Search

Cold agglutinin disease (CAD) is a rare, autoimmune, classical complement pathway (CP)-mediated hemolytic anemia. Sutimlimab selectively inhibits C1s of the C1 complex, preventing CP activation while leaving the alternative and lectin pathways intact. In Part A (26 weeks) of the open-label, single-arm, Phase 3 CARDINAL study in patients with CAD and a recent history of transfusion, sutimlimab demonstrated rapid effects on hemolysis and anemia. Results of the CARDINAL study Part B (2-year extension) study, described herein, demonstrated that sutimlimab sustains improvements in hemolysis, anemia, and quality of life over a median of 144 weeks of treatment. Mean last-available on-treatment values in Part B were improved from baseline for hemoglobin (12.2 g/dL on-treatment versus 8.6 g/dL at baseline), bilirubin (16.5 μmol/L on-treatment versus 52.1 μmol/L at baseline), and FACIT-Fatigue scores (40.5 on-treatment versus 32.4 at baseline). In the 9-week follow-up period after sutimlimab cessation, CP inhibition was reversed, and hemolytic markers and fatigue scores approached pre-sutimlimab values. Overall, sutimlimab was generally well tolerated in Part B. All 22 patients experienced ≥1 treatment-emergent adverse event (TEAE); 12 (54.5%) patients experienced ≥1 serious TEAE, including seven (31.8%) with ≥1 serious infection. Three patients discontinued due to a TEAE. No patients developed systemic lupus erythematosus or meningococcal infections. After cessation of sutimlimab, most patients reported adverse events consistent with recurrence of CAD. In conclusion, the CARDINAL 2-year results provide evidence of sustained sutimlimab effects for CAD management, but that disease activity reoccurs after treatment cessation. NCT03347396. Registered November 20, 2017. in press

Chronic/refractory immune thrombocytopenia (ITP) is a rare and pathophysiologically heterogeneous disorder with variable responsiveness to available treatments. Sutimlimab, a first-in-class humanized monoclonal anti-C1s IgG4 antibody, selectively inhibits the classical pathway. This phase 1 study (NCT03275454) assessed the safety, efficacy, pharmacokinetics, and pharmacodynamics of biweekly sutimlimab in patients with chronic/refractory ITP with an inadequate response to ≥2 therapies (platelet count ≤ 30 × 109/L). Twelve patients (median age 42 years) received sutimlimab for a median of 20.5 weeks followed by a median 2-week washout period (part A). In part B, 7 of the 12 eligible patients received sutimlimab retreatment for a median of 113 weeks. In part A, the mean (standard deviation) platelet count increased from 25 × 109/L (17) to 54 × 109/L (60) 24 hours after starting sutimlimab, maintaining ≥50 × 109/L throughout part A. Five patients (42%) achieved durable platelet count responses (≥50 × 109/L in ≥50% of follow-up visits) and 4 achieved complete response (platelet count ≥100 × 109/L). The mean platelet count returned to baseline during washout and increased upon retreatment in part B. The mean platelet count improvements accompanied the rapid inhibition of the classical pathway. There were 74 treatment-emergent adverse events in part A (n = 10) and 70 in part B (n = 6). Five serious adverse events were observed; 1 event (migraine) was assessed by the investigator as related to sutimlimab. These results demonstrated that in some patients with ITP, autoantibodies activate the classical complement pathway, accelerating platelet destruction or impairing platelet production and contributing to treatment failure. Thus, C1s inhibition may be a safe and beneficial therapeutic approach for patients with chronic/refractory ITP.

Cold agglutinin disease (CAD) is a rare chronic autoimmune haemolytic anaemia, driven mainly by classical complement pathway activation, leading to profound fatigue and poor quality of life. In the Phase 3 CADENZA trial, sutimlimab—a C1s complement inhibitor—rapidly halted haemolysis, increased haemoglobin levels and improved fatigue versus placebo in patients with CAD without a recent history of transfusion. Patient-reported outcomes (PROs) included Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-Fatigue), 12-Item Short Form Health Survey (SF-12), EuroQol visual analogue scale (EQ-VAS), Patient Global Impression of Change (PGIC) and Patient Global Impression of (fatigue) Severity (PGIS). Sutimlimab resulted in significant rapid and meaningful improvements versus placebo in PROs. From Week 1, the FACIT-Fatigue mean score increased >5 points above baseline (considered a clinically important change [CIC]). Least-squares (LS) mean change in FACIT-Fatigue score from baseline to treatment assessment timepoint was 10.8 vs. 1.9 points (sutimlimab vs. placebo; p < 0.001). Improvements in physical (PCS) and mental (MCS) component scores of the SF-12 were also considered CICs (LS mean changes from baseline to Week 26: PCS 5.54 vs. 1.57 [p = 0.064]; MCS 5.65 vs. –0.48 [p = 0.065]). These findings demonstrate that in addition to improving haematologic parameters, sutimlimab treatment demonstrates significant patient-reported benefits. Study registered at www.clinicaltrials.gov: NCT03347422.

Patients with relapsed warm antibody autoimmune hemolytic anemia (wAIHA) have limited treatment options. Fostamatinib is a potent, orally administered spleen tyrosine kinase inhibitor approved in the United States and Europe for the treatment of adults with chronic immune thrombocytopenia (ITP). This phase 2 study evaluated the response to fostamatinib, administered at 150 mg BID orally with or without food in adults with wAIHA and active hemolysis with hemoglobin (Hgb)10 g/dL who had failed at least one prior treatment. Hemoglobin levels and safety assessments were performed at visits every 2 weeks. The primary endpoint was Hgb10 g/dL with an increase of ≥2 g/dL from baseline by week 24 without rescue therapy or red blood cell transfusion. Eleven of 24 (46%) patients achieved the primary endpoint. Increases in median Hgb were detected at week 2 and sustained over time. Median lactate dehydrogenase levels and reticulocyte counts generally declined over time with little change in median haptoglobin levels. The most common adverse events (AEs) were diarrhea (42%), fatigue (42%), hypertension (27%), dizziness (27%), and insomnia (23%). AEs were manageable and consistent with the fostamatinib safety database of over 3900 patients across multiple diseases (rheumatoid arthritis, B-cell lymphoma, COVID-19, and ITP). No new safety signals were detected. Fostamatinib may be a promising therapeutic option for wAIHA. A randomized, double-blind, phase 3 study is nearing completion.

Sutimlimab, a first-in-class humanized immunoglobulin G4 (IgG4) monoclonal antibody that selectively inhibits the classical complement pathway at C1s, rapidly halted hemolysis in the single-arm CARDINAL study in recently transfused patients with cold agglutinin disease (CAD). CADENZA was a 26-week randomized, placebo-controlled phase 3 study to assess safety and efficacy of sutimlimab in patients with CAD without recent (within 6 months prior to enrollment) transfusion history. Forty-two patients with screening hemoglobin ≤10 g/dL, elevated bilirubin, and ≥1 CAD symptom received sutimlimab (n = 22) or placebo (n = 20) on days 0 and 7 and then biweekly. Composite primary endpoint criteria (hemoglobin increase ≥1.5 g/dL at treatment assessment timepoint [mean of weeks 23, 25, 26], avoidance of transfusion, and study-prohibited CAD therapy [weeks 5-26]) were met by 16 patients (73%) on sutimlimab, and 3 patients (15%) on placebo (odds ratio, 15.9 [95% confidence interval, 2.9, 88.0; P < .001]). Sutimlimab, but not placebo, significantly increased mean hemoglobin and FACIT-Fatigue scores at treatment assessment timepoint. Sutimlimab normalized mean bilirubin by week 1. Improvements correlated with near-complete inhibition of the classical complement pathway (2.3% mean activity at week 1) and C4 normalization. Twenty-one (96%) sutimlimab patients and 20 (100%) placebo patients experienced ≥1 treatment-emergent adverse event. Headache, hypertension, rhinitis, Raynaud phenomenon, and acrocyanosis were more frequent with sutimlimab vs placebo, with a difference of ≥3 patients between groups. Three sutimlimab patients discontinued owing to adverse events; no placebo patients discontinued. These data demonstrate that sutimlimab has potential to be an important advancement in the treatment of CAD. This trial was registered at www.clinicaltrials.gov as #NCT03347422.

Introduction Efgartigimod (ARGX-113) is a human IgG1-derived Fc fragment that binds with high affinity to FcRn in a pH dependent way, resulting in a blockade of FcRn-mediated recycling of IgGs. This leads to rapid degradation of all IgGs, including disease associated autoantibodies. The efficacy, safety, tolerability, and pharmacokinetic (PK) and pharmacodynamic (PD) profile of intravenously (IV) administered efgartigimod have been assessed during a Phase 1 study in healthy subjects (Ulrichts P. JCI. 2018;128), Phase 2 studies in patients with Myasthenia gravis (MG) (Howard JF. Neurol. 2019;92) and Immune Thrombocytopenia (ITP) (Newland AC. Am J Hematol. 2020;95:178-187), and a Phase 3 study in MG (Howard JF. Lancet Neurol. 2021;20). These studies have demonstrated that a dose of 10 mg/kg efgartigimod, administered in four weekly (qw) IV infusions, achieves close to maximal immunoglobulin G (IgG) reduction and a significant reduction of pathogenic autoantibodies in patients with ITP and MG. Furthermore, this dose was well-tolerated in all populations. Based on the results of the Phase 2 study in Primary ITP, a Phase 3 study was designed for IV administration in patients with persistent or chronic primary ITP (ADVANCE NCT04188379). To allow for a convenient SC administration of efgartigimod at a dose that achieves a similar PD effect comparable to IV 10 mg/kg, a co-formulation with rHuPH20 SC was developed (recombinant human hyaluronidase PH20, an enzyme used to increase the dispersion and absorption of co-administered substances when administered subcutaneously). Here we describe the dose selection process for the SC dose to be used in a Phase 3 study of patients with persistent or chronic ITP. Methods PK and PD data from a Phase 1 study, including 32 healthy adult male subjects receiving 750 mg, 1250 mg, 1750 mg, or 10 mg/kg single SC injections of efgartigimod co-mixed with rHuPH20 (8 subjects/dose group), were used for a PK/PD analysis to predict the efgartigimod PH20 SC dose that would result in a similar PD effect compared to the benchmark dose from previous studies of 10 mg/kg IV (1 hour infusion and body weight of 70 kg). Results Weekly SC administration of 1000 mg efgartigimod co-mixed with 2000 U/mL rHuPH20 was predicted to result in comparable maximum total IgG reduction after the 4 th SC injection (days 22-29) as after the 4 th IV infusion of 10 mg/kg administered qw (Figure 1). Additionally, the area under the curve for total IgG concentration after the 4th dose (days 22-29) and trough IgG reduction (measured prior to dose on day 29) were predicted to be comparable between weekly 1000 mg SC and the weekly 10 mg/kg IV benchmark dose. No statistically significant effect of body weight on the PK and PD of efgartigimod PH20 SC was found. Discussion These results informed the weekly SC dose administration schedule in ADVANCE SC, a Phase 3, multicenter, randomized, double-blinded, placebo-controlled trial (NCT04687072) for evaluation of efficacy and safety of efgartigimod PH20 SC in adults with persistent or chronic primary ITP. Efgartigimod PH20 SC or placebo PH20 SC will be given weekly on visits 1-4 and then either weekly or every other week from visits 5 to 16, as determined by platelet counts. The frequency of administration will remain unchanged for the last 7 weeks (visits 17 to 24) to evaluate the sustainable platelet count improvement as the primary objective. Secondary objectives include extent of disease control (overall platelet count response, use of rescue treatment, and changes in concurrent ITP therapy), bleeding events, and quality of life assessments. ADVANCE SC recruitment is currently ongoing across approximately 70 sites in Asia-Pacific, Europe, Japan, Latin America, Middle East, Africa, and USA. Figure 1 Figure 1. Disclosures Ghanima: Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Principia: Membership on an entity's Board of Directors or advisory committees; Sanofi: Membership on an entity's Board of Directors or advisory committees; Bayer: Honoraria, Research Funding; Pfizer: Research Funding. McDonald: Bayer, Sobi, Novartis, Amgen, argenx: Honoraria; Grifols: Research Funding. Jain: GBT: Speakers Bureau; Novartis: Speakers Bureau; Argenx: Other: advisory board; Sanofi: Other: advisory board; DOVA: Other: advisory board. Oliva: Novartis, Celgene, Bristol-Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Daiichi: Consultancy; Alexion, argenx, Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees. Hultberg: argenx: Current Employment, Patents & Royalties. Gandini: argenx: Current Employment, Current equity holder in publicly-traded company, Divested equity in a private or publicly-traded company in the past 24 months. Hofman: argenx: Current Employment. Van Bragt: Curare Consulting BV: Other: Partner; argenx: Consultancy. Parys: argenx: Current Employment. van Hoorick: argenx: Current Employment. Miyakawa: Sanofi: Consultancy; Zenyaku Kogyo: Consultancy; Sanofi: Research Funding; argenx: Consultancy, Research Funding. Broome: Alexion, argenx, Apellis, Sanofi: Honoraria.

PURPOSE: We evaluated the efficacy and toxicity of weekly paclitaxel in patients with previously treated advanced urothelial cancer. PATIENTS AND METHODS: Patients with urothelial cancer who had received one prior systemic chemotherapy regimen for advanced disease and had evidence of disease progression were eligible for enrollment. Patients received paclitaxel 80 mg/m2 by 1-hour intravenous infusion weekly. A cycle of therapy consisted of four weekly treatments. RESULTS: The study enrolled 31 patients. Mean age was 66 years, and 45% of patients had three or more involved metastatic sites. Only 26% of patients had responded to prior chemotherapy. The median number of cycles delivered was three (range, one to eight) at a mean weekly paclitaxel dose of 79 mg/m2. Three patients achieved a partial response (10%; 95% confidence interval, 0% to 20%). Median time to progression was 2.2 months, and median overall survival time was 7.2 months. Therapy was well tolerated with minimal hematologic toxicity. Grade 3 nonhematologic toxicities were also uncommon. CONCLUSION: Although the overall response rate to weekly paclitaxel in patients with previously treated advanced urothelial cancer was modest, the chemotherapy-refractory nature of the study population should be considered.

Cancer is diagnosed in women as often as in men, although the sites of primary disease can differ because of gender. When one thinks of cancer and women, the first two malignancies that come to mind are breast and ovarian, and although these are devastating diseases, they are not among the most deadly cancers that affect women. The most frequently diagnosed cancers in developed countries in descending order are lung, colon, breast, stomach, leukemias and lymphomas, prostate, bladder, uterus, cervix, pancreas, ovary, and liver. 44 Breast and prostate carcinoma are the only malignancies included in the preceding list that demonstrate a definite sex predilection in occurrence rates. In the United States, the leading cause of cancer deaths among women in 1996 was not breast carcinoma, which is the most highly publicized and feared by women. Instead, it was lung carcinoma, accounting for an estimated 25% of all cancer deaths. Lung carcinoma is followed by breast carcinoma accounting for 17% and carcinoma of the colon and rectum accounting for 10%. 31 Although breast carcinoma remains the most frequently diagnosed cancer in women, the death rate from this disease is stable or decreasing slightly, owing in large part to an extensive public health effort aimed at educating women regarding the benefits of early detection. Multimodal approaches to the early detection of breast carcinoma, such as monthly breast self-examinations, mammograms, and routine breast examinations by a health care professional, when used together lead to the detection of potentially curable breast carcinoma lesions at an increasing rate. Despite a modest success in the area of breast carcinoma, however, there remains no effective screening mechanism for the detection of the leading cause of mortality in women, lung carcinoma. Although there are mechanisms for the early detection of colon carcinoma, the insidious nature of the disease and its relative lack of symptoms in the early stages continue to make diagnosis in the early stages difficult. The details of breast carcinoma are discussed elsewhere in this issue; therefore, this article focuses on lung carcinoma and colon and rectal carcinoma, the number one and number three causes of cancer deaths in women, as well as other issues related to cancer therapy and recovery as they specifically relate to women.

Purpose To determine the response rate of trastuzumab as first-line therapy in patients with HER-2 overexpressing metastatic breast cancer. To assess the feasibility and toxicity of weekly paclitaxel/carboplatin with or without trastuzumab following initial treatment with trastuzumab. Patients and Methods Sixty-one patients received trastuzumab (8 mg/kg followed by 4 mg/kg/wk) for 8 weeks. Responding patients received 8 additional weeks of trastuzumab (4 mg/kg/wk), and then proceeded to receive trastuzumab (2 mg/kg) in combination with paclitaxel 70 mg/m2 and carboplatin (area under the curve, 2) weekly for 6 weeks followed by 2 weeks rest. Stable patients after the initial 8 weeks of trastuzumab proceeded to treatment with trastuzumab, paclitaxel, and carboplatin. Patients with disease progression during the initial 8 weeks had the trastuzumab discontinued and were treated with weekly paclitaxel/carboplatin. Results Weekly paclitaxel/carboplatin with or without trastuzumab was well tolerated. Fifty-two patients were assessable for response and all 61 patients were assessable for survival. Seventeen (33%) of 52 patients experienced a minor/partial response to single-agent trastuzumab and received 8 additional weeks of single-agent trastuzumab. Fifteen (29%) of 52 patients had stable disease and proceeded to receive paclitaxel/carboplatin/trastuzumab. Thirty-one patients with measurable disease were assessable for response after initial single-agent trastuzumab followed by paclitaxel/carboplatin/trastuzumab. An overall response rate of 84% (eight complete responses/18 partial responses), median time to progression of 14.2 months, and median overall survival of 32.2 months was reported with the triplet combination. In the patients treated with paclitaxel/carboplatin alone after disease progression on initial single-agent trastuzumab, an overall response rate of 69% (one complete response/10 partial responses), median time to progression of 8.3 months, and median overall survival of 22.2 months was reported. Median time to progression for all 61 patients is 10 months and the median overall survival is 26.7 months. Conclusion This trial confirms the activity and tolerability of weekly paclitaxel/carboplatin alone or in combination with trastuzumab in women with HER-2 overexpressing metastatic breast cancer.