Blood and Marrow Transplant Clinical Trials Network Study 1102 heralds a new era in hematopoietic cell transplantation in high-risk myelodysplastic syndromes: Challenges and opportunities in implementation.

LAY SUMMARY: People who have advanced myelodysplastic syndromes (MDS) may live longer if they get a bone marrow transplant (BMT) instead of other therapies. However, only 15% of people with MDS actually get BMT. Experts say community physicians and transplant physicians should team up with insurance companies and patient advocacy groups to 1) spread this news about lifesaving advances in BMT, 2) ensure that everyone can afford health care, 3) provide emotional support for patients and families, 4) help patients and families get transportation and housing if they need to travel for transplant, and 5) improve care for people of under-represented racial and ethnic backgrounds.

A medicare database analysis of practice patterns in patients with mantle cell lymphoma.

INTRODUCTION: Although treatment approaches to younger fit patients with mantle cell lymphoma (MCL) are well-described, the optimal treatment of older or less fit patients with varying comorbidities is less clear. The objectives of this study were to examine first-line treatment patterns, and the impact of comorbidities and age on treatment choices and overall survival (OS) in a large, predominantly older, Medicare population. PATIENTS AND METHODS: In Medicare data from 1/1/2007-8/31/2015, 3,008 patients with MCL were identified. Data on age, gender, race, Charlson comorbidities, Charlson comorbidity index (CCI), timing of injectable MCL therapies, and OS were collected and analyzed. RESULTS: Median age of the study population was 75.5 (range, 33-107; 25th, 75th: 69.9, 81.5) years. Over half of the individuals had ≥two comorbidities. The CCI was 1-2 in 45%, and 3-4 in 26.6% of patients. Rituximab was the most commonly used agent, regardless of age or comorbidity, in the first 60 days following diagnosis, being administered to 40.2% of patients. In contrast, administration of cyclophosphamide, doxorubicin, vincristine, or bendamustine in the first 60 days after diagnosis was less common (17.9%, 13.1%, 17.2%, and 12%, respectively). Overall survival was 3.23 (range, 0.003-7.668) years, and decreased with increasing number of comorbidities. DISCUSSION: Our analysis of a real-world patient population with MCL found that older patients have a high rate of comorbidities which impact administered treatment and subsequent OS. Our findings can be used to prospectively guide treatment decisions in these older, frailer, non-transplant-eligible patients, considering the impact of age and comorbidities on such choices.

Real-World Outcomes and Clinical Predictors of Immune Checkpoint Inhibitor Monotherapy in Advanced Lung Cancer.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have changed the treatment paradigm of advanced-stage non-small-cell lung cancer (NSCLC) and small-cell lung cancer (SCLC). The aim of this study was to evaluate the effectiveness and tolerance of ICIs in a real-world patient population and to investigate the predictive factors associated with survival outcomes. METHODS: Medical records of patients with advanced lung cancer who started ICI monotherapy were reviewed for data collection. Treatment outcomes included objective response rate, progression-free survival (PFS), and overall survival (OS). Immune-related adverse events (irAEs) were assessed. Multiple Cox regression models were fit to investigate the predictive factors for survival outcomes. RESULTS: We included 220 patients (median 66.5 years). Seventy-nine (35.9%) patients had Eastern Cooperative Oncology Group (ECOG) performance-status (PS) score ⩾2. Median follow-up was 11.4 months. In NSCLC, median PFS was 3.8 months (4.7 months for first line and 3.7 months for subsequent line). Median OS was 12.4 months (15.6 months for first line therapy and 11.5 months for subsequent line). In SCLC, median PFS was 1.8 months, and median OS was 4.6 months. A quarter of patients developed irAEs. There was 1 disease flare among 17 patients with pre-existing autoimmune diseases. ECOG PS of 0 to 1 and body mass index (BMI) ⩾ 25 kg/m2 (but not occurrence of irAE) were independently associated with improved OS in NSCLC, with a hazard ratio of 0.41 (95% confidence interval [CI], 0.29-0.59) and 0.62 (95% CI, 0.44-0.87), respectively. CONCLUSIONS: The clinical benefit of ICIs appears to persist in a real-world population of relatively older age, including those with poor PS and pre-existing autoimmune diseases. ECOG PS of 0 to 1 and BMI ⩾ 25 kg/m2 were independently associated with improved OS.

Development of cutaneous squamous cell carcinoma after prolonged exposure to pegylated liposomal doxorubicin and hand-foot syndrome: a newly recognized toxicity.

Pegylated liposomal doxorubicin (PLD) can be administered for prolonged periods with minimal toxicity. The risk of cutaneous squamous cell carcinoma (SCC) with this therapy has not been reported. We describe cutaneous SCC of the plantar foot in two patients exposed to high doses of PLD. A 50-year-old man with angiosarcoma received a total PLD dose of 1350 mg/m2 and developed cutaneous SCC of bilateral plantar feet. A 45-year-old woman with cutaneous T-cell lymphoma was treated with a total PLD dose of 1142 mg/m2 with subsequent diagnosis of cutaneous SCC of the right plantar foot. No risk factors for SCC of the plantar foot were identified in either patient. Cutaneous SCC is likely an unreported side effect of prolonged exposure to PLD. An extended duration of hand-foot syndrome from other anti-cancer drugs may also share this risk. Regular complete skin examination with early intervention for suspicious lesions is indicated in this patient population.

Treatment of mantle cell lymphoma in older adults.

Mantle cell lymphoma (MCL) predominantly affects older adults, with a median age at diagnosis of 70years. A frequently aggressive yet incurable lymphoma, the goal of therapy for MCL is to turn a potentially life-threatening illness into a chronic disease with prolonged periods of remission. Large randomized trial data supports the standard treatment in younger patients of cytarabine-based induction followed by autologous stem cell transplant. Most patients will not be eligible for this intensive approach based on older age, comorbidities, and functional status, making the geriatric assessment an essential step in choosing the appropriate strategy. For these older patients, an increasing number of chemotherapy and non-chemotherapy based therapies are available that allow oncologists to better tailor treatment to the fitness of the patient. We will review treatment options for older patients with MCL in the first line and relapsed/refractory settings, highlighting the available evidence for providing longer progression-free intervals while also minimizing the adverse effects of unduly aggressive treatment.

Oncolytic Viral Therapy for Mesothelioma.

The limited effectiveness of conventional therapy for malignant pleural mesothelioma demands innovative approaches to this difficult disease. Even with aggressive multimodality treatment of surgery, radiation, and/or chemotherapy, the median survival is only 1-2 years depending on stage and histology. Oncolytic viral therapy has emerged in the last several decades as a rapidly advancing field of immunotherapy studied in a wide spectrum of malignancies. Mesothelioma makes an ideal candidate for studying oncolysis given the frequently localized pattern of growth and pleural location providing access to direct intratumoral injection of virus. Therefore, despite being a relatively uncommon disease, the multitude of viral studies for mesothelioma can provide insight for applying such therapy to other malignancies. This article will begin with a review of the general principles of oncolytic therapy focusing on antitumor efficacy, tumor selectivity, and immune system activation. The second half of this review will detail results of preclinical models and human studies for oncolytic virotherapy in mesothelioma.

Differences in community and academic practice patterns for newly diagnosed myelodysplastic syndromes (MDS) patients.

PURPOSE: The heterogeneous nature of myelodysplastic syndromes (MDS) complicates therapeutic decision making, particularly for newly diagnosed disease. Factors impacting the treatment plan in this early period of disease course are poorly defined. This study determines whether therapeutic choices for newly diagnosed MDS are associated with location of treatment (community or academic), prognostic risk category, and patient age. METHODS: The adults in Minnesota with myelodysplastic syndromes (AIMMS) database was utilized in this statewide, prospective population-based study conducted by the University of Minnesota (UMN), Mayo Clinic, and Minnesota Department of Health. Adult (age 20+ years) cases of MDS newly diagnosed starting in April 2010 were invited to participate. This analysis includes patients enrolled during the first study year with 1-year follow-up data. Treatment choices (supportive, active, and transplant) were stratified by the international prognostic scoring system (IPSS) and the revised-IPSS (IPSS-R), then separated into groups by location of care and age (<65 or 65+ years). Academic-based care was any contact with the UMN and Mayo Clinic; community-based care was all other clinical sites. RESULTS: Stratification by IPSS and IPSS-R showed supportive care decreased and active care increased with advancing risk categories (p<0.0001). Comparing treatment setting, community-based care had 77% supportive and 23% active treatment; academic-based care was 36% supportive, 41% active, and 23% transplant (p<0.0001). By age groups, patients <65 years with intermediate, high, or very high risk disease by IPSS-R received 97% active care/transplant, compared to only 52% of patients age 65+. CONCLUSIONS: Younger patients and those treated at academic centers had a more aggressive treatment approach. Whether these treatment differences convey improved disease control and mortality, and therefore should be extended more frequently to older and community-based patients, is the subject of ongoing prospective study.