Effect of Caspofungin vs Fluconazole Prophylaxis on Invasive Fungal Disease Among Children and Young Adults With Acute Myeloid Leukemia: A Randomized Clinical Trial

Abstract

Importance: Children, adolescents, and young adults with acute myeloid leukemia are at high risk of life-threatening invasive fungal disease with both yeasts and molds.

Objective: To compare the efficacy of caspofungin vs fluconazole prophylaxis against proven or probable invasive fungal disease and invasive aspergillosis during neutropenia following acute myeloid leukemia chemotherapy.

Design, setting, and participants: This multicenter, randomized, open-label, clinical trial enrolled patients aged 3 months to 30 years with newly diagnosed de novo, relapsed, or secondary acute myeloid leukemia being treated at 115 US and Canadian institutions (April 2011-November 2016; last follow-up June 30, 2018).

Interventions: Participants were randomly assigned during the first chemotherapy cycle to prophylaxis with caspofungin (n = 257) or fluconazole (n = 260). Prophylaxis was administered during the neutropenic period following each chemotherapy cycle.

Main outcomes and measures: The primary outcome was proven or probable invasive fungal disease as adjudicated by blinded central review. Secondary outcomes were invasive aspergillosis, empirical antifungal therapy, and overall survival.

Results: The second interim efficacy analysis and an unplanned futility analysis based on 394 patients appeared to have suggested futility, so the study was closed to accrual. Among the 517 participants who were randomized (median age, 9 years [range, 0-26 years]; 44% female), 508 (98%) completed the trial. The 23 proven or probable invasive fungal disease events (6 caspofungin vs 17 fluconazole) included 14 molds, 7 yeasts, and 2 fungi not further categorized. The 5-month cumulative incidence of proven or probable invasive fungal disease was 3.1% (95% CI, 1.3%-7.0%) in the caspofungin group vs 7.2% (95% CI, 4.4%-11.8%) in the fluconazole group (overall P = .03 by log-rank test) and for cumulative incidence of proven or probable invasive aspergillosis was 0.5% (95% CI, 0.1%-3.5%) with caspofungin vs 3.1% (95% CI, 1.4%-6.9%) with fluconazole (overall P = .046 by log-rank test). No statistically significant differences in empirical antifungal therapy (71.9% caspofungin vs 69.5% fluconazole, overall P = .78 by log-rank test) or 2-year overall survival (68.8% caspofungin vs 70.8% fluconazole, overall P = .66 by log-rank test) were observed. The most common toxicities were hypokalemia (22 caspofungin vs 13 fluconazole), respiratory failure (6 caspofungin vs 9 fluconazole), and elevated alanine transaminase (4 caspofungin vs 8 fluconazole).

Conclusions and relevance: Among children, adolescents, and young adults with acute myeloid leukemia, prophylaxis with caspofungin compared with fluconazole resulted in significantly lower incidence of invasive fungal disease. The findings suggest that caspofungin may be considered for prophylaxis against invasive fungal disease, although study interpretation is limited by early termination due to an unplanned interim analysis that appeared to have suggested futility.

Trial registration: ClinicalTrials.gov Identifier: NCT01307579.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Fisher reported that his institution receives funding from Merck and Pfizer for research studies, which are not related to this project, and that he began service on the DSMB for Astellas after this study concluded. Dr Zaoutis reported that he provides consultant services for T2 Biosystems and Nabriva Therapeutics in projects not related to this study. Dr Wingard reported that he serves on the data committees for Astellas, Shire, Merck, and Celgene, none of which are related to this study. Ms Callahan reported that she provides consultant services for Novartis in projects not related to this study. Dr Wiley reported that he is currently employed by Leadiant Biosciences. No other disclosures were reported.

Figures

Figure 1.. Flow Through the Trial of Antifungal Prophylaxis in Patients With Acute Myeloid Leukemia

aNo information about those approached was available. The total number of patients assessed for participation and reason for exclusion were not collected. IFD indicates invasive fungal disease.

Figure 2.. Time to Proven or Probable Invasive Fungal Disease and Proven or Probable Invasive Aspergillosis

A, Median follow-up time for invasive fungal disease was 4.4 months (interquartile range [IQR], 3.0-5.2) for caspofungin and 4.6 months (IQR, 3.3-5.2) for fluconazole. B, Median follow-up time for invasive aspergillosis was 4.4 months (IQR, 3.0-5.2) for caspofungin and 4.6 months (IQR, 3.3-5.3) for fluconazole.