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Dirk Arnold, MD, PhD, Professor and Head Dept. Hematology and Medical Oncology at Tumor Biology Center in Freiburg, Germany, talks about sirflox and its phase III trials on whether or not it can properly add local ablative treatment to diffuse metastasization of the liver.


Dr. Dirk Arnold on Sirflox and its Effect on Liver Metastases 

Dirk Arnold, MD, director of the Department of Medical Oncology at Klinik fÃ¼r Tumorbiologie, Freiburg, Germany, discusses the advantages of using yttrium-90 (Y-90) as the first line treatment for patients with liver metastases from metastatic colorectal cancer (mCRC). 


Advantages of Using Y-90 for the First-Line Treatment of Patients With Liver Metastases from mCRC

ASH 2024 Preview for Community Oncologists: The Show and After Show

The American Society of Hematology (ASH) Annual Meeting and Exposition aims to educate oncology providers across an array of hematologic malignancies, with a focus on novel agents, drugs across the FDA pipeline, and more.

, co-hosts Kristie L. Kahl and Andrew Svonavec offer a glimpse at some of the presentations guaranteed to spark one’s curiosity, spur debate, and enhance the field even further. Some key highlights include:

 Continued advancements in CAR T-cell therapy are expected to revolutionize the treatment of hematologic malignancies.

 Bispecific antibodies, such as Epcoritamab (Epkinly), offer a novel approach to target multiple antigens on cancer cells.

 The assessment of MRD is becoming increasingly important in predicting treatment response and overall survival.

Advances in Acute Lymphoblastic Leukemia (ALL)

Blinatumomab (Blincyto) in pediatric ALL:

 The addition of blinatumomab to chemotherapy has shown promise in improving disease-free survival in high-risk pediatric ALL. This combination therapy may offer a more effective treatment option for young patients.

Acalabrutinib (Calquence) in mantle cell lymphoma (MCL):

 The FDA is set to review the approval of acalabrutinib with bendamustine or rituximab (Rituxan) for previously untreated MCL, based on data from the phase 3 ECHO trial (NCT02972840).

Asciminib (Scemblix) in chronic phase chronic myelogenous leukemia (CML-CP):

 The FDA recently granted accelerated approval to asciminib for newly diagnosed CML-CP. This tyrosine kinase inhibitor has shown favorable safety and tolerability profiles.

 isn't just about data, as the duo also offers food recommendations, tourist attractions and fun activities to partake in, as well as interesting facts about San Diego.

This is just a taste of the wealth of information and inspiration waiting at the 2024 ASH Annual Meeting. Check back for future meeting previews with 

Targeted Oncology co-hosts Kristie L. Kahl and Andrew Svonavec highlight abstracts for community oncologists to look out for at the upcoming ASH Annual Meeting in San Diego, with some additional tidbits to round out the main event.

News

The biologics license application (BLA) of the subcutaneous formulation of nivolumab (Opdivo) coformulated with human hyaluronidase (rHuPH20) has been accepted by the FDA.

Findings from the CheckMate -67T (NCT04810078) support this BLA of subcutaneous nivolumab as the trial met its coprimary pharmacokinetic end points and key secondary end point of overall response rate (ORR) vs intravenous (IV) nivolumab in clear cell renal cell carcinoma.

The FDA has set a Prescription Drug User Fee Act (PDUFA) goal date for December 29, 2024.

The FDA has accepted the BLA of the subcutaneous formulation of nivolumab coformulated with rHuPH20, also known as subcutaneous nivolumab, for all previously approved adult solid tumor indications of nivolumab as a monotherapy, monotherapy maintenance following completion of the combination therapy with nivolumab plus ipilimumab (Yervoy), or in combination with chemotherapy or cabozantinib (Cabometyx).

Results from the phase 3 CheckMate -67T trial of subcutaneous nivolumab support this application. In the trial, experts sought to evaluate subcutaneous nivolumab vs its intravenous (IV) formulation.

 Here, the subcutaneous form demonstrated noninferior pharmacokinetics and efficacy, as well as consistent safety compared with the IV formulation of nivolumab among patients with advanced or metastatic clear cell renal cell carcinoma (ccRCC) who have received prior systemic therapy.

A PDUFA goal date has been set for December 29, 2024. With this, subcutaneous nivolumab shows promise to become the first and only subcutaneously administered PD-1 inhibitor.

“We believe subcutaneous nivolumab has the potential to make a significant difference in the lives of patients, which is reinforced by the FDA’s acceptance of our application,” said Gina Fusaro, PhD, vice president, global program lead, Bristol Myers Squibb, in a press release.

“[Nivolumab] is a foundational PD-1 inhibitor approved for many different types of cancer, and our continued investment in research that puts patients first remains a priority. If approved by the FDA, the subcutaneous administration of nivolumab would provide patients and their physicians with a new option that delivers the same well-known benefits as IV [nivolumab] but with the improved convenience of an injection administered in 3 to 5 minutes rather than a 30- to 60-minute infusion,” Fusaro continued.

The phase 3, randomized, open-label CheckMate -67T trial is exploring subcutaneous administration of nivolumab coformulated with rHuPH20 vs IV nivolumab for the treatment of patients with advanced or metastatic ccRCC who were previously treated with systemic therapy.

In the study, 495 patients were randomly assigned to receive either subcutaneous nivolumab or IV nivolumab. Enrollment was open to patients with a histological confirmation of ccRCC, advanced RCC not amenable to curative or radiation therapy, metastatic RCC, those who received no more than 2 prior systemic therapies, those with intolerance or progression after last treatment regimen within 6 months of randomization, and those with a Karnofsky performance score ≥ 70 at screening.

Experts assessed the coprimary end points of time-averaged serum concentration over 28 days and trough serum concentration at steady-state of subcutaneous nivolumab vs IV nivolumab. A key secondary end point of the trial was ORR.

The study met its coprimary pharmacokinetic end points and key secondary end point of ORR with subcutaneous nivolumab in this patient population.

 Subcutaneous nivolumab was noninferior in regard to time-averaged nivolumab serum concentration over 28 days and steady-state trough serum concentration vs treatment with IV nivolumab. Additionally, subcutaneous nivolumab also demonstrated a noninferior ORR compared with IV nivolumab.

1. U.S. Food and Drug Administration accepts Bristol Myers Squibb’s application for subcutaneous nivolumab (nivolumab and hyaluronidase). News release. Bristol Myers Squibb. May 6, 2024. Accessed May 6, 2024. 

2. Phase 3 Check-Mate -67T trial of subcutaneous nivolumab (nivolumab and hyaluranisade) meets co-primary end points in advanced or metastatic clear cell renal cell carcinoma. News release. Bristol Myers Squibb. October 19, 2024. Accessed May 6, 2024. 

3. A study of subcutaneous nivolumab versus intravenous nivolumab in participants with previously treated clear cell renal cell carcinoma that is advanced or has spread (CheckMate-67T). ClinicalTrials.gov. Updated October 12, 2023. Accessed May 6, 2024. 

https://www.clinicaltrials.gov/study/NCT04810078

The FDA is considering a subcutaneous nivolumab formulation for various solid tumors based on promising data from the phase 3 CheckMate -67T trial. A target action date has been set for December 29, 2024.

Clinical

FDA Accepts BLA for Subcutaneous Nivolumab Across Various Solid Tumors

How do you use molecular testing, bone marrow results, and clinical features to stratify risk in patients with myelofibrosis? 

At this point, I believe we are all receiving the myeloid mutation panels. We also order 

: the 3 drivers. However, most clinicians would order a myeloid mutation panel because we know that many of the mutations are prognostic. This is the whole point of risk stratification, which is now increasingly sophisticated and integrates multiple clinical, molecular, [and] cytogenetic variables to determine who needs a transplant. 

These are the first actions I take when speaking with a new patient. I get an idea of their risk in terms of survival and prognosis, and that informs my decision to refer them to transplant. I then counsel the patient appropriately. 

I do not believe molecular testing informs treatment because our drugs are, for the most part, mutation agnostic. All we have are JAK inhibitors, which are not mutation specific. However, from a prognostic standpoint, the [role] of molecular testing is key.

Regarding mutant allele burden, is it important and how do you use it? 

We do evaluate mutant allele burden. Some [clinicians] suggest that if a patient has a lower allele burden, the prognosis might be slightly worse. We generally tend to associate those with the cytopenic phenotype, but overall, I would say that the allele burden does not impact any decisions, at least not in terms of selecting JAK inhibitors. It may be something that we would monitor, especially if we were going to add an interferon-based therapy to the JAK inhibitor. Aside from that, it does not help me [significantly].

With so many advancements in technology, is bone marrow biopsy still relevant today? 

 I believe that bone marrow biopsy is still relevant. First and foremost, you need it for assessment of blast percentage, which is involved in any scoring system to help risk stratify a patient properly. 

A higher blast percentage suggests a greater risk of the disease progressing to a more severe form, such as leukemic transformation. In addition, assessing the cellularity of the bone marrow helps us understand its state: Is it hypercellular marrow or more fibrotic hypocellular marrow? 

These are all variables that not only serve as a good baseline for a pretreatment assessment but also help us predict the direction this [disease] is going, once we pick a treatment. This helps to identify the condition of hypocellular marrow and set an expectation for cytopenia. This is true across the disease, as everything is inter- connected: the molecular factors, the marrow, the clinical picture, and the path forward toward a possible cure with allotransplant for patients who have intermediate-to-high-risk [disease].

What other factors or models guide your selection between JAK inhibitor therapy and alternative treatment approaches? 

 I do not think the molecular information guides our choice of therapy today, maybe at some point in the future. Right now, all 4 approved agents are JAK inhibitors and mutation agnostic. We know that ruxolitinib [Jakafi] is more effective if the JAK2 allele burden is over 50%. However, that is not to say that you would not use it if the JAK2 allele burden was lower than 50%. I do not believe we are quite there yet with molecular information to guide pharmacotherapy. 

It is important to appreciate the [fact that] not all patients need a JAK inhibitor. There are some alternative treatments for when a patient has anemia and does not have increased splenomegaly or other symptoms. For this type of patient, one might choose an erythropoiesis- stimulating agent with danazol [Danocrine] or luspatercept [ Reblozyl] and not necessarily a JAK inhibitor.

Do you evaluate other organ functions or models to help understand who would be a good candidate for transplant? 

When I see a patient, I evaluate their disease to decide on transplant. [One can] evaluate the risk based on whichever scoring system they choose. [From there,] when I deduce that a patient is in a category where transplant is an option, we can assess transplant-specific variables like donor type. 

The myelofibrosis transplant scoring system also helps improve risk stratification for patients undergoing transplantation. However, this scoring system does not take into account comorbidity index and performance status. These also weigh into the decision about moving forward with transplant. In a perfect world, we identify these patients prior to needing a transplant so that we can monitor them throughout and avoid organ damage.

Are there any other available treatments we use for myelofibrosis? 

I believe there is still a role for [a] watch-and-wait [approach] for some patients, so not everyone needs therapy. In addition, if you are trying to control cytopenias only, you may have identified a patient for whom something like hydroxyurea is an appropriate frontline treatment. 

We do have some ability to go [beyond using] pure JAK inhibition with the 4 FDA-approved drugs for our treatments. There are interferons, although it is becoming harder and harder to find a patient who might be a good candidate for interferon [therapy] and who has not had a JAK inhibitor yet. Thus, I believe we have some options, and it is an amazing place that we are in, having 4 FDA-approved options at this point, whereas recently we only had one and not that long ago we had 0 [options]. As the drugs improve, regarding the JAK inhibitors, and [the] more and more options we gain, it is starting to get harder and harder to find patients who, if they need treatment, are not going to end up on one of those agents.

How do you establish and manage treatment expectations across different patient populations? 

 It goes back to what we were discussing earlier. I start with prognosis because that must be foremost in patients’ minds. We know from the Myeloproliferative Neoplasm Landmark Survey that at the end of the day, what patients care about most is outcome, disease progression, and… longevity.

I start with prognosis; talk about the possibility of transplant, whether that [should happen] sooner or later; and then I discuss our therapies, which are not curative. However, some have demonstrated survival benefit. I discuss the nuances between the different drugs. They are all JAK inhibitors, but they are all different and have different strengths and weaknesses. Thus, I start with prognosis, discussing an overall big picture with a level-setting approach.

What roles do quality-of-life assessments play in your initial treatment planning? 

 I have been fortunate in that I have enabled my entire practice to use the Myeloproliferative Neoplasm Symptom Assessment Form Total Symptom Score [MPN-SAF TSS] on a regular basis and created a flow sheet in the Epic system, which took me 2 years to implement. This has been helpful because sometimes you can look back and say, “Your symptom score is quite a bit better than it was before.” Sometimes this can validate the therapy that has been chosen. 

The other aspect that is helpful with the TSS is that if fatigue is the only score that they have on the MPN-SAF TSS, there is a degree of level setting regarding whether JAK inhibitors are going to provide that same degree of benefit. If a patient has night sweats, bone pain, fevers, and weight loss, I can improve this. However, if they only have fatigue, I sometimes hesitate when starting JAK inhibitors especially if there is no splenomegaly or any other symptom that would suggest that they would need one, because I find fatigue is one of the hardest symptoms to reverse. Overall, I do believe that quantifying these, even though it can be difficult for patients, is a helpful process.

How do you determine whether bone pain or abdominal discomfort is from the myelofibrosis or something else? 

 I categorize adverse events [AEs] into the 3 arms of JAK inhibition: the cytopenia, the splenomegaly, and the “other,” [which is] all the other symptoms such as night sweats and so on. By separating these AEs into those 3 boxes, I can assess whether, for instance, the fatigue is because of cytopenias or if it is the massive splenomegaly preventing the patient from taking in more than 400 calories a day. In addition, I can assess whether the fatigue is generalized fatigue from the disease state or disease in [older] patients in their 70s, where fatigue and slowing down are a part of the natural aging process.

By separating AEs into those categories as best I can, it helps me determine the treatment direction. For instance, “Am I targeting the cytopenias? Am I targeting the global TSS? Do I want to focus on anemia?” This way, I’m trying to understand the disease well enough to know how to target a symptom while also recognizing that there will be patients for whom fatigue is so prevalent across the whole spectrum that it will be a real challenge.

Referring to the case, how do you incorporate this patient’s age and risk category symptom burden when selecting a JAK inhibitor? 

Clearly, we have identified a patient who is not a candidate for [the] watch-and-wait [approach], having both significant cytopenia and splenomegaly. This is someone who needs treatment first and foremost at 71 years of age. That puts this patient, by my referring transplant center standards, into the category of transplant eligible. Thus, this is the first conversation I would have with this patient, asking the patient if they are interested in allogeneic stem cell transplant [allo-SCT], and this sets that expectation. 

Thus, I have to consider whether everything I am doing is a bridge to allo-SCT or if it is definitive multiyear therapy outside of an allo-SCT. My recommendation would be to refer this patient for allo-SCT, but regardless of whether we go to transplant or not, we have a significant disease burden that we have to control with therapy, and this is how I would start that conversation.

Is this all you need, or do you think more information is needed to start treatment decisions? 

 I believe the information we have been provided is sufficient. We have a significant symptom burden, anemia that is perhaps not severe yet but nearly so, and a significantly enlarged spleen. Clearly, this patient is a candidate for a JAK inhibitor. 

Ruxolitinib [Jakafi] is the JAK inhibitor that we have used for the longest amount of time, and is, I believe, most physicians’ go-to drug in the frontline setting. However, this is also a patient where I would be tempted to use momelotinib [Ojjaara] due to the hemoglobin level of 8.2 g/dL, understanding that both these drugs elicit spleen and symptom benefits.

Ruxolitinib does have a demonstrated survival advantage, which I discuss with patients. This is not to say that other [drugs] would not have that advantage, but the others have not had the chance to show it as clearly as ruxolitinib, which was compared with placebo.

The information we have [for this patient] is fairly straightforward and points to the need for a JAK inhibitor. However, as Dr Abbas mentioned, the patient is 71 years old, and this does not preclude transplant.

What are your specific criteria for initiating transplant evaluation in patients with intermediate-2 risk receiving JAK inhibitor therapy? 

There are a couple of aspects. First, you want to make sure you understand what their other organ function is. If the person has chronic kidney disease and chronic obstructive pulmonary disease where they require oxygen, they are not a good candidate for transplant. Thus, I would focus on how to optimize which to take with the expectation that they would not go to transplant.

In contrast, there are plenty of people who are 70 years of age [or more] and still play tennis every day. For instance, this patient may be discouraged that he can no longer run 5 miles every day. Thus, functional status and overall health play an important role. 

In part 1, experts explores how assessing individual risk factors is crucial in selecting the appropriate JAK inhibitor for patients with myelofibrosis.

Dirk Arnold, MD

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