Global patterns of care in advanced stage mycosis fungoides/Sezary syndrome: a multicenter retrospective follow-up study from the Cutaneous Lymphoma International Consortium.

Background: Advanced-stage mycosis fungoides (MF)/Se´zary syndrome (SS) patients are weighted by an unfavorable prognosis and share an unmet clinical need of effective treatments. International guidelines are available detailing treatment options for the different stages but without recommending treatments in any particular order due to lack of comparative trials. The aims of this second CLIC study were to retrospectively analyze the pattern of care worldwide for advanced-stage MF/SS patients, the distribution of treatments according to geographical areas (USA versus non-USA), and whether the heterogeneity of approaches has potential impact on survival. Patients and methods: This study included 853 patients from 21 specialist centers (14 European, 4 USA, 1 each Australian, Brazilian, and Japanese). Results: Heterogeneity of treatment approaches was found, with up to 24 different modalities or combinations used as first-line and 36% of patients receiving four or more treatments. Stage IIB disease was most frequently treated by total-skin-electron-beam radiotherapy, bexarotene and gemcitabine; erythrodermic and SS patients by extracorporeal photochemotherapy, and stage IVA2 by polychemotherapy. Significant differences were found between USA and non-USA centers, with bexarotene, photopheresis and histone deacetylase inhibitors most frequently prescribed for first-line treatment in USA while phototherapy, interferon, chlorambucil and gemcitabine in non-USA centers. These differences did not significantly impact on survival. However, when considering death and therapy change as competing risk events and the impact of first treatment line on both events, both monochemotherapy (SHR ¼ 2.07) and polychemotherapy (SHR ¼ 1.69) showed elevated relative risks. Conclusion: This large multicenter retrospective study shows that there exist a large treatment heterogeneity in advanced MF/ SS and differences between USA and non-USA centers but these were not related to survival, while our data reveal that chemotherapy as first treatment is associated with a higher risk of death and/or change of therapy and thus other therapeutic options should be preferable as first treatment approach. multivariable Cox proportional-hazards regression model was used to es- timate the association between mortality for all causes and the variables above [20]. The proportionality assumption was assessed by examination of Schoenfeld residuals, giving no reason for violation. investigate the of the treatmentline, Statistical analyses were performed with Stata 13 (StataCorp LP, College Station, TX). Systemic immune modulators and pro-apoptotic inducers: interferon (IFN), retinoids, bexarotene, extracorporeal photoche-motherapy (photopheresis), low-dose methotrexate, lenalidomide, combinations with phototherapy plus retinoids and/or IFN; any combinations of photopheresis plus retinoids and/or IFN; (3) Single agent chemotherapy: chlorambucil, gemcitabine, pegylated doxorubi-cine, pralatrexate, other mono-chemotherapy; (4) Polychemotherapy: CHOP, CHOP-like, other poly-chemotherapy; (5) Targeted therapies: denileukin diftitox, histone deacetylase inhibitors (HDACi), alemtuzumab, mogamulizumab, zanolimumab, brentuximab vedotin, bevacizu-mab); (6) Autologous or allogeneic stem-cell or bone marrow transplantation.