What Is Myelofibrosis?

Posted on by

By Julie Scott, MSN, ANP-BC, AOCNP

Published on July 26, 2023

Myelofibrosis is a rare type of bone marrow cancer. In this condition, extensive scarring (fibrosis) occurs in the bone marrow, which keeps the bone marrow from producing the right number of blood cells.1

When myelofibrosis occurs, some people may not have any symptoms, while others have severe symptoms that require immediate treatment. This article will explain the symptoms of myelofibrosis, how it is diagnosed, and how it is treated.

How Myelofibrosis Affects the Body

Bone marrow is present inside the middle of the bones. It is normally a soft, spongy texture. It produces WBCs, RBCs, and platelets.

In myelofibrosis, one of the cells of the bone marrow begins to grow abnormally, multiply, and continue to produce more abnormal cells. Eventually, abnormal cells are present in high enough numbers to crowd out the healthy cells.

These abnormal cells cause fibrosis, which prevents the bone marrow from producing the correct number of blood cells the body needs to function normally.2 Over time, there is an increased risk of developing acute myeloid leukemia (AML), another form of blood cancer.1

Myelofibrosis Types

The initial cause of abnormal bone marrow development determines the type of myelofibrosis. The two types are primary and secondary.

Primary Myelofibrosis

With primary myelofibrosis, the change in the bone marrow cells happens spontaneously. It doesn’t occur due to a previous bone marrow condition.1

Secondary Myelofibrosis

With secondary myelofibrosis, the fibrosis occurs due to another bone marrow disorder, specifically polycythemia vera or essential thrombocythemia.3

Polycythemia vera is a blood disorder in which the bone marrow produces too many blood cells, most often red blood cells, but can also include white blood cells and platelets.2 Essential thrombocythemia is a disorder in which the bone marrow makes too many platelets.4

Myelofibrosis Symptoms

As too few blood cells are made, symptoms will start to develop. The rate at which symptoms develop and how severe they become can vary from person to person, and may take years to be experienced. Symptoms associated with myelofibrosis include:2

  • Feeling tired
  • Shortness of breath
  • Pale skin
  • Headaches
  • Fever
  • Night sweats
  • Enlarged spleen
  • Enlarged liver
  • Frequent infections
  • Easy bleeding or bruising
  • Abdominal pain
  • Joint pain
  • Bone pain

Tumors may develop in the lungs, skin, liver, or gastrointestinal tract and cause further symptoms.2

Causes of Myelofibrosis

For those living with primary myelofibrosis, the exact cause of the disease may never be known.

However, in about half of the cases of primary myelofibrosis, a mutation in the JAK2 gene is found.5 The JAK2 mutation is also frequently found in those with polycythemia vera and essential thrombocythemia.

This mutation isn’t inherited. Instead, it develops spontaneously in a bone marrow cell. It produces a protein that causes the bone marrow to overproduce platelet precursor cells called megakaryocytes. These cells stimulate other cells to produce too much collagen, a protein that then builds up and produces scarring in the bone marrow.

Other gene mutations that may play a role in developing myelofibrosis include the CALR and MPL genes.1

Risk factors that may play a role in developing primary myelofibrosis include:2

  • Increasing age
  • History of exposure to chemicals including benzene, fluoride, or phosphorus

Risk factors for developing secondary myelofibrosis include:6

  • Having another cancer that has spread into the bone marrow
  • Having polycythemia vera or essential thrombocythemia

Diagnosis of Myelofibrosis

The diagnosis of myelofibrosis often starts when someone presents to their healthcare provider for evaluation of a symptom that they are experiencing. During this evaluation, a healthcare provider may start with a detailed history and physical examination. Blood work may be taken which can start the process of finding a diagnosis.1

A complete blood count (CBC) and peripheral blood smear measure the number of WBCs, RBCs, and platelets, as well as their shape and size. Abnormal findings in the CBC may lead to further testing, which may include a bone marrow biopsy.1

During a bone marrow biopsy, a small sample of bone marrow is taken, often from the hip. This allows the pathologist (physician specializing in analyzing body fluids and tissues in a lab setting) the ability to evaluate for any changes or abnormalities in the bone marrow. This test can result in a diagnosis of myelofibrosis.

In addition, a physical exam or imaging study such as a computed tomography (CT) scan may reveal an enlarged spleen.

Other blood testing may include:1

  • Complete metabolic panel (CMP) to evaluate kidney and liver function
  • Coagulation studies
  • Iron levels
  • Lactate dehydrogenase (LDH) to assess inflammation and tissue damage
  • Testing for the JAK2, CALR, and MPL gene mutations

Once a diagnosis of myelofibrosis is made, it is further classified into different risk categories, which helps determine how likely the disease is to turn into AML and can help determine treatment options.

This score is determined by the person’s age, symptoms, hemoglobin level, platelet count, leukocyte (a white blood cell) and leukoblast (a developing white blood cell) count, and certain genetic changes. The higher the score, the more high-risk their myelofibrosis is.

Myelofibrosis Treatment

Some people diagnosed with myelofibrosis, especially those without many symptoms or who have low-risk disease, may not receive any treatment until they become symptomatic. Called a watchful waiting approach, this policy of taking no immediate action regarding treatment includes routine blood tests and visits with their healthcare provider to determine when treatment will be needed.2

If someone is experiencing symptomatic anemia (low RBCs) because of myelofibrosis, they may receive periodic RBC transfusions. There are additional medications that may be given to help the bone marrow make red blood cells.

This may not completely resolve anemia but can keep the red blood cells up at a tolerable level. If someone also has iron deficiency anemia, iron supplements may help improve red blood cell levels.2

To reduce high levels of WBCs and platelets, medications to suppress the bone marrow may be given. An example of one of these medications is hydroxyurea.

An enlarged spleen may need to be treated if it is contributing to symptoms, especially pain or severely low platelets. This can be done through radiation to the spleen or by surgical removal of the spleen.

A medication called Jakafi (ruxolitinib) can be prescribed to those with either primary or secondary myelofibrosis who fall in the moderate- or high-risk category. This medication interferes with the JAK2 pathway that the cells use to grow. Another medication, Inrebic (fedratinib) can also be used to treat intermediate or high-risk primary or secondary myelofibrosis.2

Can Myelofibrosis Be Cured?

The majority of cases of myelofibrosis are treated with the goal of decreasing symptoms of the disease. An attempt can be made to cure the disease through a stem cell transplant.

This approach requires large doses of chemotherapy to kill all of the cancer cells. Stem cells are collected before the procedure to be infused back in after chemotherapy has worked. These stem cells can then begin to resume making normal WBCs, RBCs, and platelets. This procedure is not recommended for everyone with myelofibrosis, as it can lead to severe complications.7

Complications Associated With Myelofibrosis

Complications associated with myelofibrosis are related to the severe decrease in the number of normal WBCs, RBCs, and platelets. As the disease progresses and the blood counts continue to decrease, complications may arise.

With the decrease of white blood cells comes a higher risk of developing infection. Infections can occur anywhere in the body, though most often in the lungs. The infection can be due to bacteria, viruses, or fungi. With infection may come fever, increased weakness, and cough.8

Low red blood cells can result in severe anemia, which prevents enough oxygen-rich blood from getting to the tissues in the body. With the decreased amount of available oxygen comes complications such as heart failure, in which the heart has to work too hard to try to keep up with the increased demand for oxygen.8

Not having enough normal platelets can lead to severe bleeding or hemorrhaging. The bleeding can occur following an injury or can occur spontaneously. The bleeding can become life-threatening if severe and not stopped quickly.8

Blood clotting, the opposite of bleeding, could also occur. If blood clots inappropriately, it can lead to clots moving around the body and getting stuck in areas they are not supposed to be. This can lead to damage to the brain, heart, lungs, and extremities.

Transformation to acute myeloid leukemia occurs in 5% to 10% of those diagnosed with myelofibrosis. This is most common in primary myelofibrosis and is a significant complication since the prognosis is poor with transformation into AML.9

Myelofibrosis Prognosis

The prognosis of myelofibrosis can vary from person to person. It depends upon the type and risk category of their disease. Prognosis can differ slightly based on which scale is used at the time of diagnosis. The table below references the prognosis scale MIPSS70, which is used for those 70 years old or younger and is based on risk group severity.9

 Risk Group 10-Year Survival
 Very high Less than 5%
 High  13%
 Intermediate  37%
 Low  56%
Very Low  92%

When to Contact a Healthcare Provider

See a healthcare provider if you are having symptoms associated with myelofibrosis. Many of these are also associated with other conditions. A workup and diagnosis can ensure you are getting the appropriate treatment.

If you have been diagnosed with myelofibrosis, contact your healthcare provider anytime you’re having concerns about the symptoms you’re experiencing, especially if they continue for some time without getting better.

Your provider may want to run additional tests or start treatment if your symptoms continue. If severe symptoms develop, notify your healthcare provider immediately or seek emergency care.

Summary

Myelofibrosis is a type of blood cancer in which abnormal cells cause the bone marrow to become extensively scarred (fibrosis). The fibrosis doesn’t allow the bone marrow to make blood cells properly, which leads to low blood counts and other complications.

Once formally diagnosed by a bone marrow biopsy, the results will be used by your healthcare provider to develop a treatment plan. Treatments are individualized, ranging from watchful waiting to stem cell transplant.

Read more

Know What Questions to Ask When Treating MPNs

Posted on by

July 27, 2023

Brielle Benyon

Oncology nurses must know what to look for — and what questions to ask — when treating patients with myeloproliferative neoplasms (MPNs), as side effects and other patient characteristics can play a role in determining the best treatment regimen, according to Julie Huynh-Lu, PA-C, a physician assistant from The University of Texas MD Anderson Cancer Center.

MPN-Related Symptoms

“Whenever a patient comes to see us, they also fill out the MPN10 questionnaire, [which is] a list of all the 10 symptoms that frequently occur in our patients,” Huynh-Lu said in an interview with Oncology Nursing News. “Ideally, this should be occurring at every visit. On top of them filling that out, I obviously will ask them specific pointed questions as well just to tease out some more information. But this should occur at every visit.”

Symptoms can vary based on the subtype of MPN a patient has. Huynh-Lu said that patients with polycythemia vera and essential thrombocytosis are more likely to experience headaches, confusion or difficulty focusing, or pain and tingling in the fingertips. Meanwhile, common symptoms for patients with myelofibrosis include anemia and thrombocytopenia; shortness of breath and fatigue; bleeding; and complications from spleen enlargement, such as having a poor appetite.

Knowing about these symptoms is key, as they could indicate a physical issue that warrants a change in treatment, Huynh-Lu said. For example, if a patient is not experiencing splenomegaly (enlarged spleen), there may not need to be prescribed a JAK inhibitor. However, if the patient starts to experience a decreased appetite or feel full after eating only a small amount of food, that could indicate that their spleen is becoming enlarged, and that patient may benefit from being put on a JAK inhibitor.

“It can also change the trajectory on whether or not talking about splenectomy is an option. It’s not really our go-to [treatment] in our department at MD Anderson, but that could certainly lend to a conversation into if surgery is an option,” Huynh-Lu said.

Sometimes symptoms can lead to a change in treatment, while other times there may be an easy fix to manage the issue.

If a patient is currently taking a JAK inhibitor, nurses should be sure to ask them about worsening itching, diarrhea, and frequent infections (such as urinary tract infections or pneumonia). Secondary skin cancers can also occur, said Huynh-Lu, “so we always recommend that they get dermatology checks every 6 months.”

“If their [blood] counts are starting to drop, or if their spleen is starting to grow, well, maybe the medication they’re on right now, the dosage needs to be altered. But if we alter the dose to a higher medication dose, and the side effects are worse, maybe then it’s time to switch to a different class of drugs completely, or same class of drugs, just a different type of drug. There’s also, of course, clinical trials that are available, so that could be an option as well,” Huynh-Lu said.

Patient Characteristics and Comorbidities

Regarding patient characteristics and comorbidities, clinicians should know if patients have a history of cardiac, renal, or hepatic complications, as certain medications can affect these organs.

Additionally, interferons are commonly used to treat patients with polycythemia vera. However, according to the National Institutes of Health, these drugs can impact the synthesis of serotonin, dopamine, epinephrine, and norepinephrine, thereby increasing a patient’s risk for depression. That said, clinicians should know if patients have a history of depression or an autoimmune disease before they prescribe an interferon to a patient, Huynh-Lu said.

It also may be beneficial for oncology nurses to ask patients if they are experiencing financial struggles due to their cancer care.

“I know these drugs can be quite expensive. Financially, this can be a burden for some … Sometimes the local oncologists aren’t completely aware of financial assistance available for them. So maybe just ask and say, ‘Hey, I know this drug cost this much. Do you know of any financial assistance that you guys can provide for me?’ Because I know sometimes that’s not a question that gets asked,” Huynh-Lu said.

Read more

Patients and Providers Need to Stay Vigilant in Assessing, Managing MPN Symptoms

Posted on by

July 25, 2023

Alex Biese

Nurses play a crucial role in managing symptoms experienced by patients with myeloproliferative neoplasms (MPNs) — a group of blood cancers that cause the bone marrow to overproduce red or white blood cells or platelets.

“MPNs are rare, and the nurse/nurse practitioner [must] take the time to listen to the patients and educate them about symptom management,” Alfa Lafleur, APRN, from Florida Cancer Specialists and Research Institute Trinity Cancer Center in Trinity, Florida, told Oncology Nursing News®.

Even though the MPN category includes a range of diseases such as myelofibrosis, essential thrombocythemia, and polycythemia vera, patients with MPNs experience several common symptoms. Lafleur said she likes to think of those symptoms in categories.

First, Lafleur explained, there are the inflammation-related symptoms including weight loss, night sweats, fever, fatigue and a general feeling of unwellness. Then, there are the microvascular-related symptoms related to dysregulation of the JAK2 pathway, which can cause numbness in the hands and feet as well as headaches, vision changes and a painful rash. There are also symptoms related to the enlargement of the patient’s spleen, including fullness, pain and discomfort in the upper left quadrant of the abdomen.

As MPN symptoms typically intensify over time, with patients potentially experiencing long asymptomatic periods, the symptom identification and management work of a nurse is of particular importance.

“The nurse remains vigilant in assessing for symptoms as early identification that the disease may be worsening or transforming (which) can result in improved patient outcomes,” Lafleur said.

It’s also important for patients to keep tabs on their symptoms, as the MPN Research Foundation explains on its website.

“Because symptoms can vary significantly among MPN patients, it is important to track changes in symptoms and their severity between doctor visits,” the foundation states. “Keep current on the latest MPN research updates and speak to your doctor about how changes in your symptoms may call for a change in treatment.”

Resources are available for both patients and providers. Lafleur cited the MPN Research Foundation’s education for providers and patient support hotlines staffed by counselors who can in turn provide emotional support and assistance in locating additional resources and support groups.

Additionally, Voices of MPN, she said, “has a phenomenal app that helps the patient to track their symptoms, educates on the disease process and offers other resources and support to the patient.”

Patients with MPNs, Lafleur noted, can live with their cancer for years as they undergo different treatments that are each associated with side effects and symptoms — an experience that, she said, “can be really frustrating and upsetting” — and can be accompanied by fear of MPNs’ potential transformation into more aggressive forms of cancer such as leukemia or the risk of experiencing amyocardial infarction or cerebral vascular accident, or CVA, also known as a stroke.

Lafleur has some straightforward guidance for patients: “My best advice to patients is to remind them that they are not alone in this disease,” she said. “No symptom is too small to bring to the attention of your nurse who is more than willing to assist with the physical and mental challenges that come.”

Reference

MPN Research Foundation. Accessed July 25, 2023. https://www.mpnresearchfoundation.org/

Karyopharm Receives FDA Fast Track Designation for Selinexor for the Treatment of Myelofibrosis

Posted on by

– Regulatory Designation Includes Primary Myelofibrosis, Post-Essential Thrombocythemia Myelofibrosis and Post-Polycythemia Vera Myelofibrosis –

– Pivotal Phase 3 Study of Selinexor and Ruxolitinib in Treatment-Naïve Myelofibrosis Initiated in June 2023 –

NEWTON, Mass., July 17, 2023 /PRNewswire/ — Karyopharm Therapeutics Inc. (Nasdaq: KPTI), a commercial-stage pharmaceutical company pioneering novel cancer therapies, today announced that the United States Food and Drug Administration (FDA) has granted Fast Track Designation to the development program of selinexor for the treatment of patients with myelofibrosis, including primary myelofibrosis, post-essential thrombocythemia myelofibrosis, and post-polycythemia vera myelofibrosis.

“Fast Track Designation for selinexor highlights its potential to address the unmet medical need in myelofibrosis, an important acknowledgement as we continue our pivotal Phase 3 study,” said Reshma Rangwala, MD, PhD, Chief Medical Officer of Karyopharm. “Selinexor’s unique mechanism of action, XPO1 inhibition, is a novel and potentially fundamental mechanism in myelofibrosis. We have been highly encouraged by the efficacy and safety data observed to date [in our Phase 1 study] with selinexor in combination with ruxolitinib in patients with treatment-naïve myelofibrosis and believe selinexor has the potential to shift the treatment paradigm. We look forward to continued interaction with the FDA as we advance the development of this promising treatment for patients in need.”

In June 2023, Karyopharm initiated a pivotal Phase 3 clinical trial (XPORT-MF-034) (NCT04562389) to assess the efficacy and safety of once-weekly selinexor 60 mg in combination with ruxolitinib in JAKi-naïve patients with myelofibrosis. Updated data from the Phase 1 study were presented at the American Association for Cancer Research Annual Meeting 2023, American Society of Clinical Oncology 2023 and European Hematology Association 2023, which showed rapid, deep and sustained spleen responses and robust symptom improvement in patients treated with selinexor 60 mg in combination with ruxolitinib as of the April 10, 2023 cut-off date.  Top-line data from the Phase 3 study is expected in 2025. The Company plans to expand its clinical development program in myelofibrosis by investigating selinexor in other JAKi-naïve settings, such as novel combinations, to benefit the greatest number of patients.

Fast Track Designation is intended to facilitate development and expedite review of drugs to treat serious and life-threatening conditions so that an approved product can reach the market expeditiously. Features of Fast Track Designation include frequent interactions with the FDA review team, and if relevant criteria are met, eligibility for Priority Review and Rolling Review.

Further information about the Phase 3 study can be found at www.clinicaltrials.gov.

About Karyopharm Therapeutics
Karyopharm Therapeutics Inc. (Nasdaq: KPTI) is a commercial-stage pharmaceutical company pioneering novel cancer therapies. Since its founding, Karyopharm has been an industry leader in oral Selective Inhibitor of Nuclear Export (SINE) compound technology, which was developed to address a fundamental mechanism of oncogenesis: nuclear export dysregulation. Karyopharm’s lead SINE compound and first-in-class, oral exportin 1 (XPO1) inhibitor, XPOVIO® (selinexor), is approved in the U.S. and marketed by the Company in three oncology indications and has received regulatory approvals in various indications in a growing number of ex-U.S. territories and countries, including Europe and the United Kingdom (as NEXPOVIO®) and China. Karyopharm has a focused pipeline targeting multiple high unmet need cancer indications, including in multiple myeloma, endometrial cancer, myelodysplastic neoplasms and myelofibrosis. For more information about our people, science and pipeline, please visit www.karyopharm.com, and follow us on Twitter at @Karyopharm and LinkedIn.

Forward-Looking Statements
This press release contains forward-looking statements within the meaning of The Private Securities Litigation Reform Act of 1995. Such forward-looking statements include those regarding the ability of selinexor to treat patients with myelofibrosis; and expectations related to the clinical development of selinexor and potential regulatory submissions of selinexor. Such statements are subject to numerous important factors, risks and uncertainties, many of which are beyond Karyopharm’s control, that may cause actual events or results to differ materially from Karyopharm’s current expectations. For example, there can be no guarantee that Karyopharm will successfully commercialize XPOVIO or that any of Karyopharm’s drug candidates, including selinexor and eltanexor, will successfully complete necessary clinical development phases or that development of any of Karyopharm’s drug candidates will continue. Further, there can be no guarantee that any positive developments in the development or commercialization of Karyopharm’s drug candidate portfolio will result in stock price appreciation. Management’s expectations and, therefore, any forward-looking statements in this press release could also be affected by risks and uncertainties relating to a number of other factors, including the following: the adoption of XPOVIO in the commercial marketplace, the timing and costs involved in commercializing XPOVIO or any of Karyopharm’s drug candidates that receive regulatory approval; the ability to obtain and retain regulatory approval of XPOVIO or any of Karyopharm’s drug candidates that receive regulatory approval; Karyopharm’s results of clinical trials and preclinical studies, including subsequent analysis of existing data and new data received from ongoing and future studies; the content and timing of decisions made by the U.S. Food and Drug Administration and other regulatory authorities, investigational review boards at clinical trial sites and publication review bodies, including with respect to the need for additional clinical studies; the ability of Karyopharm or its third party collaborators or successors in interest to fully perform their respective obligations under the applicable agreement and the potential future financial implications of such agreement; Karyopharm’s ability to enroll patients in its clinical trials; unplanned cash requirements and expenditures; development or regulatory approval of drug candidates by Karyopharm’s competitors for products or product candidates in which Karyopharm is currently commercializing or developing; the direct or indirect impact of the COVID-19 pandemic or any future pandemic on Karyopharm’s business, results of operations and financial condition; and Karyopharm’s ability to obtain, maintain and enforce patent and other intellectual property protection for any of its products or product candidates. These and other risks are described under the caption “Risk Factors” in Karyopharm’s Quarterly Report on Form 10-Q for the quarter ended March 31, 2023, which was filed with the Securities and Exchange Commission (SEC) on May 4, 2023, and in other filings that Karyopharm may make with the SEC in the future. Any forward-looking statements contained in this press release speak only as of the date hereof, and, except as required by law, Karyopharm expressly disclaims any obligation to update any forward-looking statements, whether as a result of new information, future events or otherwise.

Read more

EXCEED-ET Investigates an Alternative Option for Disease Modification in Essential Thrombocytopenia

Posted on by

July 16, 2023

Nichole Tucker

An overperforming JAK-STAT pathway, including the presence of JAK2, CALR, and MPL gene mutations leads to high platelet count in patients with essential thrombocytopenia (ET).1 Safe and potent therapies are needed for these populations, especially for those requiring cytoreduction, regardless of their prior exposure to hydroxyurea and/or anagrelide, according to Lucia Masarova, MD, et al.

There is also an unmet need for treatments that can reduce the risk of thrombohemorrhagic events, ultimately stopping or preventing the development of post-ET myelofibrosis.1

Ropeginterferon alfa-2b-njf (Besremi) is a next-generation interferon alfa agent. It is FDA-approved to treat another myeloproliferative neoplasm (MPN), polycythemia vera (PV). In ET, ropeginterferon alfa-2b-njf is being investigated for the treatment of adult patients in a single-arm, multicenter trial (EXCEED-ET; NCT05482971).

At the American Society of Clinical Oncology (ASCO) 2023 Annual Meeting, Masarova, assistant professor, Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, presented the EXCEED-ET study design, noting its potential to fill an unmet need for new therapies to treat adults with ET.

“Eventually, we can hopefully add it to something and maybe keep on some agents that have been around to help control the counts. At the same time, maybe we can do a low-dose interferon for a longer time as a disease modification agent, and hopefully you will wake up in an era where there’s going to be no ET or PV,” Masarova told Targeted OncologyTM, in an interview.

In the interview, Masarova, discussed EXCEED-ET in detail and provided insights into the treatment options for ET and PV.

Targeted Oncology: In terms of disease modification, what is the current state of treatment in MPNs?

Masarova: We hope there will be a goal of therapy in the coming decades. Currently, the therapy goals are kind of focused more in controlling the accounts displaying the symptoms and getting deeper responses. Right now, with some therapies that showed us that we could decrease the allele burden, or we could alter the bone marrow fibrosis, or the bone marrow morphology is going to be the disease modification. As of now, there is no agent that would do it, except for the interferon, which showed quite promisingly that we can bring it into the landscape of the disease.

What does the treatment landscape currently look like for ET?

ET is considered a benign disease. People live with it for a very long time. Currently, treatment is for only those we call high-risk disease patients. Patients that had thrombosis in the past, and then patients that are over the age of 60 years and have a dAkt mutation, and that’s according to the revised International Prognostic Score of Thrombosis for Essential Thrombocytopenia score. Those patients are treated to decrease the risk of thrombosis, but not to do anything else. This is modified just to simply increase the thrombosis risk. That is hydroxyurea, it’s a standard frontline agent, which is an easy to take oral drug. However, it could lead to some resistance or about 30% patients can become.

Because ET also affects younger people, plenty of younger females, they don’t really want to take chemotherapy forever, which I don’t blame them for. They are interested in taking something else. The standard interferon, recombinant or pegylated, which is called the peginterferon alfa-2a [Pegasys]. We’ve recently used this for the couple years has been around for MPNs, particularly for ET and the PV. That is about 40 years almost. This treatment has a lot of data, and a lot of implications. This may be a disease modifying agent, which is an agent that could decrease the allele burden, eradicate the malignant clone, and ultimately change the disease behavior. We were excited. We had novel interferon called ropeginterferon-alpha-2b-njft approved in patients with progressive disease back in 2021. That has been preceded by approval in European Union in 2019. That’s an excellent option in terms of interferons. The normal alternative with the ropeginterferon, which is the novel mono-pegylated form, is kind of more convenient because it’s used every other week. Once we reached complete hematologic control, it’s used once a month. That’s a significant improvement in inconvenience for patients and in tolerability as well as compliance issues. We were excited to get it in PV, and we have it in some studies in PV to expand the access and maybe try a different schedule, and you move it to ET patients. That’s something that we’re going to be looking at.

Then, for patients with PV refractory to hydroxyurea, we have approved sunitinib [Sutent] which is the JAK inhibitor that has solid data in the field after hydroxyurea based on results from the RESPONSE [NCT01243944] and RESPONSE-2 [NCT02038036] trials. It will be 10 years since we had refractory patients treated with ruxolitinib [Jakafi]. It’s an excellent drug for controlling the symptoms and spleen count.

Last year, we had a very excited study called MAGIC-PV [ISRCTN61925716], which was reported by our European colleagues that showed the advantage of ruxolitinib for decreasing the rate of thrombosis hemorrhage. It also actual improved event-free survival, death, and adverse events in terms of progression to myelofibrosis. So, it was exciting. If we consider disease modification is what’s going to be preventing the disease to go into myelofibrosis, I think that will be exciting to see how far we can get in that field.

Can you discuss the rationale of the EXCEED-ET study [NCT05482971]?

The EXCEED-ET study is getting the ropeginterferon, which is the novel interferon into the space of ET. It is phase 1/2 study that gets the ropeginterferon in patients in North America. The patients are hydroxyurea-refractory or hydroxyurea-naive. Patients that have ET platelets over 450,000 need the therapy with some symptoms, and do not have a contraindication for interferons, which also had to be mentioned that the drugs could not be used in patients that have previous autoimmune disease, psychiatric diseases, or neurological because it could aggravate their symptoms. But those patients, if they would be eligible, they could be getting the full access to the drug. Also, with patients with ET, the escalation is going to be a lot faster to 250 micrograms, every other week, 350, and then 500 is the maximum dose that has been explored. However, I have to say the approval of ropeginterferon for PV had even higher dose, and the maximum-tolerated dose was not reached. This is a perfectly safe dose that we have patients on. We’re going to see how it’s going to do in ET patients. There is a core treatment period, which continues after the 4 weeks of escalation of up to 56 weeks. The patients will be dosed every other week with a tolerable dose. We will be monitoring the primary end points of durability of control, hematologic control, platelets less than 450, white cells less than 10. That will basically sustain 80% of 36 consecutive weeks. Then, the key secondary end points are going to include all important end points in ET patients, such as complete hematologic response, composite hematologic response, that includes control of spleen, control of symptoms, absence of disease progression, and absence of thromboembolic events. Then, it’s going to also have this excited end point, which is basically a decline or allele burden. We’ll be checking the allo burden, what we call the molecular response, and then bone marrow morphology response.

Also, there are a couple other exploratory or pharmacokinetic studies that we’re going to be conducting. It’s a study that does not allow patients that were exposed to interferon. For example, patients and [peginterferon alfa-2a] would not be eligible. However, with a plan amendment, there is going to be measurement of neutralizing antibodies against ropeginterferon. If patients are not detected to carry those, they will be still eligible.

If positive, how do you see this study impacting the field?

I’m excited about it. I’ve used interferons in the off-label setting ever since I came to MD Anderson, and it’s been proven to be an effective therapy for young people. I have a lot of patients come in from everywhere and they don’t want to do chemotherapy, they seek the agent. So far, we’ve been only able to give them the [peginterferon alfa-2a], where we have to deal with insurance companies, because it was off-label setting.

Last year, we published 15 years follow-up on our phase 2 study. But this is going to open the use of the agent, I’m excited about the less frequent interactions, which my patients are excited about as well. I’m going to be really comparing and lucky for me, I’ve seen the tolerance of the [peginterferon alfa-2a] in these patients. I will really be comparing them to the ropeginterferon, seeing what this agent could offer, and seeing the results in PV. I’m quite excited about it. I don’t think we will have any data about what we call the disease modification or how we call it in the next 10 years, maybe because it’s a very low progressing disease, but I’m looking forward to seeing whether we’re going to see elimination or absence of disease progression to myelofibrosis. I also wonder if we will see minimization of the thromboembolic events. That will be the ultimate disease modification change.

Afterwards, hopefully we can add it to something and maybe keep patients on some agents that have been around and help control the counts. At the same time, maybe we can do a low dose interferon for a longer time as a disease modification agent, and hopefully you will wake up in an era where there’s going to be no ET or PV.

REFERENCE:

Masarova L, Mascarenhas J, Qin A, et al. EXCEED-ET: A single-arm multicenter study to assess the efficacy, safety, and tolerability of ropeginterferon alfa-2b-njft (P1101) in North American adults with essential thrombocythemia. J Clin Oncol. 2023;41(suppl 16): TPS7088- TPS7088. doi:10.1200/JCO.2023.41.16_suppl.TPS7088

Read more

 

Expert Panel Discusses Advocacy, Education for Patients With Myeloproliferative Neoplasms

Posted on by

Jul 14, 2023

Erin Hunter, Assistant Editor

Patients with hematologic myeloproliferative neoplasms (MPNs)—a group of rare blood diseases that include myelofibrosis, essential thrombocythemia (ET), and polycythemia vera (PV)—should take a more active role in their treatment plan, according to experts in oncology pharmacy who participated in a Pharmacy Times clinical forum at ASCO 2023 in Chicago, Illinois.

“I think that our role as pharmacists is to give [patients] as much information as we possibly can, and then encourage them to move forward with advocating for themselves,” said Krystal Preston, PharmD, BCPS, senior clinical specialist-oncology pharmacist, CVS Health, and professor, University of Chicago College of Pharmacy, Chicago, Illinois.

Patients who are serious about taking on an active role in their treatment could inspire health care providers to collaborate more both with them and other members of the care team, according to discussion leader Zahra Mahmoudjafari, PharmD, MBA, BCOP, FHOPA, clinical pharmacy manager of hematology, bone marrow therapy, and cellular therapeutics at the University of Kansas Health System in Mission, Kansas.

Myelofibrosis, ET, and PV are subtypes of MPNs. ET and PV typically transform into myelofibrosis, which can subsequently turn into acute myeloid leukemia (AML). At least 20% of MPNs may transform into AML, therefore, the goal for treatment is to prevent this from occurring, Mahmoudjafari explained.

More than 90% of patients with PV have a Janus kinase 2 gene (JAK2) mutation, “and it is probably, by far, the mutation that we have the most actionable ability to do something about,” Mahmoudjafari said. She added that because there are currently 3 FDA-approved JAK inhibitors for MPN—ruxolitinib (Opzelura; Incyte), fedratinib (Inrebic; Bristol Myers Squibb), and pacritinib (Vonjo; CTI Biopharma Corp.), which were approved based on results from the COMFORT-1, JAKARTA, and PERSIST-2 pivotal trials, respectively.

Ruxolitinib and fedratinib are primarily for patients with intermediate- or high-risk myelofibrosis, including intermediate-2, and primary and post-PV/ET myelofibrosis. Pacritinib is indicated for patients with a platelet count below 50,000, and all have an expected adverse events profile, which includes thrombocytopenia, anemia, bruising, dizziness, headache, and diarrhea.

The only true cure for myelofibrosis is transplant, however, there is a 30% mortality risk associated with it, Mahmoudjafari said. During the forum, panelists largely explored patient management. Compliance was cited as a predominant issue for Connor Roth, PharmD, BCOP, hematology/oncology pharmacy specialist, Franciscan Alliance, Inc, Chicago, Illinois. Whether it’s due to dosing schedule, toxicities, cost, or all of the above, “people are just forgetful,” Roth said.

Currently, it’s much harder to contact patients with a reminder via phone call because, “nobody picks up a phone number they don’t know,” Roth added.

Tammy McClellan, PharmD, a clinical oncology pharmacist at Riverside Healthcare in Kankakee, Illinois, said that one of the greatest unmet needs she is seeing is timely access to medications. Timely access is critical because the faster a patient can get on a proper treatment regimen, the better they can prevent a blood-clotting event, according to the panelists.

Insurance is a barrier to access; however, pharmacists understand how to work within the system and are best positioned to advocate for patients, Roth said. Location is equally important for access to medications because patients living close to a city can access treatment centers and pharmacies more easily than those in a rural setting. Patients in cities also have better access to clinical trials, Preston said.

McClellan noted that an unmet patient need is effective communication with their care providers. She said that patients frequently complain that they wish their provider would listen to their input more often.

The clinical oncology pharmacist said a solution to this problem may be individualized patient care. Pharmacists and providers can foster individualized care through better organized collaboration with the patient and care team, Radhakrishnan said. This can make it easier to manage AEs and drug-drug interactions because treatment is exceedingly difficult, according to Mahmoudjafari. Therefore, improving AE management can improve patient quality of life.

“[Symptoms can be] enough to drive these patients absolutely insane,” McClellan added.

Financial burden is a significant issue for many patients, therefore, some clinics have financial navigators who work with pharmacists and patients to coordinate benefits, co-pays, and prior authorization. Other institutions may assign these tasks to specialty pharmacists, who typically have experience with patient assistance programs, which help older adults or people with limited resources to access affordable medications via grants, foundational support, or other means. Ideally, insurance or patient assistance would be connected to the patient’s electronic medical record, according to Roth. The panelists also made sure to emphasize patient education.

“I really try to explain to [patients], in layman’s terms, what’s going on and just kind of listen to what their issues are and what their concerns are,” Preston said.

The panelists said that a best practice is to provide as much information about the disease state and treatment as possible. Many patients do not understand their disease state, therefore, improving their understanding can provide the patient with more control, help them learn how to express their concerns, and to be their own advocate.

“You can’t make the assumption that the patient already knows [everything],” Mahmoudjafari said.

This is especially important because oncologists or other providers may be struggling to keep up with a complicated and shifting treatment and guidelines landscape.

“Guidelines are dividing, and the drugs are—there’s so many things to know,” Roth said. “Pharmacists can be the ones to extend the hands of the physicians and be a patient advocate when [the patient] doesn’t always have one.”

Reference

American Society for Clinical Oncology. Pharmacy Times clinical forum. ASCO Annual Meeting 2023. June 2 to 6, 2023. Chicago, Illinois. Accessed July 13, 2023. https://conferences.asco.org/am/attend

Read more

Anemia-Focused Treatment Approaches Represent Future Directions in Myelofibrosis

Posted on by

July 12, 2023

Ashling Wahner

JAK inhibitor add-on agents may address an unmet need for patients with myelofibrosis with disease- or treatment-related myelofibrosis, according to Anna B. Halpern, MD, who noted that standard myelofibrosis treatments can cause adverse effects that interfere with patient quality of life (QOL).

“Myelofibrosis is generally a [relatively] rare disease,” Halpern said in an interview with OncLive®. “Having a second opinion at a center that treats a lot of myelofibrosis and has much clinical trial availability is a great option for any patient, particularly if they have higher-risk disease features.”

In the interview, Halpern discussed strides in the treatment of myelofibrosis with anemia, the shifting role of ruxolitinib (Jakafi) in this disease, and the importance of providing patients with access to clinical trials, as they may benefit from investigational treatment approaches.

Halpern also highlighted the potential benefits of moving JAK inhibitors to the upfront setting, as evidenced in cohort 3 of the phase 2 REFINE trial (NCT03222609), in which navitoclax plus ruxolitinib generated a spleen volume reduction of at least 35% (SVR35) at week 24 in subgroups of patients with JAK inhibitor–naïve myelofibrosis with historically poor prognoses, including patients at least 75 years of age (SVR35, 50%), those with a high Dynamic International Prognostic Scoring System score (SVR35, 33%), and those with HMR mutations (SVR35, 47%).1 Furthermore, she explained clinical outcomes with ruxolitinib plus pelabresib (CPI-0610) in the phase 1/2 MANIFEST trial (NCT02158858), which showed that the combination elicited an SVR35 at 24 weeks in 68% of patients with JAK inhibitor–naïve disease.2

Halpern is a physician and an assistant professor in the Clinical Research Division at Fred Hutchinson Cancer Center, as well as an assistant professor of hematology at the University of Washington School of Medicine, both in Seattle.

OncLive: How does the mechanism of action of JAK-STAT inhibitors like momelotinib contribute to their potential to ameliorate disease-related anemia?

Halpern: Disease-related anemia is partially mediated through the hepcidin pathway. JAK-STAT signaling drives overproduction of inflammatory cytokines, leading to elevated hepcidin dysregulated iron metabolism. Through the inhibition of JAK-STAT signaling, JAK inhibitors have the potential to intervene in this pathway and improve anemia.

How does the clinical benefit seen with momelotinib compare with that seen with standard agents like ruxolitinib and danazol in the anemic myelofibrosis setting?

In a study that compared momelotinib with ruxolitinib in the upfront or JAK inhibitor–naïve setting, momelotinib was better than ruxolitinib at improving anemia-related outcomes, [such as] improving or decreasing transfusion dependence, increasing transfusion independence at week 24, and decreasing the need for red blood cells. Ruxolitinib was probably better for controlling symptoms, and [the agents] were generally similarly [effective] at controlling spleen [size].

Regarding the comparison [of momelotinib] with danazol, the phase 3 MOMENTUM trial [NCT04173494] was a randomized trial of momelotinib vs danazol. This was for patients who had previously been treated with a JAK inhibitor. [In this trial], momelotinib was superior to danazol in multiple outcomes, including symptom response score, at 25% vs 9% respectively, spleen response, at 23% vs 3% respectively, and transfusion independence, at 40% vs 13%, respectively. Overall, momelotinib probably has several advantages compared with danazol.

What unmet needs exist for patients with myelofibrosis, and what should be done to address these?

One of the biggest unmet needs I see often in clinic is anemia. [Anemia occurs] both because of disease and because it’s a treatment-emergent effect with some JAK inhibitors. Ruxolitinib primarily interferes with erythropoietin signaling in the JAK-STAT pathway, which is essential for erythropoiesis. We see anemia, both because of disease and ruxolitinib, that is challenging to treat. This is a big unmet need, particularly as anemia is correlated with QOL. It’s not the only aspect correlated with QOL in patients with myelofibrosis. Their inflammatory and cytokine profile, which JAK inhibitors can control, is also important. [Anemia is] just 1 component.

Another big unmet need is treating high-risk disease and preventing progression of disease and leukemic progression. That’s a big issue because we’re not yet sure whether our therapies are disease modifying.

What efforts are being made to move ruxolitinib and navitoclax to the frontline setting?

At the 2022 ASH Annual Meeting and Exposition, many exciting therapies in myelofibrosis, both standalone and JAK inhibitor add-ons, were presented. The data we saw at ASH with navitoclax were encouraging. An arm in the REFINE trial [investigated] ruxolitinib and navitoclax in a JAK inhibitor–naïve cohort. This study was interesting because we saw changes in bone marrow fibrosis as well as reduction in the variant allele frequency [VAF] of the driver gene mutation in many patients. Those outcomes are particularly of interest because they have the potential to be biomarkers for disease modification or the disease-modifying ability of this drug combination.

It’s hard to study whether the longer-term outcomes are correlates for leukemia, progression, and survival, so we need [outcomes] in the shorter term to study. The 2 candidates of bone marrow fibrosis and VAF are strong. We’ll look forward to larger trials with these [agents] in the upfront setting.

What did the MANIFEST trial reveal about the efficacy and clinical significance of pelabresib plus ruxolitinib?

The MANIFEST trial [investigated] the BET inhibitor pelabresib plus ruxolitinib. There were multiple arms, [including a] JAK inhibitor–naïve cohort, an upfront treatment arm. We saw a good reduction in spleen volume, as well as symptom score. Considering the outcomes that may correlate with disease modification, improvement in bone marrow fibrosis and reduction in VAF, we saw that 28% of patients had 1 or greater grade 1 improvement in fibrosis, and 29.5% had an over 25% reduction in the JAK2 V617F VAF. This is promising for this combination. Now, the randomized, double-blind, phase 3 MANIFEST-2 trial [NCT04603495] is evaluating this combination in the upfront setting in a larger cohort.

What new JAK inhibitor add-ons coming down the pike in myelofibrosis are you excited to see?

It’s hard to know. We have a lot of data in phase 2 trials investigating different cohorts of different patients. In oncology, sometimes we can have many promising data in phase 1 and 2 trials, but those do not always bear fruit or come out as clearly in randomized phase 3 trials. It’s hard to compare the results of these trials, even though they have similar eligibility criteria and outcomes. I will need to wait for the phase 3 trials to know how these drugs will go.

What is your main message for colleagues regarding emerging therapies in myelofibrosis?

We have had several new drugs approved for myelofibrosis in the past few years, which is wonderful. We always like to have many treatment options for patients. However, we have much room to go. If possible, referring patients early on to our center or other centers that have many clinical trials for myelofibrosis is wonderful. That way, they have access both to standards of care and treatments coming down the pipeline. We can help study whether these treatments will improve unmet needs and help modify the natural history of this disease, which is our goal. Referral to us, even just for a second opinion, [is important], so we can help guide treatment and think about [whether patients are] eligible for any of these clinical trials.

What ongoing myelofibrosis clinical trials at Fred Hutchinson Cancer Center are you excited about?

DISC-0974 is in an early-phase trial [NCT05320198]. We don’t have any data yet. However, this trial is open at our center, and it’s interesting. DISC-0974 is a first-in-class anti-HJV monoclonal antibody that is a key regulator of hepcidin production in humans. This is a monthly subcutaneous injection for only 6 injections, and it prevents signaling in the HJV pathway, which results in suppressed hepcidin and improved erythropoiesis. This is [a particular focus in the] issue of anemia in myelofibrosis. This is an add-on agent to a patient’s ruxolitinib, JAK inhibitor, or hydroxyurea. They stay on their baseline treatment, and we add this on for anemia.

These drugs that are [being investigated] and targeting the hepcidin pathway, both in this disease as well as in other myeloid neoplasms, like myelodysplastic syndrome, are exciting. I’m hopeful that this different mechanism of action with non-overlapping toxicities with traditional JAK inhibitors could be an interesting treatment approach for anemia. This trial is currently open, so we are happy to see any patients with anemia on their current therapies.

References

  1. Passamonti F, Foran JM, Tandra A, et al. The combination of navitoclax and ruxolitinib in JAK inhibitor-naïve patients with myelofibrosis mediates responses suggestive of disease modification. Blood. 2022;140(suppl 1):583-585. doi:10.1182/blood-2022-157949
  2. Mascarenhas J, Kremyanskaya M, Patriarca A, et al. MANIFEST: pelabresib in combination with ruxolitinib for janus kinase inhibitor treatment-naïve myelofibrosis. J Clin Oncol. Published online March 7, 2023. doi:10.1200/JCO.22.01972

Read more

Discuss Symptoms, Other Health Issues for the Best MPN Treatment

Posted on by

July 11, 2023

Brielle Benyon

Patient symptoms and other health issues can play a key role in determining the appropriate myeloproliferative neoplasm (MPN) treatment strategy, highlighting the importance of patient-provider communication, explained Julie Huynh-Lu.

“I just think it’s so important that patients be very forthcoming with what they’re experiencing, whether it’s good or bad, and not be afraid to divulge that information,” Huynh-Lu, a physician assistant from The University of Texas MD Anderson Cancer Center in Houston, said in an interview with CURE®. “So, if we can change (treatment) for the better, then let’s go do it.”

Disease Symptoms Can Influence Treatment

For example, a common symptom that patients with MPNs experience is spleen enlargement, or “splenomegaly.” Patients with splenomegaly may feel sensations of fullness after eating only small amounts, and it is essential that they bring this up with their cancer care team.

Huynh-Lu explained that a commonly used class of MPN medications called JAK inhibitors help to shrink the spleen. But if a patient does not have an enlarged spleen, they may not need to take this type of drug.

“That’s not saying that they can’t start (JAK inhibitors), but there might not be a reason to,” Huynh-Lu said. “(Spleen status) can also change the trajectory of whether or not we’re talking about splenectomy (surgical resection of the spleen) as an option. That’s not really our go-to, specifically here in our department at MD Anderson … but that can certainly lead to a conversation of whether surgery is an option.”

At every visit with Huynh-Lu and the MPN team, patients fill out the MPN10 questionnaire, which has patients rank 10 common MPN symptoms on a scale of 0 (nonexistent) to 10 (worst imaginable).

“In addition to having them fill that out, I obviously will ask them specific and pointed questions to tease out more information,” Huynh-Lu said. “A lot of times these patients may be very stable for a certain time. And they might say, ‘I’m a little bit short of breath, but not too bad.’ And then all of a sudden, six months down the line, that shortness of breath can worsen, or their spleen size can get larger. So instead, now they’re saying, ‘I used to be able to eat three quarters of a hamburger, and now I’m only able to eat half of one.’ Then this can lead to the discussion of, should we change the treatment that they’re on? And or are we on the right path? Do we need to make any other treatment options available to them?”

Discuss Other Health Issues

In addition to MPN-related symptoms, it is also important for patients to disclose other health complications before starting treatment.

“There are a lot of medications that can affect the kidney or liver and others that can also effect the heart, so there can be some contraindications for certain treatment options, especially for patients with an extensive cardiac history,” Huynh-Lu said.

Interferons, which are a type of drug that can be used to treat polycythemia vera (a subtype of MPN) may not be appropriate for patients who have a history of depression or autoimmune diseases.

Huynh-Lu noted that bringing along a family member or close friend may help patients ensure that all pertinent information is being communicated with the health care team.

“It’s nice to have a family member or friend who can remember certain things and maybe (the patient) didn’t remember to ask or forgot to jot down.”

Read more

Pelabresib Combo Improves Spleen/Symptom Burden in JAKi-Naïve Myelofibrosis

Posted on by

July 9, 2023

Russ Conroy

Combination treatment with pelabresib (CPI-0610) and ruxolitinib (Jakafi) was well tolerated and demonstrated enduring improvements in spleen and symptom burden among patients with JAK inhibitor treatment–naïve patients with myelofibrosis, according to findings from arm 3 of the phase 2 MANIFEST study (NCT02158858).

At week 24, 68% (95% CI, 57%-78%) of patients who received the combination achieved a spleen volume reduction of at least 35% (SVR35), which included a median SVR of –50% (range, –84% to 28%). Additionally, SVR35 responses at 24 weeks were observed in 70% and 67% of patients with intermediate-1– and intermediate-2– or high-risk disease based on Dynamic International Prognostic Scoring System (DIPSS) criteria, respectively, and 82% and 66% of patients based on International Prognostic Scoring System (IPSS) criteria. Kaplan-Meier estimates indicated that 93.5% (95% CI, 87.4%-99.7%) of those with a SVR35 response maintained their response at 36 weeks after onset.

A total symptom score reduction of at least 50% (TSS50) was reported in 56% (95% CI, 45%-67%) of patients at week 24, with a best TSS50 response at any time of 83% and a median change in TSS of –59% (range, –100% to 225%). Additionally, 43% of patients had a TSS50 response at 48 weeks, which included a median change in TSS of –54.8% (range, –100% to 307.1%).

At 24 weeks, study treatment yielded an absolute change in hemoglobin levels from baseline between –1 and at least 1.5 g/dL in 55% of patients; hemoglobin levels improved in 36% of patients, including a mean change of 1.3 g/dL and a median of 0.8 g/dL. Moreover, 24% of patients had a mean hemoglobin increase of at least 1.5 g/dL from baseline over any 12-week period while forgoing red blood cell transfusions.

“To our knowledge, the MANIFEST trial in JAK inhibitor treatment-naïve patients is the first study with a rational combination of BET [inhibitor] pelabresib and ruxolitinib that showed clinically meaningful durable improvements in splenomegaly and symptoms, was associated with biomarker findings indicating potential disease modification, and demonstrated a generally favorable safety profile,” the study authors stated. “This combination has the potential to improve the standard of care for treatment-naïve patients with myelofibrosis and warrants further investigation.”

Investigators of the global, open-label, nonrandomized phase 2 MANIFEST study evaluated pelabresib in combination with ruxolitinib in a cohort of JAK inhibitor treatment-naïve patients with myelofibrosis. Patients received an initial dose of 125 mg of pelabresib once daily for 14 days followed by a 7-day pause in combination with continuous ruxolitinib twice a day. Patients could receive a maximum pelabresib dose of 175 mg once daily.

The study’s primary end point was SVR35 from baseline to 24 weeks measured by imaging. The secondary end point was TSS50, and exploratory end points included bone marrow fibrosis improvement based on blinded central hematopathologist review following European consensus guideline criteria for reticulin fibrosis grading and improvement in anemia and transfusion requirements.

Patients who had not been exposed to treatment with JAK inhibitors and BET inhibitors and had confirmed diagnoses of primary myelofibrosis, or post–essential thrombocythemia or post–polycythemia vera myelofibrosis were eligible for enrollment on the trial. Additional eligibility criteria included having a spleen volume of at least 450 cm3, intermediate-2– or high-risk disease based on DIPSS criteria, and at least 2 measurable symptoms using the Myelofibrosis Symptom Assessment Form v4.0.

Overall, 84 patients received at least 1 dose of the study treatment, 53 of whom remained on treatment at the time of data cutoff. The median patient age was 68 years (range, 37-85), and 70% were male. Additionally, 24% had intermediate-1, 61% had intermediate-2, and 16% had high-risk disease by DIPSS criteria. In terms of mutations, investigators most frequently observed JAK2V617F (74%), ASXL1 (46%), CALR (21%), and MPL (8%).

Blinded central pathology review of bone marrow samples indicated at least 1 grade improvement in reticulin fibrosis at week 24 in 28% of evaluable patients, including 7% who had improvements of 2 grades. Among 24 patients with grade 1 or 2 reticulin fibrosis at baseline, 4 had worsening conditions, including 2 patients each with grade 1 and 2 fibrosis. Investigators observed no significant relationship between reticulin fibrosis improvement and clinical end points in the study,

Overall, 96% of patients experienced at least 1 treatment-emergent adverse effect (TEAE), and 63% had grade 3 or higher TEAEs. The most frequent hematologic TEAEs included thrombocytopenia (52%) and anemia (42%), and the most common nonhematologic TEAEs included diarrhea (35%), fatigue (33%), musculoskeletal pain (30%), respiratory tract infection (29%), and constipation (25%).

Pelabresib dose reductions were necessary among 37% of patients, and 36% had ruxolitinib dose reductions due to TEAEs. There were 5 deaths during study treatment or within 30 days following the final pelabresib dose, including 4 determined to be unrelated to pelabresib treatment. One patient died to multiorgan failure due to sepsis secondary to pneumonia, which investigators deemed to be related to pelabresib.

Reference

Mascarenhas J, Kremyanskaya M, Patriarca A, et al. MANIFEST: pelabresib in combination with ruxolitinib for Janus kinase inhibitor treatment-naïve myelofibrosis. J Clin Oncol. Published online March 7, 2023. doi:10.1200/JCO.22.01972

Read more

Examining Pelabresib for Patients With Myelofibrosis

Posted on by

July 9, 2023

Joseph Scandura, MD, PhD

Joseph M. Scandura, MD, PhD, Weill Cornell Medicine, discusses next steps for research of pelabresib (CPI-0610) for use in patients with myeloproliferative neoplasms.

Pelabresib is an oral, small molecule inhibitor of BET, which has the potential to downregulate the expression of genes that reside within the pathogenic pathways that underlie MPN progression.

One study evaluating pelabresib is the phase 3 MANIFEST-2 trial (NCT04603495). In this multicenter, double-blind, placebo-controlled trial, investigators are examining the safety and efficacy of pelabresib plus ruxolitinib (Jakafi) vs ruxolitinib alone in patients with JAK inhibitor-naïve myelofibrosis.

Patients aged 18 years and older with primary, post-polycythemia vera, or post-essential thrombocytopenia myelofibrosis, who had advanced disease requiring therapy, splenomegaly by computed tomography or magnetic resonance imaging, and were symptomatic were eligible for enrollment. Patients must also have had a prognostic risk-factor score of intermediate-1 or higher per the Dynamic International Prognostic Scoring System.

In the study, patients were randomly assigned in a 1:1 ratio to receive ruxolitinib in addition to oral pelabresib or matched placebo daily for 14 days, which was followed by 7 days off treatment. The starting dose of pelabresib was 125 mg daily. Then, ruxolitinib was given to patients twice a day in doses of 10 mg or 15 mg. Dose increases for both were allowed per protocol criteria.

Transcription:

0:10 | The first one is that we need to wait for the data to mature. My personal bias is, all of these biomarkers are invaluable until we know outcomes such as survival or time to treatment failure or event-free survival. Until we know that, we are just kind of stuck in this circular loop of what should be, what we hope will be, what our intuitive beliefs are, but we do not really know what any of these things mean until we have those outcomes. That just takes time.

0:46 | The nice thing is there are a number of phase 3 studies, randomized trials, collaborative studies. MANIFEST-2 is a randomized phase 3 study, and that will allow us to address and follow up on some of these findings, and hopefully get to those answers about whether or not these changes that we’re observing in the short-term are predicting these long-term beneficial outcomes. It just takes time for that data to mature

REFERENCE
Phase 3 study of pelabresib (CPI-0610) in myelofibrosis (MF) (MANIFEST-2) (MANIFEST-2). ClinicalTrials.gov. Updated April 6, 2023. Accessed July 6, 2023. https://clinicaltrials.gov/ct2/show/NCT04603495

Read more