Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma
Conditions
Keywords
CLL, SLL
Brief summary
A Randomized, Multicenter, Open-label, Phase 3 Study of the Bruton's Tyrosine Kinase Inhibitor PCI-32765 versus Chlorambucil in Patients 65 Years or Older with Treatment-naive Chronic Lymphocytic Leukemia or Small Lymphocytic Lymphoma.
Detailed description
Study design: This is a randomized, multicenter, open-label, Phase 3 study designed to compare the safety and efficacy of Ibrutinib versus Chlorambucil in treatment-naive patients 65 years or older who have CLL or SLL. Eligible patients will be randomized in a 1:1 ratio to Treatment Arm A or B: * Treatment Arm A: Oral Chlorambucil 0.5 mg/kg on Days 1 and 15 of each 28-day cycle; the dose can be increased, if well tolerated, in increments of 0.1 mg/kg on Day 1 of each cycle to a maximum of 0.8 mg/kg; patients receive a minimum of 3 and a maximum of 12 cycles, in the absence of progressive disease or unacceptable toxicity. * Treatment Arm B: Oral Ibrutinib 420 mg/day Randomization will be stratified on Eastern Cooperative Oncology Group (ECOG) performance status (0,1 versus 2); presence of advanced Rai stage (yes/no), advanced being defined as Stages 3-4; and geographic region: US versus non-US.
Interventions
DRUGIbrutinib
Ibrutinib will be supplied as hard gelatin 140-mg capsules for oral (PO) administration. Ibrutinib 420 mg (3 x 140-mg capsules) is administered orally once daily. The first dose will be delivered in the clinic on Day 1, after which subsequent dosing is typically on an outpatient basis. Ibrutinib will be dispensed to patients in bottles at each visit.
DRUGChlorambucil
Chlorambucil will be supplied as 2-mg tablets for PO administration. Chlorambucil is administered orally on Days 1 and 15 of each 28-day cycle. The starting dosage (Cycle 1) is 0.5 mg/kg. If well tolerated, the Chlorambucil dose can be increased starting at Cycle 2, with increments of 0.1 mg/kg on Day 1 of each cycle to a maximum of 0.8 mg/kg.
Sponsors
Janssen Research & Development, LLC
Pharmacyclics LLC.
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Males or females of 65 years of age or greater. Patients between the ages of 65 and 70 years of age must have 1 or more of the following comorbidities that may preclude the use of frontline chemo-immunotherapy with fludarabine, cyclophosphamide, or rituximab: * creatinine clearance \< 70 mL/min using the Cockcroft-Gault equation * platelet count \< 100,000/μL or hemoglobin \< 10 g/dL * clinically apparent autoimmune cytopenia (autoimmune hemolytic anemia or immune thrombocytopenia) * ECOG performance score = 1 or 2 2. Diagnosis of CLL/SLL that meets IWCLL diagnostic criteria (Hallek 2008) 3. Active disease meeting at least 1 of the following IWCLL criteria (Hallek 2008) for requiring treatment: * Evidence of progressive marrow failure as manifested by the development of, or worsening of, anemia and/or thrombocytopenia Massive, progressive, or symptomatic splenomegaly * Massive nodes or progressive or symptomatic lymphadenopathy * Progressive lymphocytosis * Autoimmune hemolytic anemia and/or immune thrombocytopenia that is poorly responsive to corticosteroids or standard therapy * Constitutional symptoms 4. Measurable nodal disease by computed tomography (CT) 5. ECOG performance status of 0-2 6. Life expectancy \> 4 months from randomization 7. Adequate hematologic function, defined as absolute neutrophil count (ANC) ≥ 1,000/μL (independent of growth factor support for at least 7 days prior to screening) and platelet count ≥ 50,000/μL (independent of transfusion and growth factor support for at least 7 days prior to screening) 8. Adequate hepatic function, defined as serum aspartate transaminase (AST) and alanine transaminase (ALT) \< 2.5 x upper limit of normal (ULN), and total bilirubin ≤ 1.5 x ULN 9. Adequate renal function, defined as estimated creatinine clearance ≥ 30 mL/min using the Cockcroft-Gault equation 10. Willingness to receive all outpatient treatment, all laboratory monitoring, and all radiological evaluations at the institution that administers study drug for the entire study 11. Willingness of male patients, if sexually active with a female of childbearing potential, to use an effective barrier method of contraception during the study and for 3 months following the last dose of study drug 12. Ability to provide written informed consent and to understand and comply with the requirements of the study
Exclusion criteria
1. Known involvement of the central nervous system by lymphoma or leukemia 2. History or current evidence of Richter's transformation or prolymphocytic leukemia 3. Documentation of deletion of the short arm of chromosome 17: del(17p13.1) in more than 20% of cells examined on any pretreatment fluorescence in situ hybridization (FISH) or cytogenetic evaluation 4. Uncontrolled autoimmune hemolytic anemia or idiopathic thrombocytopenic purpura 5. Any previous treatment (chemotherapy, radiotherapy, and/or monoclonal antibodies) intended specifically to treat CLL/SLL 6. Received any immunotherapy, vaccine, or investigational drug within 4 weeks prior to randomization 7. Corticosteroid use within 1 week prior to first dose of study drug, with the exception of inhaled, topical, or other local administrations. Patients requiring systemic steroids at daily doses \> 20 mg prednisone (or corticosteroid equivalent, see Appendix N), or those who are administered steroids for leukemia control or white blood cell (WBC)-count-lowering are excluded. 8. Major surgery within 4 weeks prior to randomization 9. History of prior malignancy, with the exception of the following: * malignancy treated with curative intent and with no evidence of active disease present for more than 3 years prior to screening and felt to be at low risk for recurrence by treating physician * adequately treated nonmelanomatous skin cancer or lentigo maligna melanoma without current evidence of disease * adequately treated cervical carcinoma in situ without current evidence of disease 10. Currently active, clinically significant cardiovascular disease or a history of myocardial infarction within 6 months prior to randomization 11. Inability to swallow capsules or tablets, or disease significantly affecting gastrointestinal function 12. Uncontrolled active systemic fungal, bacterial, viral, or other infection or requirement for intravenous (IV) antibiotics 13. Known history of infection with human immunodeficiency virus (HIV) 14. Serologic status reflecting active hepatitis B or C infection 15. History of stroke or intracranial hemorrhage within 6 months prior to enrollment 16. Current life-threatening illness, medical condition, or organ-system dysfunction that could compromise patient safety or put the study at risk 17. Requirement for anticoagulation with warfarin 18. Requirement for treatment with a strong CYP3A4/5 and/or CYP2D6 inhibitor
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| PFS (Progression Free Survival) | Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month. | The primary objective of this study was to evaluate the efficacy of Ibrutinib compared with Chlorambucil based on the independent review committee (IRC) assessment of PFS Progressive disease according to 2008 IWCLL guidelines was defined as: * Group A * Lymphadenopathy, increase ≥50% * Hepatomegaly, increase ≥50% * Splenomegaly, increase ≥50% * Blood lymphocytes, increase ≥ 50% over baseline * Group B * Platelets counts, decrease of ≥ 50% from baseline secondary to CLL * Hemoglobin, decrease of \> 2 g/dL from baseline secondary to CLL |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Overall Survival (OS) | Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month. | OS is calculated for all randomized subjects as the duration of time from the date of randomization to the date of death due to any cause or the date last known alive for subjects who were not known to have died at study closure. |
| ORR (Overall Response Rate) | Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month. | ORR is defined as the proportion of subjects who achieved complete response (CR), complete response with incomplete marrow recovery (CRi), nodule partial response (nPR) or PR per IRC assessment. Response criteria are as outlined in the International Workshop on CLL (iwCLL) 2008 criteria with the 2012 iwCLL modification stating that treatment-related lymphocytosis in the setting of improvement in other parameters was not considered as PD and the 2013 iwCLL clarification of criteria for a partial response to therapy. |
| Proportion of Sustained Platelet Improvement | Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month. | The proportion of subjects who achieved platelet \>100 x 10\^9/L or increase ≥50% over baseline and persisted continuously for ≥56 days (8 weeks) without blood transfusion or growth factors. |
| Proportion of Sustained Hemoglobin Improvement in Subjects With Baseline Anemia | Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month. | In randomized subjects with baseline hemoglobin ≤ 11 g/dL, the proportion of subjects who achieved Hemoglobin \>11 g/dL or increase ≥ 2 g/dL over baseline persisted continuously for ≥56 days (8 weeks) without blood transfusion or growth factors. |
| Proportion of Sustained Platelet Improvement in Subjects With Baseline Thrombocytopenia | Analysis was conducted when 15 months had elapsed after the last subject was randomized with cutoff date of 4 May 2015. The median follow-up time is 18 month. | In randomized subjects with baseline platelet ≤ 100 x 10\^9/L, the proportion of subjects who achieved platelet \>100 x 10\^9/L or increase ≥50% over baseline persisted continuously for ≥56 days (8 wee without blood transfusion or growth factors. |
| Proportion of Sustained Hemoglobin Improvement | Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month. | The proportion of subjects who achieved Hemoglobin \>11 g/dL or increase ≥ 2 g/dL over baseline and persisted continuously for ≥56 days (8 weeks) without blood transfusion or growth factors. |
Countries
Australia, Belgium, Canada, China, Czechia, Ireland, Israel, Italy, New Zealand, Poland, Russia, Spain, Turkey (Türkiye), Ukraine, United Kingdom, United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Ibrutinib Ibrutinib 420 mg daily. | 136 |
| Chlorambucil Chlorambucil 0.5 mg/kg (to maximum 0.8 mg/kg) days 1 and 15 of 28-day cycle up to 12 cycles | 133 |
| Total | 269 |
Baseline characteristics
| Characteristic | Ibrutinib | Chlorambucil | Total |
|---|---|---|---|
| Age, Categorical <=18 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Categorical >=65 years | 136 Participants | 133 Participants | 269 Participants |
| Age, Categorical Between 18 and 65 years | 0 Participants | 0 Participants | 0 Participants |
| Age, Continuous | 73.1 years STANDARD_DEVIATION 5.67 | 73.4 years STANDARD_DEVIATION 5.95 | 73.3 years STANDARD_DEVIATION 5.81 |
| Sex: Female, Male Female | 48 Participants | 52 Participants | 100 Participants |
| Sex: Female, Male Male | 88 Participants | 81 Participants | 169 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | — / — | — / — |
| other Total, other adverse events | 133 / 135 | 123 / 132 |
| serious Total, serious adverse events | 55 / 135 | 33 / 132 |
Outcome results
Primary
PFS (Progression Free Survival)
The primary objective of this study was to evaluate the efficacy of Ibrutinib compared with Chlorambucil based on the independent review committee (IRC) assessment of PFS Progressive disease according to 2008 IWCLL guidelines was defined as: * Group A * Lymphadenopathy, increase ≥50% * Hepatomegaly, increase ≥50% * Splenomegaly, increase ≥50% * Blood lymphocytes, increase ≥ 50% over baseline * Group B * Platelets counts, decrease of ≥ 50% from baseline secondary to CLL * Hemoglobin, decrease of \> 2 g/dL from baseline secondary to CLL
Time frame: Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month.
Population: Intention to treat
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Ibrutinib | PFS (Progression Free Survival) | NA Months |
| Chlorambucil | PFS (Progression Free Survival) | 18.9 Months |
p-value: <0.000195% CI: [0.09, 0.28]Log Rank
Secondary
ORR (Overall Response Rate)
ORR is defined as the proportion of subjects who achieved complete response (CR), complete response with incomplete marrow recovery (CRi), nodule partial response (nPR) or PR per IRC assessment. Response criteria are as outlined in the International Workshop on CLL (iwCLL) 2008 criteria with the 2012 iwCLL modification stating that treatment-related lymphocytosis in the setting of improvement in other parameters was not considered as PD and the 2013 iwCLL clarification of criteria for a partial response to therapy.
Time frame: Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month.
Population: Intention to treat
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Ibrutinib | ORR (Overall Response Rate) | 82.4 percentage of participants |
| Chlorambucil | ORR (Overall Response Rate) | 35.3 percentage of participants |
p-value: <0.0001Cochran-Mantel-Haenszel
Secondary
Overall Survival (OS)
OS is calculated for all randomized subjects as the duration of time from the date of randomization to the date of death due to any cause or the date last known alive for subjects who were not known to have died at study closure.
Time frame: Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month.
Population: Intention to treat
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Ibrutinib | Overall Survival (OS) | NA Months |
| Chlorambucil | Overall Survival (OS) | NA Months |
p-value: 0.00195% CI: [0.05, 0.56]Log Rank
Secondary
Proportion of Sustained Hemoglobin Improvement
The proportion of subjects who achieved Hemoglobin \>11 g/dL or increase ≥ 2 g/dL over baseline and persisted continuously for ≥56 days (8 weeks) without blood transfusion or growth factors.
Time frame: Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month.
Population: Intention to treat
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Ibrutinib | Proportion of Sustained Hemoglobin Improvement | 45.6 Percentage of Participants |
| Chlorambucil | Proportion of Sustained Hemoglobin Improvement | 20.3 Percentage of Participants |
p-value: <0.0001Chi-squared
Secondary
Proportion of Sustained Hemoglobin Improvement in Subjects With Baseline Anemia
In randomized subjects with baseline hemoglobin ≤ 11 g/dL, the proportion of subjects who achieved Hemoglobin \>11 g/dL or increase ≥ 2 g/dL over baseline persisted continuously for ≥56 days (8 weeks) without blood transfusion or growth factors.
Time frame: Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month.
Population: Subjects with Baseline Anemia
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Ibrutinib | Proportion of Sustained Hemoglobin Improvement in Subjects With Baseline Anemia | 84.3 Percentage of Participants |
| Chlorambucil | Proportion of Sustained Hemoglobin Improvement in Subjects With Baseline Anemia | 45.5 Percentage of Participants |
p-value: <0.0001Chi-squared
Secondary
Proportion of Sustained Platelet Improvement
The proportion of subjects who achieved platelet \>100 x 10\^9/L or increase ≥50% over baseline and persisted continuously for ≥56 days (8 weeks) without blood transfusion or growth factors.
Time frame: Analysis was conducted when 15 months had elapsed after the last subject was randomized with the cutoff date of 4 May 2015. The median follow-up time is 18 month.
Population: Intention to treat
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Ibrutinib | Proportion of Sustained Platelet Improvement | 27.2 Percentage of Participants |
| Chlorambucil | Proportion of Sustained Platelet Improvement | 11.3 Percentage of Participants |
p-value: 0.0009Chi-squared
Secondary
Proportion of Sustained Platelet Improvement in Subjects With Baseline Thrombocytopenia
In randomized subjects with baseline platelet ≤ 100 x 10\^9/L, the proportion of subjects who achieved platelet \>100 x 10\^9/L or increase ≥50% over baseline persisted continuously for ≥56 days (8 wee without blood transfusion or growth factors.
Time frame: Analysis was conducted when 15 months had elapsed after the last subject was randomized with cutoff date of 4 May 2015. The median follow-up time is 18 month.
Population: Subjects With Baseline Thrombocytopenia
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Ibrutinib | Proportion of Sustained Platelet Improvement in Subjects With Baseline Thrombocytopenia | 77.1 Percentage of Participants |
| Chlorambucil | Proportion of Sustained Platelet Improvement in Subjects With Baseline Thrombocytopenia | 42.9 Percentage of Participants |
p-value: 0.0054Chi-squared