A Randomized Open-Label, Phase 3 Study to Evaluate Imetelstat Versus Best Available Therapy (BAT) in Patients with Intermediate-2 or High-Risk Myelofibrosis (MF) Refractory to Janus Kinase (JAK) Inhibitor
Authors: Mascarenhas John , Harrison Claire , Kiladjian Jean-Jacques , Mesa Ruben , Komrokji Rami S. , Koschmieder Steffen , Vannucchi Alessandro M. , Berry Tymara , Sherman Laurie , Dougherty Souria , Sun Libo , Huang Fei , Wan Ying , Feller Faye , Rizo Aleksandra , Verstovsek Srdan 
Published: November 2020

Background: Myelofibrosis (MF) is a life-threatening myeloproliferative neoplasm. Ruxolitinib, a Janus kinase 1 (JAK1)/Janus kinase 2 (JAK2) inhibitor and fedratinib, a JAK2/FLT3 inhibitor, are the only approved treatment options for MF. Despite the benefits reported with ruxolitinib in the front-line setting, a high proportion of patients discontinue treatment, the 1-, 2-, and 3-year discontinuation rates are 49%, 71%, and 86%, respectively (Abdelrahman et al, 2015). For patients who discontinue treatment with ruxolitinib, the median overall survival (OS) is dismal and ranges from 13 to 16 months (Kuykendall et al, 2018; Newberry et al, 2017; Schain et al, 2019; Palandri et al, 2019; Mcnamara et al, 2019). There remains a great unmet need for patients who are non-responsive to and have discontinued treatment with a JAK inhibitor.
Imetelstat, a first-in-class telomerase inhibitor, has shown meaningful clinical improvement in symptom response and improved OS in IMbark, a Phase 2 study in patients with intermediate-2 or high-risk MF who have relapsed after or are refractory to JAK inhibitors (Mascarenhas et al, ASH 2018 #685; Mascarenhas et al, EHA 2020 #EP1107). Nineteen (32.2%) patients in the 9.4 mg/kg arm and 3 (6.3%) patients in the 4.7 mg/kg arm achieved symptom response (total symptom score [TSS] reduction ≥50%) at Week 24. As of clinical cutoff (7 February 2020), with an overall study follow up of 42 months, median OS was 28.1 months for the 9.4 mg/kg arm (95% confidence interval [CI]: 22.8, 31.6) and 19.9 months for the 4.7 mg/kg arm (95% CI: 17.1, 33.9). The improvement in OS for patients treated with 9.4mg/kg imetelstat was further supported by analyses of IMbark patients with closely matched real world controls (Kuykendall et al, EHA 2019 #PS1456). Taken together, these findings support continued study of imetelstat 9.4 mg/kg dose in a well-designed Phase 3 randomized controlled study in patients with refractory MF.
Methods: Study MYF3001 is an open label, randomized (2:1), multicenter, Phase 3 study of imetelstat compared with best available therapy (BAT) in approximately 320 patients with intermediate-2 or high-risk MF (primary MF, post-essential thrombocythemia-MF, or post-polycythemia vera-MF) who are refractory to JAK inhibitor treatment. Approximately 214 patients will be randomized to Arm A to receive imetelstat, and approximately 106 patients will be randomized to Arm B to receive BAT. Eligible patients will be stratified based on: a) intermediate-2 or high-risk per Dynamic International Prognostic Scoring System (DIPSS); and b) platelet count at study entry (platelets ≥75 x 109/L and &lt;150 x 109/L versus ≥150 x 109/L). Patients randomized to Arm A will receive imetelstat at the dose of 9.4 mg/kg intravenous (IV) every 21 days. Patients randomized to BAT will receive investigator-selected therapy, which may include hydroxyurea, thalidomide, interferon, danazol, hypomethylating agents, chemotherapy, or other non-JAK inhibitor containing therapy as appropriate in this setting.
The primary endpoint of the study is OS. Secondary endpoints include symptom response rate at week 24, progression-free survival, spleen response rate at week 24, clinical response assessment per modified 2013 International Working Group - Myeloproliferative Neoplasms Research and Treatment (IWG MRT) criteria, time to and duration of response, reduction in the degree of bone marrow fibrosis, safety, pharmacokinetics, and patient-reported outcomes. One interim analysis based on OS is planned.
Biomarkers relevant to the mechanism of action of imetelstat will be assessed to demonstrate target inhibition and their association with OS and clinical responses. Mutation analyses will be performed to evaluate the impact of imetelstat on reduction/depletion of malignant clones leading to disease modification.
The study will be conducted at approximately 150 centers in North and South America, Europe, Asia, and Middle East.

Disclosures
Mascarenhas: Incyte, Kartos, Roche, Promedior, Merck, Merus, Arog, CTI Biopharma, Janssen, and PharmaEssentia: Other: Research funding (institution); Celgene, Prelude, Galecto, Promedior, Geron, Constellation, and Incyte: Consultancy. Harrison:Promedior: Honoraria; Celgene: Honoraria, Research Funding, Speakers Bureau; Gilead Sciences: Honoraria, Speakers Bureau; Sierra Oncology: Honoraria; Shire: Honoraria, Speakers Bureau; AOP Orphan Pharmaceuticals: Honoraria; Roche: Honoraria; Janssen: Speakers Bureau; Novartis: Honoraria, Research Funding, Speakers Bureau; CTI Biopharma Corp: Honoraria, Speakers Bureau; Incyte Corporation: Speakers Bureau. Mesa:Promedior: Research Funding; Genentech: Research Funding; Samus Therapeutics: Research Funding; Incyte: Research Funding; AbbVie: Research Funding; Bristol Myers Squibb: Research Funding; Novartis: Consultancy; CTI BioPharma: Research Funding; LaJolla Pharmaceutical Company: Consultancy; Sierra Oncology: Consultancy. Komrokji:Incyte: Honoraria; BMS: Honoraria, Speakers Bureau; Acceleron: Honoraria; Geron: Honoraria; Novartis: Honoraria; AbbVie: Honoraria; JAZZ: Honoraria, Speakers Bureau; Agios: Honoraria, Speakers Bureau. Koschmieder:Celgene/BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support, Research Funding; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support, Research Funding; Geron Corporation: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support; Incyte/Ariad: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support; Roche: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support; CTI Biopharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support, Research Funding; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support; Bayer: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support; AOP Pharma: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support, Research Funding; Promedior: Other. Vannucchi:AbbVie: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Celgene/BMS: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Blueprint: Membership on an entity's Board of Directors or advisory committees; Incyte: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Berry:Geron Corp: Current Employment, Current equity holder in publicly-traded company. Sherman:Geron Corp: Current Employment, Current equity holder in publicly-traded company. Dougherty:Geron Corp: Current Employment, Current equity holder in publicly-traded company. Sun:Geron Corp: Current Employment, Current equity holder in publicly-traded company. Huang:Geron Corp: Current Employment, Current equity holder in publicly-traded company. Wan:Geron Corp: Current Employment, Current equity holder in publicly-traded company. Feller:Geron Corp: Current Employment, Current equity holder in private company. Rizo:Geron Corp: Current Employment, Current equity holder in publicly-traded company. Verstovsek:PharmaEssentia: Research Funding; AstraZeneca: Research Funding; ItalPharma: Research Funding; Protagonist Therapeutics: Research Funding; CTI Biopharma Corp: Research Funding; Sierra Oncology: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Blueprint Medicines Corp: Research Funding; Genentech: Research Funding; Incyte Corporation: Consultancy, Research Funding; NS Pharma: Research Funding; Roche: Research Funding; Promedior: Research Funding; Gilead: Research Funding; Celgene: Consultancy, Research Funding.