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Title: [Observational study of chronic myeloid leukemia Chinese patients who discontinued tyrosine kinase inhibitors in the real-world].
Author: Zhao HF, Yang YF, Liu BC, Li WM, Xu N, Liu XL, Jiang Q, Dang HB, Liang LX, Zhang Y, Song YP.
Journal: Zhonghua Xue Ye Xue Za Zhi; 2022 Aug 14; 43(8):636-643. PubMed ID: 36709147.
Abstract:
Objective: This study aimed to observe whether the treatment-free remission (TFR) of second-generation tyrosine kinase inhibitors (TKI) in chronic myeloid leukemia (CML) is better than imatinib (IM) . Methods: The clinical data of 274 CML patients who discontinued treatment and with complete clinical data were retrospectively studied from June 2013 to March 2021. Using both univariate and multivariate Cox proportional hazards regression models, risk factors influencing TFR outcomes after drug withdrawal in CML patients were assessed. Results: A total of 274 patients were enrolled, 140 patients were women (51.1%) , with a median age of 48 (9-84) years at the time of TKI discontinuation. Prior to TKI discontinuation, 172 (62.8%) patients were treated with IM, and 102 (37.2%) had received second-generation TKI treatment, including 73 patients who had shifted from IM to a second-generation TKI and 29 patients who used second-generation TKI as the first-line treatment. The rationale for converting to a second-generation TKI are as follows: 37 patients aimed deep molecular response (DMR) to achieve TFR, seven patients changed due to IM intolerance, and 29 patients changed because of failure to achieve the optimal treatment response. The use of the last type of TKI included 96 patients (94.1%) with nilotinib, three patients (2.9%) with dasatinib, and two patients (2%) with flumatinib, including one patient who changed to IM due to second-generation TKI intolerance. No statistical differences were found in the median age at diagnosis and TKI discontinuation, sex, Sokal score, IFN treatment before TKI, median time of TKI treatment to achieve DMR, and the reasons for TKI discontinuation between the second TKI and IM (P>0.05) .The median cumulative treatment time of TKI (71.5 months vs 88 months, P<0.001) , the last TKI median treatment time (60 months vs 88 months, P<0.001) , and the median duration of DMR (58 months vs 66 months, P=0.002) were significantly shorter in the second-generation TKI compared with IM. In the median follow-up of 22 (6-118) months after TKI discontinuation, 88 patients (32.1%) had lost their MMR at a median of 6 (1-91) months; of the 53 patients (60.2%) who lost MMR within 6 months, the overall TFR rate was 67.9%, and the cumulative TFR rates at 12 and 24 months were 70.5% and 67.5%, respectively. Withdrawal syndrome occurred in 26 patients (9.5%) . For patients who restarted TKI treatment, 72 patients (83.7%) achieved DMR again at a median treatment of 4 (1 to 18) months. The univariate analysis showed that the TFR rate of patients treated with second-generation TKI was significantly higher than those who were treated with IM (77.5% vs 62.2%, P=0.041) . A further subgroup analysis found that the TFR rate of the second-generation TKI patients was significantly higher than those treated with IM (80.8% vs 62.2%, P=0.026) . No significant difference was found in the second-generation TKI used as the first line treatment compared with those who were treated with IM (69.0% vs 62.2%, P=0.599) . The multivariate analysis results showed that second-generation TKI treatment was an independent prognostic factor affecting TFR in patients who discontinued TKI (RR=1.827, 95%CI 1.015-3.288, P=0.044) . Conclusion: In the clinical setting, more CML patients rapidly achieved TFR using second-generation TKI than IM treatment. 目的： 观察真实世界中酪氨酸激酶抑制剂（TKI）治疗慢性髓性白血病（CML）停药患者的无治疗缓解（treatment free remission, TFR）情况，及二代TKI在TFR方面是否优于伊马替尼（IM）。 方法： 对来自国内8家血液病治疗中心的自2013年6月至2021年3月期间停用TKI且有明确停药结局和相对完整临床资料的274例CML患者进行回顾性分析，使用单因素分析和多因素Cox比例风险回归模型评估影响CML患者停药后TFR结局的危险因素。 结果： 274例患者，女性140例（51.1%），停药时中位年龄48（9~84）岁。停药前，172例（62.8%）患者应用IM治疗，102例（37.2%）接受过二代TKI治疗，包括73例IM转换二代TKI者和29例一线二代TKI治疗者。转换二代TKI的原因包括：37例因追求TFR在IM治疗获得深层分子学反应（DMR）期间转换二代TKI、7例因IM不良反应不耐受、29例因TKI治疗未达最佳治疗反应。接受过二代TKI者末次应用TKI类型包括：尼洛替尼96例（94.1%），达沙替尼3例（2.9%），氟马替尼2例（2.0%），1例为二代TKI不耐受再次更换为IM治疗。IM治疗组和二代TKI治疗组在确诊时中位年龄、停药时中位年龄、性别、Sokal评分、TKI治疗前是否应用干扰素、TKI治疗至获得DMR中位时间、停药原因等基线特征差异均无统计学意义（P值均>0.05）。停药前TKI中位累积治疗时间（71.5个月对88个月，P<0.001）、末次TKI中位治疗时间（60个月对88个月，P<0.001）、DMR中位持续时间（58个月对66个月，P=0.002），二代TKI治疗组均较IM治疗组显著缩短。停药后中位随访22（6~118）个月，88例（32.1%）患者在中位6（1~91）个月失去主要分子学反应（MMR），其中53例（60.2%）患者在≤6个月内失去MMR，总体的TFR率67.9%，12个月和24个月的累积TFR率分别为70.5%和67.5%。26例（9.5%）患者发生停药综合征。72例（83.7%）重启TKI治疗患者在中位治疗4（1~18）个月再次获得DMR。单因素分析结果显示，停药前应用二代TKI治疗组患者的TFR率显著高于IM治疗组（77.5%对62.2%，P=0.041）。进一步亚组分析发现，IM转换二代TKI治疗组患者的TFR率显著高于IM治疗组（80.8%对62.2%，P=0.026），二代TKI一线治疗组和IM治疗组TFR率差异无统计学意义（69.0%对62.2%，P=0.599）。多因素分析结果显示，应用二代TKI治疗是影响停药患者TFR的独立预后因素（RR=1.827，95%CI 1.015~3.288，P=0.044）。 结论： 真实世界中，二代TKI治疗较IM治疗使更多的CML患者更早获得更好的TFR。.

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