A Randomized Phase II Study of Two Schedules of Decitabine for Frontline Therapy of Older or Unfit Patients With Acute Myeloid Leukemia (AML)
Phase: PHASE2
Conditions: Leukemia
Sponsor: M.D. Anderson Cancer Center

2012-1017
June 7, 2017
Page 1
Protocol Page
A RANDOMIZED PHASE II STUDY OF TWO SCHEDULES OF DECITABINE 
FOR FRONTLINE THERAPY OF OLDER OR UNFIT PATIENTS WITH ACUTE 
MYELOID LEUKEMIA (AML)
2012-1017
Core Protocol Information
Short Title 
DECITABINE FOR OLDER OR UNFIT PATIENTS WITH AML
Study Chair: 
Farhad Ravandi-Kashani
Additional Contact:
Andrea L. Booker
Priscilla D. Cardenas
Leukemia Protocol Review Group
Department:
Leukemia
Phone:
713-745-0394
Unit:
428
Full Title: 
A RANDOMIZED PHASE II STUDY OF TWO SCHEDULES OF DECITABINE FOR 
FRONTLINE THERAPY OF OLDER OR UNFIT PATIENTS WITH ACUTE MYELOID 
LEUKEMIA (AML)
Protocol Type:
Standard Protocol
Protocol Phase:
Phase II
Version Status:
Terminated 05/06/2019
Version:
11
Submitted by:
Andrea L. Booker--6/7/2017 9:37:19 AM
OPR Action:
Accepted by:  Rosheta McCray -- 6/25/2017 11:12:31 AM
Which Committee will review this protocol?
 The Clinical Research Committee - (CRC)

2012-1017
June 7, 2017
Page 2
Protocol Body
 

 
 
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A RANDOMIZED PHASE II STUDY OF TWO SCHEDULES OF DECITABINE FOR 
FRONTLINE THERAPY OF OLDER OR UNFIT PATIENTS WITH ACUTE MYELOID 
LEUKEMIA 
 
 
Principal Investigator:  Farhad Ravandi-Kashani, M.D. 
 
Biostatistician:  Xuelin Huang, Ph.D. 
 
 

 
 
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Table of Contents 
1.0 
Objectives .............................................................................................................................. 3 
2.0 
Background ........................................................................................................................... 3 
3.0 
Decitabine is an investigational agent ........................................................................... 11 
4.0 
Eligibility Criteria ................................................................................................................ 13 
5.0 
Therapy ................................................................................................................................ 14 
6.0 
Correlative studies ............................................................................................................. 17 
7.0 
Pre-study evaluations ........................................................................................................ 19 
8.0 
Evaluations during the study ........................................................................................... 20 
9.0 
Response criteria ............................................................................................................... 21 
10.0  Criteria for removal from the study ................................................................................. 21 
11.0  Statistical Considerations ................................................................................................ 21 
12.0  Reporting Requirements ........................................................... Error! Bookmark not defined. 
13.0  References .......................................................................................................................... 26 
 
 
 

 
 
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A RANDOMIZED PHASE II STUDY OF TWO SCHEDULES OF DECITABINE FOR 
FRONTLINE THERAPY OF OLDER OR UNFIT PATIENTS WITH ACUTE MYELOID 
LEUKEMIA 
 
1.0 
Objectives 
 
1.1 
Primary: Compare the response rates of two schedules of decitabine in patients 
with AML 60 and older than 60 and/or unfit for standard cytotoxic chemotherapy. 
1.2 
Secondary: Compare response durations, survivals and side effects of the two 
schedules. 
1.3 
Tertiary:  To examine the correlation of a number of biological and 
pharmacodynamics correlates with response to therapy including global and 
gene-specific methylation, specific somatic gene mutations, micro-RNA, and 
immune effector function 
2.0 
Background 
 
2.1  
The Disease – Acute Myeloid Leukemia in the elderly 
Acute myeloid leukemia (AML) is the most common form of acute leukemia in adults in 
the US, with an incidence of approximately 12,000 per year.1 The median age at diagnosis is 
65-70 and the incidence rises with increasing age with the age-adjusted incidence being 17.6 
per 100,000 and 1.8 per 100,000 in those older and younger than 65, respectively. This 
problem is not unique to the US with an increase in the incidence of AML in the older 
population worldwide, likely due to an overall increase in life-expectancy, increased application 
and success of chemotherapeutic agents and radiation therapy in cancer patients, and 
perhaps an overall increase in environmental toxin exposure as a result of industrialization.  
2.1.1 Attitudes towards treatment of older patients 
Despite the high incidence of AML in the older population, until recently, many of the 
trials in this disease had been conducted in the younger population and much of the available 
data was inapplicable to them. This reflected reluctance by both patients and physicians to 
expose the older patients to the toxic effects of anti-leukemic therapy. Such under-
representation of patients 65 years and older in cancer treatment trials has been well 
documented but is probably more of an issue in acute leukemias where the chemotherapeutic 
regimens are generally more intensive than in other tumors.2 Furthermore, clinical trials 
conducted in the older population have been generally biased due to the exclusion of patients 
with poor performance status and co-morbid medical conditions. Using the linked Surveillance, 
Epidemiology, and End Results (SEER)-Medicare database, Menzin and colleagues 
retrospectively evaluated the outcomes of approximately 3500 elderly patients with AML.3,4 
They reported that only about a third of the patients received induction chemotherapy, ranging 
from 7% of patients ≥ 85 years of age to 49% of patients 65-74 years of age. Treatment rates 
increased during the decade of analysis, ranging from 29% to 38% of patients diagnosed in 

 
 
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1991 and 1999 respectively but the increased rates were confined to younger patients (those 
65-74 vs. 75-84 years of age).4  Median survival across all study population was 2.4 months 
with fewer than 7% of patients alive at 2 years further emphasizing the dismal outcome of 
these patients in the community with current strategies. However, the authors also 
demonstrated that patients who did receive therapy benefited from a prolongation of survival, 
be it modest.3  
Clearly the decision making process in treating elderly patients with AML has been 
highly influenced by the attitudes of patients and their physicians and their expectations of 
success. Juliusson and colleagues, using the Swedish Leukemia Registry data, retrospectively 
evaluated the outcomes of 506 patients aged 70-79 with AML (Acute promyelocytic leukemia-
APL excluded) from 6 Swedish health regions with known differing attitudes towards remission 
induction.5 Although the 5-year survival of the overall 70-79 year old population in these 
regions was similar, the survival of 70-79 year-old AML patients was significantly better in 
regions were more elderly patients were judged eligible for remission induction.5  
In a more recent study, the same investigators and using data from the same registry 
reported an improvement in early death rates and long-term survival among elderly patients 
who received induction chemotherapy as compared to those who received palliation only.6 
Furthermore, long term survivors were found in the group given intensive therapy despite poor 
initial performance status.6 This has also been reported by a number of other studies that have 
compared chemotherapy (intensive or non-intensive) to palliation.7,8  Lowenberg and 
colleagues randomized 60 patients with AML aged 65 or older to receive either immediate 
intensive induction chemotherapy or palliative treatment with only mild cytoreductive 
chemotherapy only for relief of progressive disease.7 They demonstrated a higher complete 
remission (CR) rate (58% vs. 0%), and a higher survival duration (21 vs. 11 weeks, p=0.15) in 
patients treated more intensively.7 Results from the non-intensive chemotherapy arm of the 
AML14 trial showed that median survival significantly improved with low-dose cytarabine (20 
mg twice daily for 10 days, every 4 to 6 weeks) compared with hydroxyurea.8 CR occurred in 1 
of 92 (1%) patients in the hydroxyurea treatment arm and in 15 of 92 (17%) patients in the low-
dose cytarabine arm. Benefits were limited to patients who had intermediate-risk karyotype. In 
another earlier study, Tilly and colleagues randomized 87 patients 65 years and older to low 
dose cytarabine (20 mg/m2 daily for 21 days) or intensive chemotherapy with cytarabine and 
an anthracycline.9 Overall survival and CR duration was similar for the two groups with 
significantly higher CRs as well as significantly higher early death and severe infections in the 
in the intensively treated group.9. Clearly and considering the results from the hitherto 
mentioned studies, this population benefits at least modestly from receiving chemotherapy as 
opposed to palliation only. The decision regarding the intensity of the chemotherapy 
administered remains one of the most debated issues in AML therapy. It is also clear that 
although age per se is an important predictor of the outcome, other factors (covariates) 
influence it. The heterogeneity of patients labeled “elderly” is clearly masked by terms 
commonly used to describe this population such as “ineligible to undergo intensive 
chemotherapy”. It is also worth noting here that the estimations of response to intensive 
therapy may be highly divergent between the patients and their treating physicians, further 
complicating the process of decision-making.10 
2.1.2 
Predictors of outcome in elderly AML 

 
 
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Age per se has been repeatedly shown to be associated with an inferior outcome when 
considering fairly uniformly treated populations of patients (Figure 1a).11,12 In a study by the 
German AML co-operative group, 4-year survival in those younger and older than 60 years 
was 37% vs. 16% (p0.001).12 It can be argued that age should be considered as a continuum 
with no clear demarcating age above and below which patient is considered elderly. However, 
for practical purposes, age ≥60 years is a commonly accepted criterion for defining elderly. 
Appelbaum and colleagues analyzed data from 5 Southwest Oncology Group (SWOG) clinical 
trials which included 968 patients.11 Increasing age was associated with less favorable 
cytogenetics, poorer performance status scores, lower white blood cell counts, and a lower 
percentage of marrow blasts.11 Increasing age was also associated with a higher incidence of 
early death after induction therapy, a lower CR rate, and shorter survival.11 However, among 
the older population, those with a poorer performance status at presentation had a very high 
early mortality an indication of the interaction between covariates. 
Other factors that are clearly important predictors of outcome include patient-related 
factors such as organ function, and presence of uncontrolled infection, and leukemia-related 
factors such as biological determinants of resistance to chemotherapy. Cytogenetics has been 
clearly established as one of the most important predictors of outcome in AML.13-15 16 Although 
the overall outcome of older patients with AML is inferior to younger adults, survival is 
generally improved for patients with favorable and intermediate cytogenetic aberrations 
compared to those with adverse karyotype. Recent data confirm the importance of pre-
treatment karyotype on the outcome of older patients.17-20 In a report examining the prognostic 
factors in older patients treated on the MRC AML11 and AML14 trials, the survival was very 
much dependent on the cytogenetic risk. In another study by the German-Austrian AML study 
group high risk cytogenetics and age above 70 years were independent prognostic factors 
affecting overall survival.19 Stratification using these parameters identified a large subgroup 
(55%) of patients with very poor outcome despite intensive chemotherapy. Whether pre-
treatment cytogenetics should be factored in the choice of therapy in older AML patients 
remains a subject of debate. As typically the result of this analysis may not be available for up 
to a week, it can be argued that cytogenetics should not influence the initial decision making 
process in selecting therapy. However, a recent study by Sekeres and colleagues 
demonstrated that accounting for other covariates available at the time of diagnosis, in patients 
older than 60 years and with white blood cell (WBC) less than 50 x 109/L, time from diagnosis 
to initiation of therapy did not affect CR rate or overall survival suggesting that this population 
may not be harmed from a delay to obtain the results of additional testing.21 Others have also 
recommended waiting until the cytogenetic results are available.22 Obviously, this is highly 
dependent on the availability of treatment strategies that are clearly superior to standard in 
particular cytogenetic subgroups or the recognition that patients with specific characteristics 
such as those described by Malfuson and colleagues are unlikely to benefit from standard 
induction regimens.22 
More recently, it has been reported that younger patients with normal karyotype can be 
further characterized by the absence or presence of specific molecular aberrations that can 
affect their outcome.23 Few studies have examined the role of these molecular abnormalities 
and their influence on the outcome of elderly patients with AML. However, in a recent study, 
the investigators from the Cancer and Leukemia Group B (CALGB) reported that mutations in 
the nucleophosmin (NPM1) gene were associated with a better prognosis in cytogenetically 

 
 
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normal older patients and in particular in those ≥ 70 years.24 Other predictors of a worse 
outcome in the elderly have been identified. A higher incidence of intrinsic drug resistance in 
the leukemic blasts, mediated  by expression of multidrug resistance glycoprotein MDR1 (and 
other efflux pumps that actively extrude chemotherapeutic agents from leukemic cells), has 
been reported in older patients with AML and has been associated with a lower CR rate and 
increased resistance.25 Similarly, presence of antecedent hematological disorders such as 
myelodysplastic syndromes (MDS) and myeloproliferative disorders (MPD) as well as co-
morbidity are well-known predictors of a poorer outcome.26 
2.1.3  Choice of therapy 
Therefore, although the outcome of treatment for the older patients with AML is 
generally inferior to that in the younger patients, it is possible to identify subgroups of patients 
based on their disease biology and clinical condition who are likely to fare better with the more 
intensive standard regimens. Previous studies of traditional chemotherapy in selected older 
patients have reported relatively high CR rates.27,28  Indeed, it may even be possible to further 
Intensify the treatment in selected older patients as was demonstrated in the study by 
Lowenberg and colleague in which among patients 60-65 years a higher dose of daunorubicin 
at induction (90 mg/m2 vs. 45 mg/m2) was associated with a higher CR rate (73% vs. 51%), 
event-free survival (29% vs. 14%), and overall survival (38% vs. 23%).29 In the study by 
Pautas and colleagues using either daunorubicin 80 mg/m2 daily x 3 or idarubicin 12 mg/m2 
daily for 3 or 4 days in addition to standard dose cytarabine in patients aged 50 to 70 years, 
the overall CR rate was 77%.28 However, in the majority of these studies there is a selection 
against patients with poor performance status and poor organ function and, in some, patients 
with history of antecedent hematological disorder such as MDS or MPD are excluded. in 
general, strategies to improve the efficacy of the traditional cytarabine plus anthracycline 
regimens have largely benefited the younger patients with less adverse characteristics.29,30  
A number of risk scores have been developed that can be used to identify patients less 
likely to benefit from the traditional cytarabine containing induction regimens.17,18,22 Kantarjian 
and colleagues were able to divide 998 patients with AML or high-risk MDS  ≥ 65 years to 
favorable, unfavorable and intermediate subgroups with different expectations of CR, 8-week 
mortality, and survival.17 It is potentially possible to use these scoring systems to select 
patients with a low expectation of CR and a high likelihood of early mortality with such 
regimens for clinical trials of investigational agents designed against specific molecular targets 
or drugs thought to be more tolerable and/or convenient.31  
 
2.2   The Treatment - Decitabine (5 aza-2'deoxycytidine, Decitabine) 
Decitabine is a deoxycytidine analog which is phosphorylated to its nucleotide and 
incorporated into DNA.  Once incorporated, it covalently binds to DNA-methyltransferases and 
traps the enzyme thus acting as an irreversible inhibitor of DNA-methyltransferase.  
Decitabine produces marked DNA hypomethylation (superior to azacytidine in this effect) via 
inhibition of DNA methyltransferase.32-34  At high doses, decitabine appears to cause DNA 
synthesis arrest due to the formation of a DNA/DNA-methyltransferase adducts, which results 
in cytotoxicity and apoptosis. At low doses, minimal cytotoxicity is observed, and treated cells 
exhibit marked reduction in DNA-methyltransferases activity, reduced overall and gene-

 
 
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specific DNA methylation and reactivation of silenced genes. This is associated with tumor 
suppressor gene activation, induction of cellular differentiation, and inhibition of clonogenic 
growth of leukemic progenitors. 
 
2.2.1. Clinical Experience with Decitabine at standard doses at MD Anderson 
 
A phase 2 trial of Decitabine in accelerated phase (CML-AP) and blastic phase CML 
(CML-BP) was completed at MD Anderson. Initially, patients were treated at 100 mg/m
2 q12h 
for 5 days (1,000 mg/m
2 per course) but the dose had to be reduced initially by 25% and 
eventually by 50% because of prolonged myelosuppression.  In CML-BP, a total of 42 
patients were treated, with a complete hematologic response seen in 5%, partial hematologic 
response in 5% and hematologic improvement in 19%, for a total response rate of 29%. In 
CML-AP, a total of 39 patients were treated. CHR was seen in 18%, PHR in 38% and HI in 
8%, for a response rate of 62%. Unique features of decitabine in this setting were:(1) a slow 
pattern of reduction of blasts, (2) a rapid rise in platelets following therapy, and (3) occasional 
responses late into therapy (after 2 cycles). These suggested that responses to decitabine 
might involve a differentiation component, similar to what was observed with other 
differentiating agents in leukemia. A subset analysis of older (>50 years) patients in CML-BP 
showed that decitabine therapy resulted in better survival than historical controls treated with 
combination chemotherapy.35,36  
 
2.2.2 Clinical Experience with low-dose Decitabine at MD Anderson 
 
Based on in-vitro data suggesting greater hypomethylating activity at lower doses, a 
phase I biological study of decitabine was initiated at MD Anderson. To maximize the 
hypomethylating effects of decitabine, multiple low dose schedules in patients with 
relapsed/refractory myeloid malignancies were tried.  Initially, patients were treated at 5 
mg/m
2 IV over 1 hour daily for 10 days (dose 30 fold lower than the reported MTD). The dose 
was then escalated to 10, 15 and 20 mg/m
2 daily for 10 days. Finally, a group of patients 
received 15 mg/m
2 daily for 15 days then 20 days. A total of 48 patients were enrolled on the 
study. Responses were seen at all dose levels, but 15 mg/m
2 appeared to induce the most 
responses, with no further benefit for increasing the dose or duration of administration. There 
were 9 complete remissions (CR 18%) and 7 partial remissions (14%), for a response rate of 
32%.  Responses were seen in refractory/relapsed AML (8/37=22%), MDS (4/7=57%), and 
CML (4/5=80%). In some patients who responded, there was a gradual diminution of blasts 
over 2-4 weeks, and eventual recovery of normal hematopoiesis at 5-6 weeks, suggesting a 
non-cytotoxic mode of action for this regimen. Response duration ranged from 2 months to 
10+ months. DNA methylation studies are ongoing, but preliminary data suggests that 
hypomethylation of Alu repeats was associated with response. Therefore low-dose decitabine 
is an effective agent in myeloid malignancies, and appears to induce remissions in part 
through demethylation rather than cytotoxicity.  The effective low dose administration 
schedule derived from this phase I study is 15 mg/m
2 IV over 1 hour daily for 10 days.37  An 
ongoing study of low dose decitabine in imatinib resistant CML is confirming the good 
response rate of this regimen. However, in patients in chronic phase CML, grade III-IV 

 
 
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myelosuppression is universal at the decitabine dose of 15 mg/m
2 daily x 10. There were no 
other non-hematologic serious side-effects attributable to decitabine in the first 18 patients 
treated. Therefore, in the current study in MDS we propose to reduce the total dose per 
course from 150 mg/m
2 to 100 mg/m
2 to avoid excessive myelosuppressive complications.
 
 
2.2.3 Decitabine in Myelodysplastic Syndrome (MDS) 
 
The standard for MDS therapy is hypomethylating agents, decitabine and azacytidine. 
The experience with 5-azacytidine indicated this to be the first non-transplant modality to 
affect MDS prognosis.38 Decitabine is a hypomethylating agent similar to 5-azacytidine and is 
more effective in vitro.  Intensive chemotherapy is associated with CR rates of 40% to 60% 
induction mortality rates of 10% to 40% and no improvement in MDS survival.38     
 
Azacytidine, another hypomethylating agent, was given subcutaneously to 99 patients 
with MDS and  compared with observation (n=92); 67% had advanced-stage disease by FAB.  
The response rate on the treatment arm was 60%: 7% CR and 16% PR, 37% HI. This was 
compared to 7% HI with observation (p<0.001).  The median time to leukemic transformation 
or death was 21 months on treatment and 13 months on observation (p=0.007).  Median 
survival was 20 months for azacytidine and 14 months for the controls difference (p=0.1).  
Quality of life measures were higher for azacytidine.  Azacytidine was relatively well tolerated, 
although side effects included cytopenias and one treatment-related death.  The results of this 
study appear to confirm a role for hypomethylating agents in the treatment of MDS.38 
 
Several studies have shown the activity of decitabine in MDS. Zagonel et al. reported 
on 10 patients with advanced MDS treated with decitabine at 45-50 mg/m
2/day administered 
for three days.  The response rate was 50% (CR and PR).  The median CR duration was 11 
months (10-14+ months), and the median number of courses to CR was 2.39 Serious 
infections occurred in 40%, marrow hypoplasia in 50%.39 
 
Wijerman et al. reported on 66 patients treated with decitabine (16 intermediate-1, 25 
intermediate-2, and 25 high risk).  Their median age was 68 years.  Decitabine was 
administered at 45 mg/m
2/day given as a four-hour infusion every eight hours for three days.  
The response rate was 49%: 20% CR, 5% PR, and 24% improvement.  Median response rate 
was 39 weeks.  Median survival was 15 months.  Normalization of abnormal karyotypes was 
seen.  Infectious episodes were common (27% fever, 20% infection, and 11% sepsis).40,41   
 
Wijermans et al recently updated the results of 169 patients with MDS treated on 
multiple studies with decitabine 45-50 mg/m
2 IV (continuous infusion, or over 4 hours Q 8 
hours) daily x 3 (135-150 mg/ m
2 per course) every 4-8 weeks.42  The CR rate was 20%, the 
overall response rate was 50%, the induction mortality was 8%.  The median response 
duration was 9 months; the median survival was 15 months. There was no difference in 
response rate by risk group. 
In a pivotal study, a total of 170 patients with MDS were randomized to receive either 
decitabine at a dose of 15 mg/m2 given intravenously over 3 hours every 8 hours for 3 days (at 

 
 
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a dose of 135 mg/ m
2 per course) and repeated every 6 weeks, or best supportive care.43 
Response was assessed using the International Working Group criteria and required that 
response criteria be met for at least 8 weeks. Patients who were treated with decitabine 
achieved a significantly higher overall response rate (17%), including 9% complete responses, 
compared with supportive care (0%) (P < .001). An additional 12 patients who were treated 
with decitabine (13%) achieved hematologic improvement. Responses were durable (median, 
10.3 mos) and were associated with transfusion independence. Patients treated with 
decitabine had a trend toward a longer median time to acute myelogenous leukemia (AML) 
progression or death compared with patients who received supportive care alone (all patients, 
12.1 mos vs. 7.8 mos [P = 0.16]; those with International Prognostic Scoring System 
intermediate-2/high-risk disease, 12.0 mos vs. 6.8 mos [P = 0.03]; those with de novo disease, 
12.6 mos vs. 9.4 mos [P = 0.04]; and treatment-naive patients, 12.3 mos vs. 7.3 mos [P = 
0.08]). Decitabine was found to be clinically effective in the treatment of patients with MDS, 
provided durable responses, and improved time to AML transformation or death. The duration 
of decitabine therapy may improve these results further. This study led to the approval of 
decitabine for patients with MDS.43 
In a more recent trial, we investigated the clinical and pharmacodynamic results of 
different dose schedules of decitabine.44 Adults with advanced MDS or chronic 
myelomonocytic leukemia (CMML) were randomized to 1 of 3 decitabine schedules: (1) 20 
mg/m
2 intravenously daily for 5 days; (2) 20 mg/m
2 subcutaneously daily for 5 days; and (3) 10 
mg/m
2 intravenously daily for 10 days. Randomization followed a Bayesian adaptive design. 
Ninety-five patients were treated (77 with MDS, and 18 with CMML). Overall, 32 patients (34%) 
achieved a complete response (CR), and 69 (73%) had an objective response by the new 
modified International Working Group criteria. The 5-day intravenous schedule, which had the 
highest dose-intensity, was selected as optimal; the CR rate in that arm was 39%, compared 
with 21% in the 5-day subcutaneous arm and 24% in the 10-day intravenous arm (P < .05). 
The high dose-intensity arm was also superior at inducing hypomethylation at day 5 and at 
activating P15 expression at days 12 or 28 after therapy. We concluded that a low-dose, dose-
intensity schedule of decitabine optimizes epigenetic modulation and clinical responses in 
MDS.44 
2.3 
Studies of Decitabine in AML 
We have previously investigated whether treatment with hypomethylating agents (5-
azacytidine /decitabine) leads to an improved outcome in patients with AML who are older 
and/or have adverse cytogenetics.45 Between January 2004 and December 2007, 81 patients 
(37 [46%] with AML [>or=20% blasts]; 44 [54%] with high-risk MDS) with chromosome 5 and 7 
abnormalities were treated with hypomethylating agents as their initial therapy. These included 
68 patients with complex (>or=3) abnormalities and 13 with <3 aberrations. During the same 
period, 151 patients (126 with AML, 25 with MDS) with chromosome 5 and 7 abnormalities 
(128 complex, 23 noncomplex) were treated with intensive chemotherapy (including 
cytarabine-based regimens in 72% and other regimes in 28%). The median ages for the 2 
groups were 66 years and 61 years, respectively (ranges, 37-85 years and 19-89 years). 
Thirty-three (41%) patients in the hypomethylating group achieved complete remission (CR) 

 
 
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versus 53 (35%) in the chemotherapy group (P=.395). With a median follow-up of 51 weeks 
(range, 12-101 weeks) and 40 weeks (range, 5-128 weeks), 22 of 33 patients in the 
hypomethylating group and 33 of 53 patients in the chemotherapy group had developed 
disease recurrence. The median CR duration was 45 weeks and 23 weeks, respectively 
(P=.153). The overall survival was superior for the hypomethylating group compared with the 
chemotherapy group (P=.019). The investigators concluded that treatment with 
hypomethylating agents may be superior to chemotherapy in patients with chromosome 5 and 
7 abnormalities.45  
In a multicenter, phase II study, patients older than 60 years who had AML (ie, > 20% 
bone marrow blasts) and no prior therapy for AML were treated with decitabine 20 mg/m2 
intravenously for 5 consecutive days of a 4-week cycle. Response was assessed by weekly 
CBC and bone marrow biopsy after cycle 2 and after each subsequent cycle.46 Patients 
continued to receive decitabine until disease progression or an unacceptable adverse event 
occurred. Fifty-five patients (mean age, 74 years) were enrolled and were treated with a 
median of three cycles (range, one to 25 cycles) of decitabine. The expert-reviewed overall 
response rate was 25% (complete response rate, 24%). The response rate was consistent 
across subgroups, including in patients with poor-risk cytogenetics and in those with a history 
of myelodysplastic syndrome. The overall median survival was 7.7 months, and the 30-day 
mortality rate was 7%. The most common toxicities were myelosuppression, febrile 
neutropenia, and fatigue. The investigators concluded that decitabine given in a low-dose, 5-
day regimen has activity as upfront therapy in older patients with AML, and it has acceptable 
toxicity and a low 30-day mortality.46 
In another phase II clinical trial with decitabine in older patients (>or=60 years) with 
previously untreated AML who were not candidates for or who refused intensive 
chemotherapy, subjects received low-dose decitabine at 20 mg/m2 i.v. over 1 h on days 1 to 
10. Fifty-three patients were enrolled with a median age of 74 years (range, 60-85).47 Nineteen 
(36%) had antecedent hematologic disorder or therapy-related AML; 16 had complex 
karyotypes (>or=3 abnormalities). The complete remission rate was 47% (n = 25), achieved 
after a median of three cycles of therapy. Nine additional subjects had no morphologic 
evidence of disease with incomplete count recovery, for an overall response rate of 64% (n = 
34). Complete remission was achieved in 52% of subjects presenting with normal karyotype 
and in 50% of those with complex karyotypes. Median overall and disease-free survival 
durations were 55 and 46 weeks, respectively. Death within 30 days of initiation of treatment 
occurred in one subject (2%), death within 8 weeks in 15% of subjects. They also examined 
the relationship of clinical response and pretreatment level of miR-29b, previously shown to 
target DNA methyltransferases. Higher levels of miR-29b were associated with clinical 
response (P = 0.02). They concluded that this schedule of decitabine was highly active and 
well tolerated in this poor-risk cohort of older AML patients and suggested that levels of miR-
29b should be validated as a predictive factor for stratification of older AML patients to 
decitabine treatment.47 
Most recently a multicenter, randomized, open-label, phase III trial compared the 
efficacy and safety of decitabine with treatment choice (TC) in older patients with newly 
diagnosed acute myeloid leukemia (AML) and poor- or intermediate-risk cytogenetics.48 

 
 
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Patients (N = 485) age ≥ 65 years were randomly assigned 1:1 to receive decitabine 20 mg/m2 
per day as a 1-hour intravenous infusion for five consecutive days every 4 weeks or TC 
(supportive care or cytarabine 20 mg/m2 per day as a subcutaneous injection for 10 
consecutive days every 4 weeks). The primary end point was overall survival (OS); the 
secondary end point was the complete remission (CR) rate plus the CR rate without platelet 
recovery (CRp). Adverse events (AEs) were recorded. The primary analysis with 396 deaths 
(81.6%) showed a nonsignificant increase in median OS with decitabine (7.7 months; 95% CI, 
6.2 to 9.2) versus TC (5.0 months; 95% CI, 4.3 to 6.3; P = .108; hazard ratio [HR], 0.85; 95% 
CI, 0.69 to 1.04). An unplanned analysis with 446 deaths (92%) indicated the same median OS 
(HR, 0.82; 95% CI, 0.68 to 0.99; nominal P = .037). The CR rate plus CRp was 17.8% with 
decitabine versus 7.8% with TC (odds ratio, 2.5; 95% CI, 1.4 to 4.8; P = .001). Adverse events 
were similar for decitabine and cytarabine, although patients received a median of four cycles 
of decitabine versus two cycles of TC. The most common drug-related AEs with decitabine 
were thrombocytopenia (27%) and neutropenia (24%). Therefore, in older patients with AML, 
decitabine improved response rates compared with standard therapies without major 
differences in safety. An unplanned survival analysis showed a benefit for decitabine, which 
was not observed at the time of the primary analysis.48 
 
2.4 
Study Rationale 
 
The current standard dose for decitabine in MDS and AML is 20 mg/m2 daily x 5 days. A 
study conducted by the Ohio State University has produced significantly higher response rate 
when an extended schedule of decitabine 20 mg/m2 daily x 10 days was used. The objective of 
the study is to demonstrate whether this extended 10 day schedule is superior compared to 
the standard 5 days schedule in producing responses and at least comparable with regards to 
toxicity and response duration. 
3.0 
Decitabine 
 
3.1 
Chemical Name 
 
 4-amino-1-(2-deoxy-ß-D-erythro-pentofuranosyl)-1,3,5-triazin-2(1H)-one 
 
 Other Names:  deoxyazacytidine, 5-aza-2'-deoxycytidine, 1-(2'-deoxy-D-ribofuranosyl)-5-
azacytosine, DAC, 5-Aza-CdR, dezocitidine 
 
 Classification:  Antimetabolite, DNA hypomethylating agent 
 
 Molecular Formula:  
C8H12N4O4     M.W.: 228.21 
 
 Approximate Solubility:  Slightly soluble in water (25mg/mL), ethanol and virtually insoluble 
in chloroform 
 

 
 
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3.2 
Mode of Action:  Hypomethylation of DNA followed by stimulation of gene 
expression and cell differentiation. Inhibits DNA methyltransferase. Targets for latter 
mechanism are selected genes silenced by DNA methylation. Inhibits DNA synthesis 
 
3.3 
How Supplied:  Decitabine is supplied as a lyophilized white to almost white, 
finely crystalline, odorless powder for injection in 20mL vial glass vials, containing 50 mg of 
decitabine, monobasic potassium phosphate, and sodium hydroxide. 
 
3.4 
Preparation:   When reconstituted with 10 mL of sterile water for injection each 
mL will contain 5 mg of decitabine, 6.8 mg of KH2PO4, and approximately 1.1 mg NaOH.  
The pH of the resulting solution is 6.5 - 7.5.  
 
The reconstituted solution can be further diluted to a concentration of 1 mg/mL or 0.1 
mg/mL in cold infusion fluids (0.9% Sodium Chloride Injection USP, 5% Dextrose in Water 
Injection, USP, or Lactated Ringer's Injection USP). 
 
3.5  
Storage and Stability:  Vials should be stored at 25°C (77°F); excursions 
permitted to 15°C to 30°C (59°F to 86°F). After reconstitution, use decitabine within 15 
minutes. If diluted with cold (2°C to 8°C) fluids, the diluted solution is stable for up to 7 hours if 
stored between 2°C and 8°C (36°F to 46°F). 
 
Reconstitution and dilution of the powder for injection (with 10mL of sterile water for 
injection) results in a rapidly decomposing solution. The concentration of decitabine in the 
reconstituted and diluted solution decreases about 10 % after 4 hours at 25°C or about 10% 
after 24 hours at 4°C. Since 10% is the maximum allowable decomposition, and the solution 
will also decompose during administration (infusion), the solution should be prepared just prior 
to administration. If this is not possible the solution should be prepared at least twice a day 
and kept in a refrigerator (2-8°C) until administration. Furthermore, the solution should be 
prepared only with cold infusion fluids at a temperature of 2-8°C; (36-46°F). This solution can 
be infused over a maximum period of 3 hours. 
 
3.6  
Route of Administration: Intravenous 
 
3.7 
Precautions 
 
Drug handling precautions will be strictly followed. Skin contact with the solution should 
be avoided and protective gloves should be worn. Drug spilling can be inactivated by 2 M 
sodium hydroxide solution. The skin should be treated with a borax buffer solution pH 10 and 
after that thoroughly washed with water and soap. 
 
3.8 
Drug supply and distribution:  Decitabine will be obtained from commercial 
source. 
 
3.8 
Reported Adverse Events and Potential Risks 
 

 
 
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Autoimmune reaction and/or chemical imbalances in the blood (antiplatelet 
antibodies, erythema nodosum), decreased hemoglobin, decreased leukocytes (total WBC), 
decreased neutrophils/granulocytes (ANC/AGC), decreased platelets, drowsiness, fatigue 
(lethargy, malaise, asthenia), alopecia, diarrhea, peritonitis, nausea, vomiting, anorexia, 
stomatitis/pharyngitis (oral/pharyngeal, mucositis), increase bilirubin, increased SGOT (AST) 
(serum glutamic oxaloacetic transaminase), increased SGPT (ALT) (serum glutamic pyruvic 
transaminase), liver damage, depressed level of consciousness, abdominal pain or 
cramping. 
 
Also reported on Decitabine trials but with the relationship to Decitabine still 
undetermined:  allergic reaction; allergic rhinitis ; GVHD; bone marrow cellularity; atrial 
fibrillation; cardiac ischemia/infarction; cardiopulmonary arrest; hypotension; left ventricular 
systolic dysfunction; right ventricular dysfunction; fever; insomnia; rigors/chills; weight loss; 
pruritus; rash; anal ulcer; ascites; constipation; distension; esophagitis; GI obstruction; ileus; 
taste alteration; CNS hemorrhage; GI hemorrhage; lung hemorrhage; nose hemorrhage; 
petechiae; urinary hemorrhage; cholecystitis; liver dysfunction/failure; infection without 
neutropenia; opportunistic infection; perianal abscess; head/neck edema; alkaline 
phosphatase; creatinine; hypercalcemia; hyponatremia; fracture; agitation; CNS ischemia; 
confusion; depression; dizziness; extrapyramidal/involuntary movement; motor neuropathy; 
psychosis; seizure; sensory neuropathy; bone pain; headache; muscle pain; urinary pain; 
ARDS; bronchospasm; cough; dyspnea; hiccoughs; pneumonitis/pulmonary infiltrates; 
cystitis; renal failure; urinary frequency; phlebitis; thrombosis/thrombus/embolism; veno-
occlusive disease. 
4.0 
Eligibility Criteria 
 
4.1  
Inclusion criteria 
 
1. Patients with previously untreated AML (by the WHO criteria, i.e.> 20% blasts) 
Prior biologic therapies (such as growth factors) and targeted therapies 
administered for the treatment of prior myelodysplastic syndrome are allowed, 
with the exception of hypomethylating agents 5-azacytidine or decitabine. Patients 
must have been off such therapy for 1 week prior to entering this study and 
recovered from the toxic effects of that therapy, unless there is evidence of rapidly 
progressive disease.  Hydroxyurea, and a single dose of cytarabine up to 3 g/m2, 
is permitted for control of counts prior to treatment.  
 
2. Patients > 60 are eligible if not a candidate for standard cytarabine plus 
anthracycline chemotherapy as determined by Kantarjian’s score (Appendix D) 
Patients younger than 60 may also be included if felt not to be a candidate for 
intensive anthracycline plus cytarabine based chemotherapy. 
 
3. Performance 0-3 (ECOG).  
 

 
 
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4. Adequate liver function (Total bilirubin of < 2 mg/dl) unless due to hemolysis, 
leukemia organ infiltration or Gilbert’s syndrome and renal function (creatinine < 
2.5 mg/dl).  
 
5. Signed informed consent 
 
4.2 Exclusion Criteria 
 
1. Nursing and pregnant females.  Female patients of childbearing potential and 
male patients should practice effective methods of contraception such as double 
barrier method. Should a woman become pregnant or suspect she is pregnant 
while participating in this study, she should inform her treating physician 
immediately. Negative urine pregnancy test (women of childbearing potential) 
 
2. Active and uncontrolled infections. 
 
3. Uncontrolled intercurrent illness including, but not limited to, symptomatic 
congestive heart failure, unstable angina pectoris, active significant other cancers 
requiring chemotherapy and/or radiation therapy within past 6 months (excluding 
non-melanoma skin cancer) or psychiatric illness/social situations that would limit 
compliance with study requirements. 
5.0 
Therapy 
 
5.1 
Protocol registration: 
 
All patients will be registered through the Protocol Data Management System 
(PDMS) or Clinical Oncology Research (CORe).  The study chairman must be notified 
before any patients are registered.   
 
5.2 
Therapy 
  
The initial Decitabine courses should be given at MD Anderson Cancer Center (or Regional 
Cancer Centers), either as in-patient or as out-patient. Decitabine will be dosed based on 
actual body weight. However, at the treating physician’s discretion an adjusted body weight 
may be used, if actual body weight is >40% over ideal body weight. Adjusted body weight = 
((Actual body weight – Ideal body weight) 0.4) + Ideal body weight. Decitabine may be 
subsequently administered at any of the Regional Cancer Centers (RCC) or at the patients’ 
local oncologist offices.  Patients will be assigned in a selective Bayesian design to one of two 
treatment arms. 
 
1)  Decitabine 20 mg/m
2 IV over approximately 1 hour daily x 5. 
2)  Decitabine 20 mg/m
2 IV over approximately 1 hour daily x 10. 
 
 
Start at dose level 0 as shown below. There will be no dose escalation of Decitabine. 

 
 
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Patients will receive one course every 4-8 weeks; however delays of more than 8 
weeks may be allowed if determined by the investigator to be in the best interest of the 
patient after discussion with the PI and the discussion documented in the patient’s medical 
record.  Doses may be given as close as 8 hours apart if approved by the PI.  If prolonged 
aplasia and/or a major infection is seen, may decrease 1 dose level after marrow 
regeneration. This will be rounded to the following daily lower dose (15, 10, 7.5, 5 mg/m
2). 
Otherwise continue at the same dose level every 4-8 weeks depending on recovery of 
counts and disease status.  If persistent disease, start next course regardless of counts.  If 
marrow complete response is achieved with adequate cellularity, start subsequent courses 
when granulocytes > 0.75 x 10
9/L and platelets > 50 x 10
9/L. 
 
Patients on the 10 day regimen will receive 5 day dosing after achieving CR during 
consolidation/maintenance. The 5 day dosing may also be initiated in these patients after 
the first course, if it is thought to be in the best interest of the patient after discussion with 
the PI and the discussion documented in the patient’s medical record. Patients on the 5 day 
regimen will continue to receive the 5 day regimen after the first course whether in CR or 
not. 
 
Modifications of dose schedule or dose level other than above are allowed if felt to be 
in the patients best interest to optimize response or reduce toxicity.  These decisions should 
be documented in the patient’s medical record. 
 
 
Decitabine mg/m
2 daily x days 
Dose level 
10 days 
5 days 
0 
20 
20 
-1 
15 
15 
-2 
10 
10 
-3 
7.5 
7.5 
-4 
5 
5 
 
5.3 
Duration of Therapy 
 
In the absence of treatment delays due to clinically significant study drug related 
adverse events, treatment may continue until one of the following criteria applies: 
 
 Relapsed or clinically significant progressive disease; no response after > 3 courses.  
Patients may continue therapy as long as they have stable disease, as long as it is 
determined to be in the best interest of the patient. 
 
 Intercurrent illness that prevents further administration of treatment, 
 
 Patient decides to withdraw from the study, or 
 

 
 
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 General or specific changes in the patient's condition render the patient unacceptable for 
further treatment in the judgment of the investigator. 
 
 Up to a total of 24 courses of therapy; about 2 to 3 years. 
 
a. 
Patients who show no evidence of life-threatening infection or hemorrhage, or 
less than grade 2 clinically significant drug related non-hematologic toxicity (vomiting 
included) may be given a subsequent course at the same dose as the previous course. If 
clinically significant drug-related grade 2 toxicity is observed, the patient must have 
recovered to grade <1 before institution of the next course.  If patients have clinically 
significant drug-related grade 3-4 non-hematologic toxicity, they may receive a subsequent 
course at one reduced dose level after resolution of toxicity to < grade 1. 
 
b. 
Patients with a response (defined under section 10.0) and pre-course counts of 
granulocytes >10
9/L and platelets >50 x 10
9/L who have sustained low counts of 
granulocytes <0.5 x 10
9/L or a platelet count <30 x 10
9/L for more than 2 consecutive weeks 
in the current cycle, may receive a subsequent course at 1 dose level reduction.  A reduction 
of 2 dose levels may be considered if the myelosuppression was deemed severe and life 
threatening by the treating physician, and if it is in the patient's best interest. 
 
c. 
Patients may receive further courses of therapy not earlier than 4 weeks from 
the previous course, provided the patient has recovered from myelosuppression considered 
to be related to chemotherapy. Patients with rapid increase in blasts may start additional 
therapy before 28 days from start of the previous course. 
 
d. 
A minimum of 1 full course (or 4 weeks from the start of therapy) will be 
required for a patient to be considered as having received an adequate trial to evaluate 
efficacy.  All patients receiving at least one dose of decitabine will be considered evaluable 
for toxicity.  Patients achieving a partial response or with stable disease may continue on 
therapy until definite evidence of disease progression. 
 
e. 
Patients who achieve CR or CRi  may be treated with additional courses of 
decitabine every 4-8 weeks or longer if approved by the PI.  The dose of decitabine can be 
adjusted down by one dose level for toxicity (see above). Patients may be taken off study or 
treated on other programs (e.g. bone marrow transplantation) if this is judged more 
appropriate for their therapy and overall outcome.  Delays of more than 8 weeks to 
subsequent course may be allowed if determined by the investigatory to be in the best 
interests of the patient after discussion with the PI and the discussion documented in the 
patient’s medical record. Abnormalities in chemistries including BUN, LDH (lactic 
dehydrogenase), alkaline phosphatase, magnesium, glucose, phosphorus, calcium and 
electrolytes will not be reported as adverse events.  These are indications of disease process 
and not of toxicity, therefore clinically insignificant.  Delayed recovery in patients post CR is 
common in MDS and AML not associated with significant clinical complications such as 
bleeding or infections.  Therefore, delayed myelosuppression after a course in CR will be 

 
 
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reported as ADR only if platelets < 20 x 10
9/L or granulocytes < 0.5 x 10
9/L 6 weeks after 
completion of treatment. 
 
5.4 
Concomitant medications  
 
GCSF or other growth factors are permitted on therapy only as per ASCO guidelines.  
Use of hydroxyurea with rapidly proliferative disease is allowed for the first two weeks on 
therapy.   
6.0 
Correlative studies 
 
One of the goals of this protocol is to measure the biological effect of epigenetic 
therapies.  Several correlative laboratory studies will be carried an attempt to assay the 
biological effect of decitabine.  Patient samples including peripheral blood and bone marrow 
will be collected prior to, during and after completion of treatment. 
 
6.1 
Gene-mutations effecting methylation machinery 
  
Mutations of several genes believed to be important in the methylation apparatus of the 
cell have been recently described in patients with acute myeloid leukemia (AML) but their 
presence has not been correlated with a worse or better outcome using hypomethylating 
agents. We have previously evaluated the association of mutations in IDH1, IDH2, DNMT3A, 
and EZH2 with the outcome [complete response (CR) rate, event free survival (EFS) and 
overall survival (OS)] among patients older than 60 with AML (≥ 20% blasts) treated with 
hypomethylating agents as their first line of treatment. TET2 mutations were not evaluated due 
to lack of available material. Among the 68 patients (median age 72 years; range, 60 – 83) with 
available data, 11 patients (16%) had IDH1 or IDH2 mutations (mutually exclusive) and 10 
patients (15%) had DNMT3A mutations with 5 patients (7%) having both IDH and DNMT3A 
mutations. Cytogenetics was diploid in 19 (28%), abnormal chromosome 5/7 and/or complex in 
27 (40%), trisomy 8 in 5 (7%), miscellaneous in 14 (21%), and insufficient in 3 (4%). Presence 
of IDH mutations was associated with a diploid karyotype and the presence of NPM1 
mutations (p=.03 and p=.02, respectively) but not with FLT3-ITD or RAS mutations (present in 
7 and 4 patients, respectively). DNMT3A mutations were not associated with any specific 
karyotype or with the presence of NPM1, FLT3-ITD, or RAS mutations. None of the 68 patients 
had EZH2 mutations. All patients were treated with hypomethylating agents [decitabine in 39 
(57%) and 5-azacytidine in 29 (43%)] with 42 patients (62%) receiving concomitant histone 
deacetylase inhibitor therapy (SAHA or valproic acid). Overall, 17 patients (25%) achieved CR; 
the presence of IDH or DNMT3A mutations or both was not associated with achievement of 
CR.  With a median duration of follow-up of 60 months, the median EFS is 3.3 months (range, 
0.25 – 3.75 months) and the median overall survival is 6 months (range, 0.25 – 90.5 months). 
Presence of IDH mutations was not associated with an impact on EFS (p=.29) or OS (p=.14). 
Similarly, DNMT3A mutations were not associated with an effect on EFS (p=.21) or OS 
(p=.58). The presence of both IDH and DNMT3A mutations was also not associated with a 
better or worse response, EFS, or OS as compared with patients with neither mutation. We 

 
 
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were unable to detect an association between presence of IDH1/2 and DNMT3A mutations 
and outcome in this elderly population of patients with AML treated with epigenetic modulators. 
In this study we propose to evaluate the potential effect of mutations of 1DH1, IDH2, 
DNMT3A, TET2, EZH2 and other genes believed to be in the DNA methylation program 
prospectively by assessing the patients for the presence of these mutations prior to the 
initiation of therapy. We will also examine follow-up samples to determine if the leukemic blasts 
harboring these genes remain after therapy.  
Using more sophisticated assessments of gene panels and whole exome sequencing 
we will expand this prospective evaluation and will determine if certain gene signatures are 
associated with response. 
We will also evaluate the levels of 2-hydroxyglutarate in patients with DNMT3A mutation 
and will determine if there is any association with response to therapy and outcome. 
 
6.2  Gene specific methylation.  
 
The proposed mechanism of action of hypomethylating agents such as decitabine is 
through their action against DNA methyltransferase enzymes responsible for methylation of 
promotor regions (and hence silencing of) genes responsible for differentiation. We will 
examine this hypothesis though the examination of gene-specific and global methylation of 
the leukemic cell genome pre and post therapy. Quantitative methylation analysis of the p15 
promoter and other genes, including Alu elements will be performed using "COBRA" analysis 
(Combined Bisulfite and Restriction Analysis).  This technique takes advantage of the ability 
of bisulfite to selectively convert cytosine to uracil, but without affecting 5-methylcytosine.  
Thus DNA can be treated with bisulfite, amplified by PCR, and the PCR product digested 
with restriction enzymes which will quantitatively assess gene specific methylation depending 
on the converted DNA sequence. 
 
6.2.1 Assessment of genome wide methylation. Total genome DNA methylation 
can be measured using high pressure liquid chromatography and assaying directly for 5-
methylcytosine.  This technique however requires large amounts of DNA sample 
(approximately 50ug). 
 
Therefore COBRA analysis described above will be used to assess methylation of 
genes and Alu repetitive elements in the patient samples.  Alu elements are short DNA 
repeats which litter the genome.  It is estimated that there are one million Alu's in the human 
genome.  These elements are also heavily methylated, and therefore allow the opportunity to 
simultaneously study demethylation of one million sites in the genome rather than a single 
gene. 
 
6.3 
Micro-RNA analysis 
 
As mentioned previously, higher levels of miR-29b were associated with clinical 
response. We will evaluate this prospectively by analyzing pre-treatment bone marrow 
samples for the relevant micro-RNAs in collaboration with the laboratory of Dr. George Calin. 

 
 
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6.4 
Assessment of immune function and effector cells 
 
The role of an intact immune effector cell function towards response and eradication of 
minimal residual disease will be evaluated in collaboration with Dr. Katy Rezvani’s laboratory. 
Immune suppression is an unavoidable consequence of current therapeutic modalities and is 
associated with significant morbidity and mortality due to opportunistic infections.  We have 
developed sensitive laboratory methods that allow the study of immune subset recovery (T cell, 
B cell and NK cell recovery).  At this time, careful studies of immune recovery are not routinely 
performed in subjects with AML undergoing treatment with decitabine.  Such studies would allow 
us to better understand the effects of the drug on the recovery of immune function in AML50-53.  
We propose to systematically collect specimens of blood, bone marrow and plasma from 
patients with AML undergoing therapy with decitabine.  Samples may be collected prior to 
initiation of therapy, at the time of achieving complete remission and suspected relapse and prior 
to every 3rd or 4th cycle of therapy; Omissions will not be considered as violations.  Assays to be 
performed may include the following:  1) T cell immunophenotyping (to define the recovery of T 
cell subsets associated with a “naïve” or “memory” T cell phenotype); 2) Functional studies of 
antigen-specific T cell responses to pathogens and to leukemia-associated antigens (e.g., to 
defined epitopes that have been identified as potential malignancy-specific targets);1,2,3 3) 
Studies examining the molecular diversity of the T cell repertoire;5 4) Assays of plasma levels of 
cytokines (e.g., interleukin-7) that may be important in T cell reconstitution; 5) Studies to assess 
the role of other immune subsets involved in anti-pathogen and anti-leukemia responses 
including natural killer (NK) cells, B lymphocytes, antigen presenting cells (e.g. dendritic cell 
subsets) and subsets involved in immunoregulatory pathways such as macrophages and 
myeloid derived suppressor cells; 6) Molecular studies will be performed on total RNA or DNA 
extracted from PBMC to assess the role of immune-related genes in treatment outcome 
(infection and relapse). Some or all of these studies may be performed at the time of collection.  
In most cases, cryopreserved PBMC or plasma samples will be used for these assays.  
Cryopreserved cells in excess of requirements for studies of immune reconstitution will be 
banked to allow access of other investigators to these specimens. 
7.0 
Pre-study evaluations (to be performed within 14 days unless otherwise noted) 
 
7.1 
History and physical exam. 
 
7.2 
CBC, platelet count, differential; creatinine, bilirubin, SGPT (within 7 days). 
 
7.3 
Bone marrow aspirate (within 14 days) and cytogenetics  
 
7.4  
Molecular studies in bone marrow specimens for FLT3-ITD, FLT3-TKD, NPM1, 
IDH1, IDH2, DNMT3A, TET2, EZH2, RAS, JAK2 (if appropriate, e.g. in patients 

 
 
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with history of MPN), and the Leukemia mutation panel (whichever is available 
at the time of enrollment) 
 
7.5 
Whole genome sequencing (performed at Dr. Lynda Chin’s laboratory) 
 
7.6 
Blood sample (20-50 cc) and marrow aspirate sample (2 cc) for methylation 
studies, to be sent to Dr. Garcia-Manero's laboratory. Not all samples may be 
collected at all times points and omissions will not be considered deviations. 
Samples obtained prior to consenting may be used. 
 
7.7 
Blood sample (25-35cc) will be collected for assessment of immune function 
and effector cells to be sent to Dr. Katy Rezvani’s lab.  Not all samples may be 
collected at all times points and omissions will not be considered deviations.  
Samples obtained prior to consenting  may be used. 
 
7.8 
Pregnancy (urine or blood) test only for women of childbearing potential within 
7 days. 
8.0 
Evaluations during the study 
 
8.1 
CBC, differential, platelet count 1-2 times weekly for 1st course, then every 2-4 
weeks while on therapy. The frequency can be reduced to once per cycle after 
achieving CR or after sixth cycle (whichever first) 
 
8.2 
Creatinine, bilirubin, SGPT weekly for 1st course, then every 2-4 weeks while 
on therapy. The frequency can be reduced to once per cycle after achieving CR 
or after sixth cycle (whichever first) 
 
8.3 
Bone marrow aspiration to document remission then every 1-3 courses.  
 
8.4 
Cytogenetics at remission if abnormal pretherapy any time a bone marrow 
exam is performed. Omissions will not be considered as deviations. 
 
8.5  
Molecular testing depending on the positive tests pre-study (specific mutations, 
whole genome sequencing) any time a bone marrow exam is performed. 
Omissions will not be considered as deviations.  
 
8.6 
Multi-parameter flow cytometry for the presence of leukemia associated 
immunophenotype (minimal residual disease) any time a bone marrow exam is 
performed. Omissions will not be considered as deviations..  
 
8.7 
Blood samples (20-50cc) on days 1 (any time prior to first dose), 5 and 10 (+/- 3 
days) of therapy (optional); marrow sample (2 cc) every 1-3 courses (optional). 
Samples are to be sent to Dr. Garcia-Manero's lab (pager 713-404-0277).  (Not 
all research samples may be collected at all time-points and omissions will not 

 
 
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be considered deviations.)   Precourse samples may be obtained after day 27 
of the preceding course, but prior to first dose of next course. 
 
8.8 
Blood sample (25-35cc) will be collected for assessment of immune function 
and effector cells at the time of remission, relapse, and about every 3 – 4 
cycles.  Samples are to be sent to Dr. Katy Rezvani’s lab.  (Not all samples 
may be collected at all times points and omissions will not be considered 
deviations.) 
 
8.9 
Peripheral blood specimens will be obtained at the time of complete remission 
and relapse, and evaluated for the presence of various T-cell subsets, NK cells 
and other immune effector measures 
9.0 
Response criteria 
 
9.1 
Complete Remission:  Normalization of the peripheral blood and bone marrow 
with <5% bone marrow blasts, a peripheral blood granulocyte count > (1.0 x 
10
9/L, and a platelet count > 100 x 10
9/L). 
 
9.2 
Partial Remission: as above except for the presence of 6-15% marrow blasts, 
or 50% reduction if <15% at start of treatment. 
 
9.3 
Complete remission with incomplete recovery (CRi): meets all criteria for CR 
except for platelet recovery to >100 x 10
9/L and/or granulocyte count > (1.0 x 
10
9/L 
 
9.4 
Clinical benefit: platelets increase by 50% and to above 30 x 10
9/L 
untransfused (if lower than that pretherapy); or granulocytes increase by 100% 
and to above 10
9/L (if lower than that pretherapy); or hemoglobin increase by 2 
g/dl; or transfusion independent; or splenomegaly reduction by > 50%; or 
monocytosis reduction by > 50% if pretreatment > 5 x 10
9/L. 
10.0 Criteria for removal from the study 
 
10.1 No improvement or clinically significant progressive disease 
 
10.2 Patient refusal 
 
10.3 Pattern of patient non-compliance; physician judgment 
11.0 
Statistical Considerations 
 
11.1 
General description 

 
 
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This is a Phase II open-label, efficacy and toxicity study of two treatment arms (arm A: 
Decitabine 20mg/m2 IV daily for 5 days versus arm B: Decitabine 20mg/m2 IV daily for 10 days) in 
subjects with AML > 60 or unfit for standard cytotoxic chemotherapy.  Patients will be enrolled to 
evaluate the 2 dose schedules. For both arms, one course will consist of 4 weeks. An adaptive 
randomization design will be employed to compare the efficacy between the two arms. The primary 
efficacy outcome is the complete response which is defined as the complete remission (CR) or complete 
remission with incomplete recovery (CRi) assessed after three cycles. At the end of the trial, we will 
estimate the probability that one arm is superior to the other. We will also evaluate toxicity on each arm. 
A maximum of 100 patients will be accrued, at an expected accrual rate of 5 patients per month. 
 
11.2 
Randomization 
 
The Department of Biostatistics will provide and maintain a website (“Clinical Trial Conduct”:  
https://biostatistics.mdanderson.org/ClinicalTrialConduct/) for patients enrolled on this study. The 
Clinical Trial Conduct website resides on a secure server, and access is gained through usernames and 
passwords provided to personnel responsible for enrolling patients and updating patient data.  The 
website is accessed through a browser using secure socket layer (SSL) technology. Personnel 
responsible for enrolling patients on trials, which includes the principal investigator(s), research 
nurse(s), and data coordinator(s), will be trained by members of the Department of Biostatistics 
(specifically the statistical collaborators on the study) in the use of the trial website; the importance of 
timely updating of follow-up times and recording of events will be emphasized in training. 
 
11.3 
Study Design 
 
A maximum of 100 patients will be adaptively randomized into two treatment groups: 
 
      Arm A:  Decitabine 20mg/m2 IV daily for 5 days 
      Arm B:  Decitabine 20mg/m2 IV daily for 10 days 
Patients will be assigned to receive different schedules of Decitabine, using an adaptive 
procedure that bases assignment probabilities on observed results in preceding patients. At first, 20 
patients will be assigned to each arm with equal probability. As efficacy data accrues, patient 
assignment to the two arms will become unbalanced in favor of the one that has the higher complete 
response rate (RR). The RR for both arms will be estimated with a 95% CI (similar to Bayesian highest 
posterior density interval).49 
 
Based on previous studies, we expect a RR of about 30% in both arms. Therefore, we assume RR 
has a prior Beta distribution (0.6, 1.4) with mean 0.3. Let RRa and RRb denote the response rates for 
arm A and arm B, respectively. Beginning with the 21st patient in each arm and for each subsequent 
patient, we will compare RRa with RRb, incorporating data from all patients with evaluable response. In 
order to avoid favoring one arm earlier in a large trial, instead of assigning patients with posterior 
probability (Pa=Pr(RRa>RRb|data) and Pb=1-Pa), we use the following formula to assign patients: 

 
 
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Aa=
Pb
Pa
Pa

,  Ab=1-Aa, where Aa is the probability of assigning patients to arm A,  Ab is the 
probability of assigning patients to arm B, Pa is the posterior probability that arm A is superior to arm B 
and Pb is the posterior probability that arm B is superior to arm A. 
 
If at any point during the trial Pr(RRa>RRb|data)>0.95(or <0.05) the schedule A(or B) will be 
selected as superior. If accruing information gives strong evidence that a RR of 30% or greater is 
unlikely to be true for any one of the treatment arms (Pr(RRa or RRb>0.3|data)<0.05), assignment to 
that arm will be stopped. If the maximum of 100 patients is enrolled and evaluated and 
Pr(RRa>RRb|data)>0.9 (or <0.1), we will declare that arm A(or B) has a higher RR rate than arm B (or 
A). Otherwise, the trial will be inconclusive. We used simulation (5,000 simulations per scenario) to 
evaluate the performance of the adaptive randomization procedure under several different scenarios 
(Table 2). Adaptive Randomization version 4.1 has been used for the simulation. Adaptive 
Randomization version 4.1 has been used for the simulation. 
 
 
11.4  Toxicity Monitoring 
 
Evidence of Toxicity will be monitored closely in all patients. For each arm, treatment will be 
terminated if Pr(non hematological grade 3 or higher clinically significant study drug related Toxicity 
>0.3 | data)  >0.95.  We assume PE ~ beta (0.3, 0.7).  Table 1 shows the simulation of the trial.  The 
treatment will be stopped accrual if the number of patients with clinically significant study drug related  
toxicities equal to or greater than indicated (i.e., #pts with tox) among the number of patients accrued 
(i.e., #pts):  2/2, 3/3, 4/5, 5/7, 6/9, 7/11, 8/14, 9/16, 10/19, 11/21, 12/24, 13/27, 14/29, 15/32, 16/35, 
17/38, 18/40, 19/43, 20/46, 21/49, 22/52, 23/54, 24/57, 25/60, 26/63, 27/66, 28/69, 29/72, 30/75, 31/77. 
Multc99 version2.1 has been used for the simulation and boundary computation.  
 
Table 1: Operating characteristics of 
Safety Monitoring (based on 10000 
simulations) 
True 
probability 
Stop 
probability 
median 
sample size 
(interquantile) 
0.2 
0.06 
80 (80, 80) 
0.25 
0.13 
80 (80, 80) 
0.3 
0.28 
80 (45, 80) 
0.35 
0.53 
65 (12, 80) 
 

 
 
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Table 2: Operating characteristics of adaptive 
randomization design to compare DAC in two 
schedules. Randomly assign 20 patients to each 
arm with equal probability before adapting the 
randomization 
 
Arm A 
Arm B 
RR Rate 
0.05 
0.1 
Expected # of Patients 
20.1 
20.1 
Pr(Select) 
0.02 
0.14 
Pr(Select Early) 
0.01 
0.10 
Pr(Stop Early) 
0.95 
0.73 
 
 
 
RR Rate 
0.1 
0.3 
Expected # of Patients 
21.5 
22.6 
Pr(Select) 
0.003 
0.66 
Pr(Select Early) 
0.001 
0.52 
Pr(Stop Early) 
0.96 
0.07 
 
 
 
RR Rate 
0.3 
0.65 
Expected # of Patients 
21.7 
24 
Pr(Select) 
0.0002 
0.99 
Pr(Select Early) 
0.0002 
0.98 
Pr(Stop Early) 
0.98 
0.0002 
 
 
 
RR Rate 
0.3 
0.3 
Expected # of Patients 
40.2 
40.3 
Pr(Select) 
0.15 
0.15 
Pr(Select Early) 
0.11 
0.12 
Pr(Stop Early) 
0.21 
0.2 
 
 
 
RR Rate 
0.5 
0.6 
Expected # of Patients 
36.7 
43 
Pr(Select) 
0.03 
0.47 
Pr(Select Early) 
0.03 
0.42 
Pr(Stop Early) 
0.42 
0.03 
 
 
 
 

 
 
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11.5  Analysis Plan 
Data analysis will be performed using SAS or S-plus, as appropriate. All patients will be included 
in the intent-to-treat analysis for efficacy.  Demographic and disease characteristics of the patients at 
registration will be summarized using descriptive statistics such as mean, standard deviation (SD), median 
and range. The RR for both arms will be estimated by Bayesian posterior estimates, along with the 95% 
credible intervals. The posterior probability that one treatment is better than the other will be computed, 
and the 95% credible interval of the posterior probability will also be estimated. The time-to-event 
variables will be estimated by Kaplan-Meier method. The survival difference between the two treatment 
schedules will be compared by Log-rank test. The OS is defined as the time period from the start of 
treatment till death or last follow-up whichever comes first. Duration of response (DoR) is for the patients 
who achieve CR or CRi, and it is defined as the time between the date of response confirmed (CR or CRi) 
and the date of progression or death (whichever occurs first). DoR will be censored on the date of last 
follow-up. 
 
 

 
 
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