Chronic Myeloid Leukemia—the Promise of Tyrosine Kinase Inhibitor Discontinuation

Narra, Ravi Kishore; Flynn, Kathryn E.; Atallah, Ehab

doi:10.1007/s11899-017-0404-z

Cited by 8 publications

(21 citation statements)

References 50 publications

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“…Although TKIs have had a more substantial impact on survival, the long‐term financial burden must be considered given current recommendations for patients with CML who are in complete cytogenic response to remain on TKI therapy indefinitely . Given previous projections that approximately 50% of the Medicare population has <$13,800 in available liquid assets, the annual patient cost responsibility identified in the current study results in a devastating financial burden among these older patients over a 5‐year period.…”

Section: Discussionmentioning

confidence: 99%

“…A SEER‐based study found that TKIs had created >$143 billion in social value, >90% of which was retained by patients and society . However, although TKI discontinuation studies currently are ongoing, with positive treatment‐free survival noted for subsets of patients, a majority of patients will need lifelong TKI therapy with the attendant challenges, especially among older patients on a fixed income. The results of the current study have highlighted service‐specific spending over time with approximately 80% of patients with CML who are receiving TKI therapies reaching the catastrophic coverage phase within the first 2 years from the time of diagnosis, and demonstrated the critical need to ensure the adequacy of time receiving TKI therapy for modest differences in spending between those patients with adequate and inadequate time receiving therapy.…”

Section: Discussionmentioning

confidence: 99%

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Medicare and patient spending among beneficiaries diagnosed with chronic myelogenous leukemia

Kenzik

Bhatia

Williams

et al. 2019

Cancer

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Background The authors examined Medicare spending and patient spending in older patients with chronic myelogenous leukemia (CML) over the first 5 years from the time of CML diagnosis in the tyrosine kinase inhibitor (TKI) era. Methods Medicare beneficiaries with CML who were diagnosed between 2007 and 2012 at age >65 years were identified from the Surveillance, Epidemiology, and End Results (SEER)–Medicare database (805 beneficiaries). A noncancer Medicare beneficiary sample was frequency‐matched based on age, sex, and race/ethnicity (805 individuals). Patients were followed until 5 years from diagnosis, disenrollment, death, or December 31, 2014, whichever came first. Total Medicare spending, service‐specific spending, and amount owed by patients was estimated monthly and then summed over 60 months and averaged to generate annual spending. Results The median age at the time of diagnosis of CML was 76 years (range, 66‐102 years). Overall, 51.4% of patients received TKIs (27.8% received imatinib alone), 28% received non‐TKI therapy, and 21% received no treatment. The 5‐year survival rate for patients with ≥85% time receiving TKIs was 79% compared with 76% for noncancer controls versus 62% for those with <85% time receiving TKIs. Annual Medicare spending was found to be significantly higher for patients treated with TKIs ($143,053) compared with those treated without TKIs ($41,268 vs $10,498 for noncancer controls). Annual patient cost responsibility was $11,712 per patient receiving any TKIs versus $7330 for those receiving non‐TKI outpatient chemotherapy versus $3561 for noncancer controls. Conclusions Older patients with CML with adequate time receiving TKI therapy have 5‐year survival rates that are comparable to those of their counterparts without cancer. However, TKI use is accompanied with significant Medicare and patient spending; patients receiving multiple TKIs (ie, dasatinib or nilotinib along with imatinib) constitute the group with the highest spending.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Medicare and patient spending among beneficiaries diagnosed with chronic myelogenous leukemia

Kenzik

Bhatia

Williams

et al. 2019

Cancer

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“…Younger patients have other problems because living with TKI interferes with family planning, availability for the job market, life insurance, and so on. 4 Besides, as more and more patients are living with their disease, high treatment costs are becoming an important issue. 5…”

Section: Introductionmentioning

confidence: 99%

Observational study of chronic myeloid leukemia Italian patients who discontinued tyrosine kinase inhibitors in clinical practice

et al. 2019

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It is judged safe to discontinue treatment with tyrosine kinase inhibitors (TKI) for chronic myeloid leukemia (CML) in experimental trials on treatment-free remission (TFR). We collected a total of 293 Italian patients with chronic phase CML who discontinued TKI in deep molecular response. Seventy-two percent of patients were on treatment with imatinib, and 28% with second generation TKI at the time of discontinuation. Median duration of treatment with the last TKI was 77 months [Interquartile Range (IQR) 54;111], median duration of deep molecular response was 46 months (IQR 31;74). Duration of treatment with TKI and duration of deep molecular response were shorter with second generation TKI than with imatinib ( P <0.001). Eighty-eight percent of patients discontinued as per clinical practice, and reasons for stopping treatment were: toxicity (20%), pregnancy (6%), and shared decision between treating physician and patient (62%). After a median follow up of 34 months (range, 12-161) overall estimated TFR was 62% (95%CI: 56;68). At 12 months, TFR was 68% (95%CI: 62;74) for imatinib, 73% (95%CI: 64;83) for second generation TKI. Overall median time to restart treatment was six months (IQR 4;11). No progressions occurred. Although our study has the limitation of a retrospective study, our experience within the Italian population confirms that discontinuation of imatinib and second generation TKI is feasible and safe in clinical practice.

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“…1,2,4,10,14,[32][33][34][35][36][37][38][39][44][45][46][47][48] All first-line TKIs for the treatment of CP CML have been associated with increased bleeding risk; however, this risk appears to be more pronounced with dasatinib. 1,2,4,10,12,14,16,17,[32][33][34][35][36][37][38][39][44][45][46][47][48] Dasatinib inhibits platelet function and should be used with caution in patients receiving antiplatelet/anticoagulant medications or with a history of bleeding. 32,38 In general, the concomitant use of anti-coagulants with all BCR-ABL TKIs is associated with an increased risk of bleeding in patients with CP CML.…”

Section: Cardiovascular Considerationsmentioning

confidence: 99%

“…1,8 Additionally, treatment goals now attempt to minimize disease transformation to AP or BP, achieve a deep molecular remission, and to potentially stop treatment. 1,8,12,13 Long-term treatment with TKIs requires that patients have to be clinically managed and monitored over long periods of time, with a focus on managing treatment-emergent toxicities and maintaining patient adherence to medication. 8,14 Poor treatment adherence in CML has been associated with the inability to achieve adequate molecular responses and with poorer treatment outcomes.…”

Section: Introductionmentioning

confidence: 99%

Front-line use of tyrosine kinase inhibitors in chronic phase chronic myeloid leukemia: Practice considerations

Reff¹,

Shillingburg

Shah

et al. 2019

J Oncol Pharm Pract

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The development of BCR-ABL-targeting tyrosine kinase inhibitors has transformed chronic phase chronic myeloid leukemia (CP CML) from a disease with a terminal prognosis to a treatable chronic illness. Long-term treatment with tyrosine kinase inhibitors means that patients have to be clinically managed and monitored over extended periods of time, thus a patient-centered, medically integrated, and multidisciplinary oncology healthcare team is required to support patients through their journey. Pharmacists work with patients, physicians, and the wider support team to select the optimum therapy plan for a given patient. These decisions are based on risk factors, comorbidities, concomitant medications, and personal circumstances and pharmacists advise on the efficacy and safety of different treatment options. Additionally, pharmacists are a key point-of-contact and resource for monitoring patient response to treatment, identifying and managing adverse events and drug–drug interactions, any subsequent therapy plan modifications, and, potentially, treatment-free remission. Pharmacists also assist with patient education, medication adherence, and financial discussions with patients throughout the long course of the disease. This review provides an overview of BCR-ABL tyrosine kinase inhibitors, discusses the role of the medically integrated pharmacy team, and suggests strategies that pharmacists can use in patient management and clinical decision-making to optimize the treatment of CP CML.

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Chronic Myeloid Leukemia—the Promise of Tyrosine Kinase Inhibitor Discontinuation

Cited by 8 publications

References 50 publications

Medicare and patient spending among beneficiaries diagnosed with chronic myelogenous leukemia

Medicare and patient spending among beneficiaries diagnosed with chronic myelogenous leukemia

Observational study of chronic myeloid leukemia Italian patients who discontinued tyrosine kinase inhibitors in clinical practice

Front-line use of tyrosine kinase inhibitors in chronic phase chronic myeloid leukemia: Practice considerations

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