During a Targeted Oncology Case Based Peer Perspective event, Usama Gergis, MD, MBA, professor of Oncology, director, Bone Marrow Transplant and Immune Cellular Therapy at Sidney Kimmel Cancer Center, at the Thomas Jefferson University Hospital, discussed the case of a 48-year-old male patient with acute graft-versus-host-disease (GVHD).
Targeted Oncology™: For a patient such as this, what is the risk of developing acute (GVHD) following transplant?
GERGIS: The list of risk factors for GVHD is huge: donor HLA [human leukocyte antigen] disparities that are major/minor, sex matching, donor parity, donor age, blood type—while it’s controversial—donor CMV seropositivity, gene polymorphism, and stemcell graft source. Obviously, peripheral mobilized stem cells have more T cells than bone marrow. Other factors include graft composition, the higher CD34 the higher lymphocytes, and conditioning intensities. There are a bunch of factors here, at least for our patient, who had a MAC. The fact that his donor is a multirisk, 50-year-old woman and a MUD [infers] similar higher risk.
How quickly do you determine whether a patient is steroid refractory or steroid dependent?
Basically, steroid refractoriness or resistance versus dependence versus intolerance [can be determined in] as early as 3 days. If there is progression of the grade of GVHD, this is considered steroid refractory. If by 4 weeks it does not go to grade 0, it’s considered refractory. However, I disagree with the 28-day [timeline]. I think it’s a long time to wait. Usually, I look at 2 weeks.
This has been the consensus among many of us. I think the trials REACH-1 [NCT02953678] and REACH-2 [NCT02435433] looked at 28 days; but if you go to the 2 papers, most responses took place in 7 to 14 days. Again, this is in the second-line setting.
I’ve been doing this for 15 years. I’ve been through most of this; so many lines [of therapy and] so many heartbreaks. I teach my fellows to look at any [research] paper in second-line GVHD—the overall response rate is 30%. I’ve done it with MMF [mycophenolate mofetil], sirolimus [Rapamune], infliximab [Remicade], ATG [antithymocyte globulin], cyclophosphamide, Ontak [denileukin diftitox], and mesenchymal stem cells and overall response rate is 30%.
Which data support the use of ruxolitinib (Jakafi) in patients who are steroid refractory?
Based on a small trial of 49 patients, a phase 2 trial [INCB 18424-271; NCT02953678], ruxolitinib was approved as a second-line therapy for patients with acute steroid-refractory GVHD.1
Review the details of the REACH-2 trial.
The REACH-2 trial data were just published in 2020. Ruxolitinib was approved based on a small trial of 49 patients with steroid-refractory acute GVHD. They enrolled 70 but only 49 were available for efficacy. Obviously, it was a pilot phase 2 with no comparative arm, and the response rates across the board were [somewhere in the range of] 50% or so by day 28.
Then they were asked to run a phase 3 trial comparing ruxolitinib at 10 mg twice daily versus best available care. The best available care goes through the list that I just mentioned, including photopheresis, ATG, and others. After 4 weeks, patients who were not responders on the best available care were allowed to cross over to ruxolitinib.
By day 28, the responders on the ruxolitinib composed 60% of the cohort versus 40% on the control arm with a P value of less than .001. The durability of response at 8 weeks was 40% versus 20% [odds ratio, 2.38; 95% CI, 1.43 to 3.94; P < .001].
This tell us that ruxolitinib works in this group, that it does not work that great in one-third of patients who lose their response at 8 weeks, and that it’s just better than anything else [that’s available]. A good thing about the ruxolitinib arm is that the response duration was much longer than best available treatment, as illustrated by the Kaplan-Meier curve for response duration.
Failure-free survival [in this trial] was 5.0 months versus 1.0 month [HR, 0.46; 95% CI, 0.35-0.60].
Do you apply this therapy to any of your patients?
We have a patient [at my institution] who has steroid-refractory GVHD. Last Friday in our weekly meeting, we were discussing his [case]. He has lower GI [gastrointestinal] GVHD—grade IV, steroid-refractory, as bad as it gets—and I said let’s start him on ruxolitinib. One of my colleagues said it doesn’t work well in the lower GI. I asked the organizers to pull [data] from the supplemental figures on the New England Journal of Medicine paper of REACH-2 [indicating that these patients did have a benefit with ruxolitinib].2
1. FDA approves ruxolitinib for acute graft-versus-host disease. FDA. May 24, 2019. Accessed October 10, 2020. https://bit.ly/2SMU7I8
2. Zeiser R, von Bubnoff N, Butler J, et al; REACH2 Trial Group. Ruxolitinib for glucocorticoid- refractory acute graft-versus-host disease. N Engl J Med. 2020;382(19):1800-1810. doi: 10.1056/NEJMoa1917635
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