who received G-CSF and 83% of those who did not had ≥1 occurrence of grade 4 neutropenia (defined as a laboratory value of ANC &lt;500/μL) after remission (Table S7). The median time to neutrophil count recovery (absolute neutrophil count ≥500/μL) from onset of grade 4 neutropenia was similar in the venetoclax arm regardless of G-CSF use (14 days [IQR, 8–22] in patients who received G-CSF; 14 days [IQR, 8.5–30.5] in those who did not). Similarly, most patients in the placebo-azacitidine arm (73% of those who received G-CSF; 55% of those who did not) had ≥1 occurrence of grade 4 neutropenia after remission. The median time to neutrophil count recovery from first post-remission grade 4 neutropenia was shorter with G-CSF use (12 days [IQR, 10.5–21.5] in patients who received G-CSF; 21 days [IQR, 13–39] in those who did not). Nadir and median neutrophil counts per treatment cycle among patients who achieved CR/CRi and received G-CSF in the venetoclax-azacitidine arm of the VIALE-A trial generally increased with each cycle (Figure S1). Similar trends were observed in VIALE-C (Table S8 and Figure S2).</p>\n<p>In the venetoclax-azacitidine arm of VIALE-A, grade ≥3 neutropenia occurred in 34% (32/95) of patients receiving G-CSF versus 28% (27/96) not receiving G-CSF (median duration, 16.0 vs. 15.5 days post-remission; Tables S9 and S10). Grade ≥3 febrile neutropenia occurred in 44% (42/95) of patients receiving G-CSF versus 21% (20/96) of patients not receiving G-CSF (median duration, 8.5 vs. 9.5 days). Grade ≥3 infections occurred in 62 patients (65%) who received G-CSF and 47 patients (49%) who did not. Selected grade ≥3 treatment-emergent adverse events and durations among CR/CRi responders are summarized in Tables S9 and S10 for VIALE-A and Tables S11 and S12 for VIALE-C. A clear impact of G-CSF use on incidence or duration of febrile neutropenia was not observed, which may be confounded by more frequent G-CSF use in patients experiencing neutropenia.</p>\n<p>Among CR/CRi responders treated with venetoclax-azacitidine in VIALE-A, the median DOR was 25.5 months (95% CI, 18.1–32.4) for those receiving G-CSF and 12.8 months (95% CI, 7.9–18.0) for those not receiving G-CSF (Figure 1A, Table S13). In the placebo-azacitidine arm, the median DOR was 15.1 months (95% CI, 8.5–25.0) for patients receiving G-CSF and 6.7 months (95% CI, 3.5–13.5) for those not receiving G-CSF. The median OS was 30.8 months (95% CI, 24.4–38.8) for CR/CRi responders in the venetoclax-azacitidine arm receiving G-CSF versus 21.1 months (95% CI, 15.8–27.3) for those not receiving G-CSF (Figure 1B, Table S13). In the placebo-azacitidine arm, the median OS was 25.0 months (95% CI, 15.4–39.4) for CR/CRi responders receiving G-CSF versus 15.2 months (95% CI, 10.6–27.5) for those not receiving G-CSF. Similar outcomes were observed in VIALE-C (Figure S3, Table S14).</p>\n<figure><picture>\n<source media=\"(min-width: 1650px)\" srcset=\"/cms/asset/18427a98-ec76-4a06-98d3-2914748380fa/ajh27515-fig-0001-m.jpg\"/><img alt=\"Details are in the caption following the image\" data-lg-src=\"/cms/asset/18427a98-ec76-4a06-98d3-2914748380fa/ajh27515-fig-0001-m.jpg\" loading=\"lazy\" src=\"/cms/asset/b485f385-3e13-4fcb-b43e-40c97f69bad0/ajh27515-fig-0001-m.png\" title=\"Details are in the caption following the image\"/></picture><figcaption>\n<div><strong>FIGURE 1<span style=\"font-weight:normal\"></span></strong><div>Open in figure viewer<i aria-hidden=\"true\"></i><span>PowerPoint</span></div>\n</div>\n<div>Duration of CR/CRi (A) and overall survival (B) by G-CSF use post-remission in patients achieving CR/CRi in VIALE-A. Aza, azacitidine; CI, confidence interval; CR, complete remission; CRi, complete remission with incomplete hematologic recovery; G-CSF, granulocyte-colony stimulating factor; Pbo, placebo; Ven, venetoclax.</div>\n</figcaption>\n</figure>\n<p>In both trials, patients who received venetoclax and achieved MRD response (&lt;10<sup>−3</sup>) appeared more likely to receive G-CSF. In VIALE-A, among CR/CRi responders in the venetoclax-azacitidine arm who received G-CSF, 51% (41/80) achieved an MRD response, whereas 49% (39/80) did not. Among patients who did not receive G-CSF, 33% (28/85) achieved an MRD response, whereas 67% (57/85) did not (Table S15). This may partially explain the numerically higher OS and DOR observed in patients who received G-CSF. The median OS among patients with MRD response in the venetoclax-azacitidine arm was 38.8 months (95% CI, 28.8-not estimable) for patients who received G-CSF and 29.3 months (95% CI, 21.1–40.1) for those who did not. Among patients who did not achieve MRD response, the median OS was 22.9 months (95% CI, 12.7–36.3) for patients who received G-CSF and 15.2 months (95% CI, 11.2–21.8) for those who did not. The placebo-azacitidine arm showed similar trends. VIALE-C results are in Table S16.</p>\n<p>In the venetoclax-azacitidine arm of VIALE-A, the median venetoclax dosing duration was 21 days (IQR, 21–28) per cycle among all CR/CRi responders, irrespective of G-CSF use (Table S17, Figure S4). Among all CR/CRi responders, the median duration of end-of-cycle dose holds (defined as reduced venetoclax duration per cycle plus delay of next cycle) was 12 days (IQR, 7–18) versus 14 (IQR, 7–21) days in patients with versus without G-CSF use, respectively (Table S17, Figure S4). The median time from day 1 of one cycle to day 1 of the next cycle was 32 days (IQR, 28–38) for those receiving G-CSF and 35 days (IQR, 28–42) for those who did not. The median duration of end-of-cycle dose holds in CR/CRi responders was 10 days (IQR, 7–15) in those who frequently received G-CSF (≥50% of cycles) versus 13 days (IQR, 7–20) in those who received G-CSF in &lt;50% of cycles. The median time from the start of one cycle to the start of the next cycle was 30 days (IQR, 28–36) in responders with frequent G-CSF use versus 33 days (IQR, 28–38) in patients receiving G-CSF in &lt;50% of cycles. Shorter delays between treatment cycles were also observed in long-term CR/CRi responders who received ≥6 cycles of venetoclax-azacitidine (Table S17). VIALE-C results are in Figure S4 and Table S18.</p>\n<p>In this exploratory analysis of the VIALE-A and VIALE-C trials, post-remission G-CSF use was not associated with new safety signals and had no negative impact on DOR or OS among venetoclax-treated patients. Delays between treatment cycles were shorter in patients who received post-remission G-CSF. While G-CSF itself is unlikely to provide direct anti-leukemic benefits, the ability to maintain treatment cycles with shorter delays may translate into benefit for patients. Limitations of this analysis include small patient numbers and administration of G-CSF as per institutional practice rather than protocol-mandated, potentially leading to heterogeneous G-CSF use. Although VIALE-A and VIALE-C studies were not designed to evaluate the impact of G-CSF on cytopenia management, this post hoc analysis supports the use of G-CSF in addition to recommended dose modifications for management of cytopenias in patients with intensive-chemotherapy–ineligible AML who receive venetoclax-based therapy.</p>","PeriodicalId":7724,"journal":{"name":"American Journal of Hematology","volume":null,"pages":null},"PeriodicalIF":10.1000,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"American Journal of Hematology","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1002/ajh.27515","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"HEMATOLOGY","Score":null,"Total":0}
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Abstract

Based on results from the randomized, placebo-controlled phase 3 VIALE-A (NCT02993523) and VIALE-C (NCT03069352) trials,1-4 venetoclax in combination with hypomethylating agents or low-dose cytarabine (LDAC) has become standard of care in patients with newly diagnosed acute myeloid leukemia (AML) who are ineligible for intensive chemotherapy. Cytopenias are common adverse events with venetoclax and are primarily managed with protocol-mandated dose modifications, including dose interruptions and cycle delays.2, 5 Neutropenia and febrile neutropenia may be mitigated with granulocyte-colony stimulating factor (G-CSF)4, 6; however, limited evidence exists on G-CSF use and impact on safety and efficacy in patients receiving low-intensity therapies. The present analysis assessed outcomes by G-CSF use post-remission (i.e., following blast clearance) among patients with newly diagnosed, intensive-chemotherapy–ineligible AML who received venetoclax-azacitidine or venetoclax-LDAC in the VIALE-A and VIALE-C trials, respectively.

VIALE-A and VIALE-C study designs have been previously described.1, 3 Both trials enrolled patients aged ≥18 years with newly diagnosed AML who were ineligible for induction chemotherapy (aged ≥75 years or with comorbid conditions precluding intensive chemotherapy treatment). In VIALE-A, patients received venetoclax-azacitidine or placebo-azacitidine; in VIALE-C, patients received venetoclax-LDAC or placebo-LDAC. Both trial protocols allowed G-CSF use with administration for cytopenia management as per institutional practice. In this exploratory post hoc analysis, patients treated with venetoclax combinations who had achieved a best response of complete remission (CR)/CR with incomplete hematologic recovery (CRi) were assessed for outcomes by G-CSF use, including overall survival (OS), duration of CR/CRi (DOR), and safety. G-CSF use was analyzed from the time of remission achievement (post-remission), defined as blast clearance (<5% bone marrow blasts) for this analysis. Clinical data cutoff was December 1, 2021 for VIALE-A and February 15, 2021 for VIALE-C.2, 3 The analysis populations included patients who achieved best response of CR/CRi, unless otherwise specified.1, 3 Data presentation is descriptive in nature, and formal statistical comparisons were not performed due to the post hoc nature of this analysis. Additional details are in the Data S1.

Approximately half of patients treated with venetoclax combinations in VIALE-A and VIALE-C received G-CSF post-remission. In VIALE-A, 50% (95/191) of CR/CRi responders in the venetoclax-azacitidine arm and 26% (11/42) in the placebo-azacitidine arm received G-CSF post-remission (Tables S1 and S2). In VIALE-C, 46% (32/69) of CR/CRi responders in the venetoclax-LDAC arm and 22% (2/9) in the placebo-LDAC arm received G-CSF post-remission (Tables S3 and S4). In both trials, baseline characteristics, including baseline grade ≥3 neutropenia, were generally similar between patients who received G-CSF and those who did not (Tables S5 and S6). In VIALE-A, the median time to first G-CSF use after remission was 36 days (range, 2–483) in the venetoclax-azacitidine arm, and 45/95 patients (47%) received G-CSF in ≥50% of treatment cycles; similar results were observed in the placebo arm (Table S2). Patients received concomitant G-CSF for a median of five treatment cycles in both arms (Table S2). Time to G-CSF use and treatment cycles for VIALE-C are in Table S3.

In the venetoclax-azacitidine arm of VIALE-A, 89% of CR/CRi responders who received G-CSF and 83% of those who did not had ≥1 occurrence of grade 4 neutropenia (defined as a laboratory value of ANC <500/μL) after remission (Table S7). The median time to neutrophil count recovery (absolute neutrophil count ≥500/μL) from onset of grade 4 neutropenia was similar in the venetoclax arm regardless of G-CSF use (14 days [IQR, 8–22] in patients who received G-CSF; 14 days [IQR, 8.5–30.5] in those who did not). Similarly, most patients in the placebo-azacitidine arm (73% of those who received G-CSF; 55% of those who did not) had ≥1 occurrence of grade 4 neutropenia after remission. The median time to neutrophil count recovery from first post-remission grade 4 neutropenia was shorter with G-CSF use (12 days [IQR, 10.5–21.5] in patients who received G-CSF; 21 days [IQR, 13–39] in those who did not). Nadir and median neutrophil counts per treatment cycle among patients who achieved CR/CRi and received G-CSF in the venetoclax-azacitidine arm of the VIALE-A trial generally increased with each cycle (Figure S1). Similar trends were observed in VIALE-C (Table S8 and Figure S2).

In the venetoclax-azacitidine arm of VIALE-A, grade ≥3 neutropenia occurred in 34% (32/95) of patients receiving G-CSF versus 28% (27/96) not receiving G-CSF (median duration, 16.0 vs. 15.5 days post-remission; Tables S9 and S10). Grade ≥3 febrile neutropenia occurred in 44% (42/95) of patients receiving G-CSF versus 21% (20/96) of patients not receiving G-CSF (median duration, 8.5 vs. 9.5 days). Grade ≥3 infections occurred in 62 patients (65%) who received G-CSF and 47 patients (49%) who did not. Selected grade ≥3 treatment-emergent adverse events and durations among CR/CRi responders are summarized in Tables S9 and S10 for VIALE-A and Tables S11 and S12 for VIALE-C. A clear impact of G-CSF use on incidence or duration of febrile neutropenia was not observed, which may be confounded by more frequent G-CSF use in patients experiencing neutropenia.

Among CR/CRi responders treated with venetoclax-azacitidine in VIALE-A, the median DOR was 25.5 months (95% CI, 18.1–32.4) for those receiving G-CSF and 12.8 months (95% CI, 7.9–18.0) for those not receiving G-CSF (Figure 1A, Table S13). In the placebo-azacitidine arm, the median DOR was 15.1 months (95% CI, 8.5–25.0) for patients receiving G-CSF and 6.7 months (95% CI, 3.5–13.5) for those not receiving G-CSF. The median OS was 30.8 months (95% CI, 24.4–38.8) for CR/CRi responders in the venetoclax-azacitidine arm receiving G-CSF versus 21.1 months (95% CI, 15.8–27.3) for those not receiving G-CSF (Figure 1B, Table S13). In the placebo-azacitidine arm, the median OS was 25.0 months (95% CI, 15.4–39.4) for CR/CRi responders receiving G-CSF versus 15.2 months (95% CI, 10.6–27.5) for those not receiving G-CSF. Similar outcomes were observed in VIALE-C (Figure S3, Table S14).

Abstract Image
FIGURE 1
Open in figure viewerPowerPoint
Duration of CR/CRi (A) and overall survival (B) by G-CSF use post-remission in patients achieving CR/CRi in VIALE-A. Aza, azacitidine; CI, confidence interval; CR, complete remission; CRi, complete remission with incomplete hematologic recovery; G-CSF, granulocyte-colony stimulating factor; Pbo, placebo; Ven, venetoclax.

In both trials, patients who received venetoclax and achieved MRD response (<10−3) appeared more likely to receive G-CSF. In VIALE-A, among CR/CRi responders in the venetoclax-azacitidine arm who received G-CSF, 51% (41/80) achieved an MRD response, whereas 49% (39/80) did not. Among patients who did not receive G-CSF, 33% (28/85) achieved an MRD response, whereas 67% (57/85) did not (Table S15). This may partially explain the numerically higher OS and DOR observed in patients who received G-CSF. The median OS among patients with MRD response in the venetoclax-azacitidine arm was 38.8 months (95% CI, 28.8-not estimable) for patients who received G-CSF and 29.3 months (95% CI, 21.1–40.1) for those who did not. Among patients who did not achieve MRD response, the median OS was 22.9 months (95% CI, 12.7–36.3) for patients who received G-CSF and 15.2 months (95% CI, 11.2–21.8) for those who did not. The placebo-azacitidine arm showed similar trends. VIALE-C results are in Table S16.

In the venetoclax-azacitidine arm of VIALE-A, the median venetoclax dosing duration was 21 days (IQR, 21–28) per cycle among all CR/CRi responders, irrespective of G-CSF use (Table S17, Figure S4). Among all CR/CRi responders, the median duration of end-of-cycle dose holds (defined as reduced venetoclax duration per cycle plus delay of next cycle) was 12 days (IQR, 7–18) versus 14 (IQR, 7–21) days in patients with versus without G-CSF use, respectively (Table S17, Figure S4). The median time from day 1 of one cycle to day 1 of the next cycle was 32 days (IQR, 28–38) for those receiving G-CSF and 35 days (IQR, 28–42) for those who did not. The median duration of end-of-cycle dose holds in CR/CRi responders was 10 days (IQR, 7–15) in those who frequently received G-CSF (≥50% of cycles) versus 13 days (IQR, 7–20) in those who received G-CSF in <50% of cycles. The median time from the start of one cycle to the start of the next cycle was 30 days (IQR, 28–36) in responders with frequent G-CSF use versus 33 days (IQR, 28–38) in patients receiving G-CSF in <50% of cycles. Shorter delays between treatment cycles were also observed in long-term CR/CRi responders who received ≥6 cycles of venetoclax-azacitidine (Table S17). VIALE-C results are in Figure S4 and Table S18.

In this exploratory analysis of the VIALE-A and VIALE-C trials, post-remission G-CSF use was not associated with new safety signals and had no negative impact on DOR or OS among venetoclax-treated patients. Delays between treatment cycles were shorter in patients who received post-remission G-CSF. While G-CSF itself is unlikely to provide direct anti-leukemic benefits, the ability to maintain treatment cycles with shorter delays may translate into benefit for patients. Limitations of this analysis include small patient numbers and administration of G-CSF as per institutional practice rather than protocol-mandated, potentially leading to heterogeneous G-CSF use. Although VIALE-A and VIALE-C studies were not designed to evaluate the impact of G-CSF on cytopenia management, this post hoc analysis supports the use of G-CSF in addition to recommended dose modifications for management of cytopenias in patients with intensive-chemotherapy–ineligible AML who receive venetoclax-based therapy.

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在新确诊急性髓性白血病患者的 Venetoclax 联合疗法 3 期研究中使用缓解后粒细胞集落刺激因子的影响
在接受 G-CSF 治疗的患者中,44%(42/95)发生了≥3 级发热性中性粒细胞减少症,而在未接受 G-CSF 治疗的患者中,这一比例为 21%(20/96)(中位持续时间为 8.5 天对 9.5 天)。62名接受G-CSF治疗的患者(65%)和47名未接受G-CSF治疗的患者(49%)发生了≥3级感染。VIALE-A的表S9和表S10以及VIALE-C的表S11和表S12汇总了CR/CRi应答者的部分≥3级治疗突发不良事件和持续时间。没有观察到使用 G-CSF 对发热性中性粒细胞减少症的发生率或持续时间有明显的影响,这可能与中性粒细胞减少症患者更频繁地使用 G-CSF 有关。在VIALE-A中接受venetoclax-azacitidine治疗的CR/CRi应答者中,接受G-CSF治疗者的中位DOR为25.5个月(95% CI,18.1-32.4),未接受G-CSF治疗者的中位DOR为12.8个月(95% CI,7.9-18.0)(图1A,表S13)。在安慰剂-阿扎胞苷治疗组中,接受 G-CSF 治疗的患者的中位 DOR 为 15.1 个月(95% CI,8.5-25.0),未接受 G-CSF 治疗的患者的中位 DOR 为 6.7 个月(95% CI,3.5-13.5)。接受 G-CSF 治疗的 Venetoclax-azacitidine 组 CR/CRi 反应者的中位 OS 为 30.8 个月(95% CI,24.4-38.8),而未接受 G-CSF 治疗的 CR/CRi 反应者的中位 OS 为 21.1 个月(95% CI,15.8-27.3)(图 1B,表 S13)。在安慰剂-阿扎胞苷治疗组中,接受 G-CSF 治疗的 CR/CRi 反应者的中位 OS 为 25.0 个月(95% CI,15.4-39.4),而未接受 G-CSF 治疗者的中位 OS 为 15.2 个月(95% CI,10.6-27.5)。在 VIALE-C 中也观察到了类似的结果(图 S3,表 S14)。图 1在图形浏览器中打开PowerPoint在 VIALE-A 中获得 CR/CRi 的患者中,根据缓解后使用 G-CSF 的情况,CR/CRi 持续时间(A)和总生存期(B)。Aza,阿扎胞苷;CI,置信区间;CR,完全缓解;CRi,完全缓解伴不完全血液学恢复;G-CSF,粒细胞集落刺激因子;Pbo,安慰剂;Ven,venetoclax.在这两项试验中,接受venetoclax治疗并达到MRD反应(&lt;10-3)的患者似乎更有可能接受G-CSF治疗。在VIALE-A试验中,接受G-CSF治疗的Venetoclax-阿扎胞苷治疗组CR/CRi应答者中,51%(41/80)获得了MRD应答,而49%(39/80)未获得MRD应答。在未接受 G-CSF 治疗的患者中,33%(28/85)获得了 MRD 反应,而 67%(57/85)未获得 MRD 反应(表 S15)。这可能是接受 G-CSF 治疗的患者的 OS 和 DOR 数值较高的部分原因。在 Venetoclax-azacitidine 治疗组的 MRD 反应患者中,接受 G-CSF 治疗的患者的中位 OS 为 38.8 个月(95% CI,28.8-无法估计),未接受 G-CSF 治疗的患者的中位 OS 为 29.3 个月(95% CI,21.1-40.1)。在未获得 MRD 反应的患者中,接受 G-CSF 治疗的患者的中位 OS 为 22.9 个月(95% CI,12.7-36.3),未接受 G-CSF 治疗的患者的中位 OS 为 15.2 个月(95% CI,11.2-21.8)。安慰剂-阿扎胞苷治疗组也呈现出类似的趋势。VIALE-C的结果见表S16。在VIALE-A的venetoclax-阿扎胞苷治疗组中,无论是否使用G-CSF,所有CR/CRi应答者每个周期的中位venetoclax用药时间为21天(IQR,21-28)(表S17,图S4)。在所有 CR/CRi 反应者中,使用 G-CSF 与未使用 G-CSF 患者的周期末停药中位持续时间(定义为每个周期 Venetoclax 持续时间缩短加上下一周期延迟)分别为 12 天(IQR,7-18)和 14 天(IQR,7-21)(表 S17,图 S4)。接受 G-CSF 治疗的患者从一个周期的第 1 天到下一周期第 1 天的中位时间为 32 天(IQR,28-38),未接受 G-CSF 治疗的患者为 35 天(IQR,28-42)。经常接受G-CSF治疗(≥50%的周期)的CR/CRi应答者周期末停药的中位时间为10天(IQR,7-15天),而50%的周期接受G-CSF治疗的CR/CRi应答者周期末停药的中位时间为13天(IQR,7-20天)。频繁使用 G-CSF 的应答者从一个周期开始到下一个周期开始的中位时间为 30 天(IQR,28-36),而 50%周期接受 G-CSF 的患者为 33 天(IQR,28-38)。在接受≥6个周期 venetoclax-azacitidine 治疗的长期 CR/CRi 反应者中,也观察到治疗周期之间的延迟较短(表 S17)。VIALE-C试验结果见图S4和表S18。在这项对VIALE-A和VIALE-C试验的探索性分析中,缓解后使用G-CSF与新的安全性信号无关,对接受venetoclax治疗的患者的DOR或OS没有负面影响。接受缓解后 G-CSF 治疗的患者治疗周期之间的延迟时间更短。虽然G-CSF本身不太可能带来直接的抗白血病益处,但能够维持更短的治疗周期可能会使患者获益。这项分析的局限性包括:患者人数较少,G-CSF的使用是按照机构惯例而非方案规定进行的,这可能会导致G-CSF的使用不尽相同。 尽管 VIALE-A 和 VIALE-C 研究的目的不是评估 G-CSF 对细胞减少症治疗的影响,但这项事后分析支持在接受以 Venetoclax 为基础的强化化疗不合格 AML 患者的细胞减少症治疗中,除了建议的剂量调整外,还使用 G-CSF。
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来源期刊
CiteScore
15.70
自引率
3.90%
发文量
363
审稿时长
3-6 weeks
期刊介绍: The American Journal of Hematology offers extensive coverage of experimental and clinical aspects of blood diseases in humans and animal models. The journal publishes original contributions in both non-malignant and malignant hematological diseases, encompassing clinical and basic studies in areas such as hemostasis, thrombosis, immunology, blood banking, and stem cell biology. Clinical translational reports highlighting innovative therapeutic approaches for the diagnosis and treatment of hematological diseases are actively encouraged.The American Journal of Hematology features regular original laboratory and clinical research articles, brief research reports, critical reviews, images in hematology, as well as letters and correspondence.
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