Bosutinib in Elderly Chronic Myeloid Leukemia (BEST)

Bosutinib Efficacy, Safety, Tolerability (BEST) Study in Elderly Chronic Myeloid Leukemia Patients Failing Front-line Treatment With Other Tyrosine Kinase Inhibitors

The objective of the present study is to evaluate a new drug called bosutinib as it is believed that this agent may be able to predict an excellent prognosis in patients that did not obtain any benefit with other drugs before. Still, this needs to be proved and we hope this study is able to do so.

Study Overview

• Status: Active, not recruiting
• Conditions: Chronic Myeloid Leukemia
• Intervention / Treatment: Drug: Bosutinib

Detailed Description

Bosutinib is a potent tyrosine kinase inhibitor (TKI) active at nM concentration on BCR-ABL1 and most BCR-ABL1 mutations. Bosutinib has been approved by the FDA and the EMA for the treatment of patients with Ph+/BCR-ABL1+ chronic myeloid leukemia who fail treatment with other TKIs, first or second line. The goal of second-line treatment of CML is to achieve a response that would predict for a survival equal to, or very close to, the survival of non leukemic people, that is to say to achieve a complete cytogenetic response (CCyR) or a major molecular response (MMR). To achieve that goal, it is necessary to find and keep the right balance between activity, safety, and tolerability. There are no studies comparing TKIs in second-line. From phase 2, single-arm, studies, the reported efficacy of Bosutinib is similar to the reported efficacy of dasatinib and nilotinib. The median age of newly diagnosed CML patients is about 56 years, and at least 40% of all newly diagnosed patients are more than 60 years old. Particularly for these patients, the choice of the TKI must take into account the safety and the tolerability profile of the TKIs. The use of dasatinib and nilotinib is burdened by pleural and pulmonary complications, by infections, and by cardiovascular, thrombotic and metabolic (diabetes mellitus, dyslipidemia) complications. These complications are more frequent and more clinically relevant in the elderly. The safety and tolerability of Bosutinib has been reported in first- as well as in second- and third-line. The standard dose (500 mg once daily) is tolerated and safe, but at that dose several adverse events (AEs) limit the tolerability, require dose reduction or interruption, and affect patient quality of life, including diarrhea, nausea, vomiting, skin rash. Also an increase of AST, ALT and lipase are of concern and a cause of treatment discontinuation. On the contrary, an increased frequency of infections and of pleuro-pulmonary, cardiovascular, thrombotic, and metabolic AEs has not been reported. The reported hematologic toxicity of Bosutinib is at least as low as, or even lower than, that reported for the other TKIs, in spite of the fact that Bosutinib is a dual, BCR-ABL1 and src inhibitor. Until today, all studies of TKIs in CML have tested a fixed initial dose, providing for dose adjustment in case of toxicity (dose decrease) or in case of unsatisfactory response (dose increase). No study so far was designed to test the adaptation of the dose to the response, taking advantage of the fact that the efficacy of TKI treatment can be assessed rapidly and precisely by measuring the BCR-ABL1 transcripts level with real-time PCR (RT-PCR) in peripheral blood cells. An RT-PCR monthly for the first few months provides the best assessment of the response to treatment. We predict that a more flexible strategy of treatment (adapting the dose to the response) will result into a more convenient balance between activity and toxicity, hence into a better outcome. Based on these premises, it is proposed to test the activity, the safety, and the tolerability of Bosutinib, second-line, beginning with a low dose and adjusting subsequent doses based on molecular response, and on AEs, in a population of elderly patients. In almost all prior studies of TKIs in second- or third-line, the primary efficacy was assessed using cytogenetic response, both major and complete, at different time points. To make the results of this study comparable to the results of prior studies, the cytogenetic response will be evaluated as specified in section 5, but since the response to therapy and the evaluation of the efficacy of therapy are more and more based on molecular response, dose adaptation and efficacy evaluation will be based primarily on molecular response.

• Study Type: Interventional
• Enrollment (Anticipated): 65
• Phase: Phase 2

Contacts and Locations

Study Locations

• Italy
  • Alessandria, Italy
    • S.O.C. di Ematologia - Azienda Ospedaliera - SS. Antonio e Biagio e Cesare Arrigo
  • Ancona, Italy
    • Azienda Ospedaliero - Universitaria Ospedali Riuniti Umberto I - G.M. Lancisi - G. Salesi
  • Bari, Italy
    • UO Ematologia con trapianto-Università degli Studi di Bari Aldo Moro
  • Bologna, Italy
    • Fausto Castagnetti
  • Bologna, Italy
    • Istituto di Ematologia "Lorenzo e A. Seragnoli" - Policlinico S. Orsola - Malpighi
  • Cagliari, Italy
    • ASL N.8 - Ospedale "A. Businco" - Struttura Complessa di Ematologia e CTMO
  • Catania, Italy
    • Università di Catania - Cattedra di Ematologia - Ospedale "Ferrarotto"
  • Cuneo, Italy
    • S.C. Ematologia ASO S. Croce e Carle
  • Ferrara, Italy
    • Arcispedale Sant'Anna Dipartimento di Scienze Mediche Sezione di Ematologia
  • Firenze, Italy
    • Policlinico di Careggi
  • Foggia, Italy
    • Struttura Complessa di Ematologia Ospedali Riuniti Foggia
  • Genova, Italy
    • IRCCS_AOU San Martino-IST-Ematologia 1-Monoblocco 11°piano- lato ponente
  • Lecce, Italy
    • ASL Le/1 P.O. Vito Fazzi - U.O. di Ematologia ed UTIE
  • Meldola, Italy
    • Istituto Scientifico Romagnoli per lo Studio e la Cura dei Tumori- IRST
  • Messina, Italy
    • Policlinico G. Martino Dipartimento di Medicina Interna - U.O. Messina
  • Milano, Italy
    • U.O. Ematologia e Trapianto di MIdollo - Ist.Scientifico Ospedale San Raffaele
  • Milano, Italy
    • Unità Trapianto di Midollo Ist. Nazionale Tumori
  • Milano, Italy
    • Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico UOC Oncoematologia
  • Monza, Italy
    • Azienda Ospedaliera "S.Gerardo"
  • Napoli, Italy
    • Azienda Università degli Studi di Napoli "Federico II" - Facoltà di Medicina e Chirurgia
  • Novara, Italy
    • S.C.D.U. Ematologia - Università del Piemonte Orientale Amedeo Avogadro
  • Orbassano, Italy
    • Dip. di Scienze Cliniche e Biologiche - Ospedale S. Luigi Gonzaga-Medicina Interna 2
  • Padova, Italy
    • Università degli Studi di Padova - Ematologia ed Immunologia Clinica
  • Palermo, Italy
    • U.O. di Ematologia con trapianto - A.U. Policlinico "Paolo Giaccone"
  • Parma, Italy
    • Cattedra di Ematologia CTMO Università degli Studi di Parma
  • Pavia, Italy
    • S.C. Ematologia - Fondazione IRCCS Policlinico S. Matteo
  • Piacenza, Italy
    • Dipartimento di Oncologia ed Ematologia - AUSL Ospedale G. da Saliceto
  • Potenza, Italy
    • Ematologia - Ospedale San Carlo
  • Ravenna, Italy
    • Dipartimento Oncologico - Ospedale S.Maria delle Croci
  • Reggio Emilia, Italy
    • Unità Operativa Complessa di Ematologia - Arcispedale S. Maria Nuova
  • Rimini, Italy
    • Ospedale "Infermi"
  • Rionero in Vulture, Italy
    • U.O. di Ematologia - Centro Oncologico Basilicata
  • Roma, Italy
    • Complesso Ospedaliero S. Giovanni Addolorata
  • Roma, Italy
    • Università Cattolica del Sacro Cuore - Policlinico A. Gemelli
  • Roma, Italy
    • Divisione Ematologia - Università Campus Bio-Medico
  • Roma, Italy
    • Padiglione Cesalpino - I piano - Divisione di Ematologia - Ospedale S. Camillo
  • Roma, Italy
    • UOC Pronto Soccorso - Dipartimento Biotecnologie Cellulari Università di Roma "Sapienza"
  • San Giovanni Rotondo, Italy
    • Istituto di Ematologia - IRCCS Ospedale Casa Sollievo della Sofferenza
  • Siena, Italy
    • U.O.C. Ematologia e Trapianti - A.O. Senese - Policlinico " Le Scotte"
  • Terni, Italy
    • A.O. Santa Maria - Terni S.C Oncoematologia
  • Torino, Italy
    • Divisione di Ematologia - "Città della Salute e della Scienza di Torino"
  • Torino, Italy
    • S.C. Ematologia 2 A.O. Città della Salute e della Scienza di Torino San Giovanni Battista
  • Udine, Italy
    • Clinica Ematologica-Centro Trapianti e Terapie cellulari
  • Varese, Italy
    • Medicina Interna I - Ospedale di Circolo
  • Verona, Italy
    • A. O. - Istituti Ospitalieri di Verona- Div. di Ematologia - Policlinico G.B. Rossi

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 60 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Molecular confirmed diagnosis of BCR-ABL1+ CML
2. Chronic phase CML (ELN 2013 criteria)
3. 60 years of age or older
4. Prior first-line treatment with any other TKIs

5. Intolerance to prior treatment, based on investigator and patient assessment or failure of prior treatment according to any one of the ELN 2013 criteria, as listed below

   • Non complete hematologic response (CHR) at 3 months
   • No cytogenetic response (Ph+ > 95%) at 6 months
   • Less than Partial Cytogenetic Response (PCyR) (Ph+ >35%) at 6 months
   • BCR-ABL1 > 10% at 6 months
   • Non complete CyR (CCyR) (Ph+ > 0) at 12 months
   • BCR-ABL1 > 1% at 12 months
   • Loss of CHR at any time
   • Loss of CCyR at any time
   • Confirmed loss of major molecular response (MMR) (BCR-ABL1 > 0.1%) in two consecutive tests, of which one > 1%, at any time
6. An effective form of contraception from enrolment through 30 days after the end of treatment
7. Signed written informed consent according to ICH/EU/GCP and national and local laws prior to any study procedures
8. Willingness and ability to comply with scheduled visits and study procedures.

Exclusion Criteria:

1. Accelerated or blastic phase CML (according to ELN 2013 criteria)
2. Patients with the T315I or the V299L mutation
3. Patients previously treated with 2 TKIs or more
4. Compelled to take medications that are known to be associated with Torsades de Pointes and/or with significant QTc prolongation
5. Any condition or illness that, in the opinion of the Investigator, would compromise patient safety or interfere with the evaluation of the drug
6. HBV markers positivity
7. Lack of informed consent

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm

Intervention / Treatment

Experimental: Bosutinib treatment

Drug: Bosutinib; Bosutinib is given orally accordingly with this scheme: A. 200 mg OD: starting dose ("wash-in" period) at week 1 and week 2 B. 300 mg OD: from week 3 to the end of week 16 At the end of week 12 evaluation of molecular response (BCR-ABL1 level by RT-Q-PCR). Bosutinib dose is then managed as follows : C1. if BCR-ABL1 ≤1% at week 12: 300 mg OD from week 17 to week 52 C2. if BCR-ABL1 > 1% at week 12: 400 mg OD from week 17 to week 52 All the responsive patients who are still on Bosutinib at the end of week 52, will continue Bosutinib at the same dose (300 mg OD or 400 mg OD) for the next two years ( if tolerated and in absence of safety concerns).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Number of patients who are in major molecular response (MMR)	One year treatment

Secondary Outcome Measures

Outcome Measure	Time Frame
Number of patients who obtain molecular response	At 6 and 12 months from treatment start
Number of patients discontinuing treatment for failure, adverse events or other reasons	At 12 and 36 months
Number of Adverse Events (AEs)	At 36 months
Number of patients alive	At 36 months
Number of patients on treatment at 200, 300 and 400 mg or more daily	At 6, 12 and 36 months
Number and type of BCR-ABL1 mutations	At 36 months
Patient reported quality of life	At 3, 6, and 12 months

Collaborators and Investigators

• Sponsor: Gruppo Italiano Malattie EMatologiche dell'Adulto
• Investigators: Study Chair: Fausto Castagnetti, Department of Hematology, S. Orsola-Malpighi University of Bologna

Publications and helpful links

Helpful Links

• GIMEMA Foundation website

Study record dates

Study Major Dates

• Study Start (Actual): November 17, 2016
• Primary Completion (Actual): April 30, 2020
• Study Completion (Anticipated): April 1, 2022

Study Registration Dates

• First Submitted: June 15, 2016
• First Submitted That Met QC Criteria: June 20, 2016
• First Posted (Estimate): June 23, 2016

Study Record Updates

• Last Update Posted (Actual): January 5, 2022
• Last Update Submitted That Met QC Criteria: January 4, 2022
• Last Verified: January 1, 2022

More Information

Terms related to this study

• Keywords: chronic myeloid leukemia; bosutinib
• Additional Relevant MeSH Terms: Neoplasms by Histologic Type; Neoplasms; Bone Marrow Diseases; Hematologic Diseases; Myeloproliferative Disorders; Leukemia; Leukemia, Myeloid; Leukemia, Myelogenous, Chronic, BCR-ABL Positive
• Other Study ID Numbers: CML1516; 2016-002216-40 (EudraCT Number)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No