Cancer Conference Update: A Multimedia Review of Key Presentations from the 2016 American Society of Hematology Annual MeetingAbstracts 223, 224: Lenalidomide with or without epoetin alfa in patients with MDS
4:55 minutes.
TRANSCRIPTION:
DR LOVE: So let’s talk about, I know, one of your favorite topics, MDS. DR STEENSMA: Yes. DR LOVE: And there was a big paper presented. I was really curious to see what your thoughts were, lenalidomide with and without EPA and granulocyte-stimulating factor. DR STEENSMA: Sure. There were 2 papers presented, one Alan List presented, the ECOG E2905 study. That was for patients for whom ESAs alone had failed. And a few patients got on whose baseline EPO level was over 500. And they compared lenalidomide alone to lenalidomide plus continuing the ESA or starting the ESA if it hadn’t been before. The ECOG E2905 study is actually a lot easier to interpret than this one. I moderated this session. And I still don’t understand this European study, because it was so confusing. Because you could add EPO back. You could add GCSF. There were different dose levels. It was just a very, very challenging study to understand. The bottom line for clinicians, I think, is that lenalidomide plus EPO has a higher hematologic response rate than lenalidomide alone. But where we would use these agents together in combination, I think, is a little bit tricky. So the ECOG E2905 study, they found with the lenalidomide alone, 29% response rate. Lenalidomide plus EPO, 40% response rate. So a little bit higher when the combination was given. In this study, they saw a response rate of 33% in patients for whom EPO had failed. And it’s so confusing the way all the EPO was added back, and the GCSF, that I don’t even want to get into that. But I do think that this suggests that in some cases, lenalidomide may resensitize to EPO. And so right now, the party line is, if a patient’s had 8 to 12 weeks of an ESA, they haven’t responded. You stop the drug and you move on. These studies collectively suggest that if you’re going to add lenalidomide, at least then maybe you should continue the EPO if you can get it paid for, because the response rate might be a little bit higher with the combination. DR LOVE: For practical purposes right now, where does lenalidomide fit into your del(5q) and nondel(5q) algorithm nowadays? DR STEENSMA: For del(5q), I think it’s pretty straightforward for lower-risk disease, because the response rate, the transfusion independence, the hemoglobin response rate is so high, over 70%. So it is very acceptable to use it as a first-line therapy. If you want to use EPO first and the patient’s serum EPO level is under 500, that’s fine. But lenalidomide then would be if the EPO didn’t work. For the nondel(5q) patients, it’s a little bit more difficult, because the response rate is lower, 26%, to monotherapy with len in 2 different randomized studies. And also, it’s an off-label use. So it’s not reimbursed very well. One of the big predictors of response is the platelet count. So if the patient is thrombocytopenic, if their platelet count is less than 50 especially, nobody responds to lenalidomide. So I wouldn’t use it in that setting. However, if the patient’s primary problem is anemia and their platelet count is preserved and they’re non-del(5q), I would give it a go. The good thing, you know quite quickly with lenalidomide if it’s going to work or not, 5, 6 weeks. By week 8, if you’ve given them 2 cycles, you haven’t seen a response, you can stop. And that would be an appropriate use of it. The 1 mistake I see that’s commonly made with lenalidomide in patients that are referred to me is higher-risk MDS or AML, complex karyotype, excess blasts. And that complex karyotype happens to include a chromosome 5 abnormality, whether it’s del(5q) or monosomy 5. That’s a different disease. And those patients don’t respond to lenalidomide. Often, lenalidomide is tried. And it just doesn’t work in that setting. So those are patients who would be better suited to going straight to an HMA. |