Assessment of Outcomes After Stopping Tyrosine Kinase Inhibitors Among Patients With Chronic Myeloid Leukemia
Authors: Ehab Atallah, Charles A. Schiffer, Jerald P. Radich, Kevin P. Weinfurt, Mei-Jie Zhang, Javier Pinilla-Ibarz, Vamsi Kota, Richard A. Larson, Joseph O. Moore, Michael J. Mauro, Michael W. N. Deininger, James E. Thompson, Vivian G. Oehler, Martha Wadleigh, Neil P. Shah, Ellen K. Ritchie, Richard T. Silver, Jorge Cortes, Li Lin, Alexis Visotcky, Arielle Baim, Jill Harrell, Bret Helton, Mary Horowitz, Kathryn E. Flynn
Journal: JAMA Oncology (2020)

<h3>Importance</h3> Tyrosine kinase inhibitors (TKIs) have been associated with improved survival of patients with chronic myeloid leukemia (CML) but are also associated with adverse effects, especially fatigue and diarrhea. Discontinuation of TKIs is safe and is associated with the successful achievement of treatment-free remission (TFR) for some patients. <h3>Objective</h3> To evaluate molecular recurrence (MRec) and patient-reported outcomes (PROs) after TKI discontinuation for US patients with CML. <h3>Design, Setting, and Participants</h3> The Life After Stopping TKIs (LAST) study was a prospective single-group nonrandomized clinical trial that enrolled 172 patients from 14 US academic medical centers from December 18, 2014, to December 12, 2016, with a minimum follow-up of 3 years. Participants were adults with chronic-phase CML whose disease was well controlled with imatinib, dasatinib, nilotinib, or bosutinib. Statistical analysis was performed from August 13, 2019, to March 23, 2020. <h3>Intervention</h3> Discontinuation of TKIs. <h3>Main Outcomes and Measures</h3> Molecular recurrence, defined as loss of major molecular response (BCR-ABL1 International Scale ratio &gt;0.1%) by central laboratory testing, and PROs (Patient-Reported Outcomes Measurement Information System computerized adaptive tests) were monitored. Droplet digital polymerase chain reaction (ddPCR) was performed on samples with undetectable BCR-ABL1 by standard real-time quantitative polymerase chain reaction (RQ-PCR). <h3>Results</h3> Of 172 patients, 89 were women (51.7%), and the median age was 60 years (range, 21-86 years). Of 171 patients evaluable for molecular analysis, 112 (65.5%) stayed in major molecular response, and 104 (60.8%) achieved TFR. Undetectable BCR-ABL1 by either ddPCR or RQ-PCR at the time of TKI discontinuation (hazard ratio, 3.60; 95% CI, 1.99-6.50;<i>P</i> &lt; .001) and at 3 months (hazard ratio, 5.86; 95% CI, 3.07-11.1;<i>P</i> &lt; .001) was independently associated with MRec. Molecular recurrence for patients with detectable BCR-ABL1 by RQ-PCR was 50.0% (14 of 28), undetectable BCR-ABL1 by RQ-PCR but detectable by ddPCR was 64.3% (36 of 56), and undetectable BCR-ABL1 by both ddPCR and RQ-PCR was 10.3% (9 of 87) (<i>P</i> ≤ .001). Of the 112 patients in TFR at 12 months, 90 (80.4%) had a clinically meaningful improvement in fatigue, 39 (34.8%) had a clinically meaningful improvement in depression, 98 (87.5%) had a clinically meaningful improvement in diarrhea, 24 (21.4%) had a clinically meaningful improvement in sleep disturbance, and 5 (4.5%) had a clinically meaningful improvement in pain interference. Restarting a TKI resulted in worsening of PROs. <h3>Conclusions and Relevance</h3> In this study, TKI discontinuation was safe, and 60.8% of patients remained in TFR. Discontinuation of TKIs was associated with improvements in PROs. These findings should assist patients and physicians in their decision-making regarding discontinuation of TKIs. Detectable BCR-ABL1 by RQ-PCR or ddPCR at the time of TKI discontinuation was associated with higher risk of MRec; clinical application of this finding should be confirmed in other studies. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT02269267