blood and marrow transplant clinical trials network (bmt ctn): past, present and future
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Blood and Marrow Transplant Clinical Trials Network (BMT CTN): Past, Present and Future. Hillard M. Lazarus, MD The George & Edith Richman Professor and Distinguished Scientist in Cancer Research Director of Novel Cell Therapy University Hospitals Case Medical Center - PowerPoint PPT PresentationTRANSCRIPT
Blood and Marrow Transplant Clinical Trials Network (BMT CTN):
Past, Present and FutureHillard M. Lazarus, MD
The George & Edith Richman Professor and Distinguished Scientist in Cancer Research
Director of Novel Cell TherapyUniversity Hospitals Case Medical Center
Case Western Reserve University
E Donnall Thomas, MD 1920-2012Nobel Prize in Physiology or Medicine, 1990
• N=6 pts: variety of diseases, malignant & non-malignant• differing marrow products infused• demonstrated safety (no marrow emboli)• demonstrated some donor engraftment
ED Thomas, et al. N Engl J Med 257: 491-496, 1957
BONE MARROW TRANSPLANTATIONInitial Report: Mary Imogene Bassett Hospital
F Appelbaum. N Engl J Med 357: 1472-1475, 2007
Genesis
I can’t cover everything
BLOOD AND MARROW TRANSPLANT CLINICAL TRIALS NETWORK
Established November 2001 Mission: Conduct scientifically meritorious
multicenter trials in an efficient manner to improve transplant outcomes
Provide infrastructure to allow promising therapies to be developed/evaluated in high quality, multicenter studies that give definitive answers as rapidly as possible
NHLBI & NCI
STEERING COMMITTEE
AdministrativeCommittees
TechnicalCommittees
Data and Coordinating Center
BMT03new_2.ppt
Protocol Teams
Affiliate Clinical Centers
20 Clinical Cores; High-performing Affiliate Centers
NCI Coop Group Chairs (ex officio)
Protocol ReviewCommittee
Data and SafetyMonitoring Board
BMT CTN Organizational Structure
NMDPPatient Advocacy
Contracting
Overall Coordination
Statistical Design/Analysis
Protocol Development/
Implementation
Scientific Leadership
Medical Monitoring
* EMMESTrial Oversight/
Monitoring
Lab/Repository
Management
ElectronicCommunications
DataManagement
BMT CTNData and Coordinating Center
CIBMTR
* professional partner to clinicians, scientists, program leaders
BLOOD & MARROW TRANSPLANTATION1st State of Science Symposium: 4/01/2000
• Stem cell source & donor selection – Horowitz, Champlin, Anasetti, Hansen, Wagner, Confer
• Regimen-related toxicity – Armitage, Blume, McDonald, Jones
• Graft-versus-host disease – Blazar, Martin, Guinan, Parkman, Storb, Ferrara
• Recurrence after autograft – Nadler, Vose, Press, Gribben, Antman
BLOOD & MARROW TRANSPLANTATION1st State of Science Symposium: 4/01/2000
• Recurrence after allograft – O’Reilly, Scheinberg, Barrett, Levitsky, Riddell
• Infectious complications – Wingard, Forman, Zaia, Heslop
• Late complications & immune recovery – Sullivan, Weinberg, Gress, Vogelsang
BLOOD & MARROW TRANSPLANTATION1st State of Science Symposium
Conclusions:
1. Necessity of multi-institutional studies
2. Studies can be adapted to multi-institutional setting
3. Studies could be completed in a responsible time
Conclusions for studies needed:
1. Blood vs marrow in matched sibling donors – (NA)2. Blood vs marrow in matched unrelated donors – (0201)3. Techniques to improve cord blood engraftment – (0501)4. T-cell depletion studies – (0303) 5. Methods to improve autologous cell collection – (NA)6. Comparisons of related and unrelated HCT vs standard chemotherapy for high risk patients – (S1203)
BLOOD & MARROW TRANSPLANTATION1st State of Science Symposium
RFA from NHLBI in 2001 Competition for Data Coordinating Center (DCC)
Emmes Corp, NMDP and CIBMTR awarded
Competition for Centers Established 16 Core Centers Case Consortium original Core Center
( Re-competition: expanded to 20 in July 2011 )
BMT CTN FOUNDATION Creation and Organization/Administration
Case Western Reserve University (CWRU); Oregon Health Sciences University (OHSU); University of Illinois Chicago
Transition to add Washington University (St. Louis) and Ohio State University (through 2011)
Present configuration CWRU, OHSU Cleveland Clinic, West Virginia University
BMT CTN Case Consortium (Original & Current)
Formation of committees and teams: Manual of Policies/Procedures (MOP) Disease-specific teams Protocol-specific teams Liaison relation with cooperative oncology groups Electronic data capture system Per patient reimbursement model Websites for members & public Metrics for center performance: “Report Card”
BMT CTN FOUNDATION Creation and Organization/Administration
Protocol Development & Prioritization
Feasibility Issues
Scientific Rationale
Logistical/ budgetary
Constraints
Clinical Population
No. pts 440 1,058 1,615 2,133 2625 3048 4,200 5,200
Collaboration with cooperative groups to avoid duplication
C
= Enrollment complete
= Enrollment on-going
= Cumulative actual [projected] accrual
= Coop group collaboration(see color key above)
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
0101 PIII Vori vs. Fluconazole0201 PIII Unrelated PBSC vs. Marrow
0102 PIII Myeloma Tandem HCT
0202 PIII follicular NHL (closed early)
0301 PII Unrelated Tx for aplastic anemia
0302 PII AGVHD therapy0303 PII T-depleted HCT for AML
0401 PIII BEAM vs BEAM-Bexxar for Lymphoma
0402 PIII GVHD prophylaxis
0403 PIII Etanercept for IPS (closed early)
0501 III Single vs Double CBT
0502 PII NST for AML >60y
0601 PII Sickle Cell NST0603 PII Haplo in Adult
0604 PII DCB in Adult
0701 PII NST for NHL
0702 PIII Myeloma Follow-on
0703 PII HD
0704 PIII MM maintenance
0801 P II/III CGVHD Treatment0802 PIII AGVHD Treatment
0803 HIV+ Lymphoma
0804 High Risk CLL0901 Full vs RIC - MDS/AML
0902 Post Tx Stress Mgmt
0903 Allo Tx for HIV+1101 Haplo vs. 2 UCB
Mmh11_9.ppt
BMT CTN Centers, 2013>115 centers enrolled >5000 pts since 2003
= Core Centers = PBMTC Centers = Affiliate Centers
BMT CTN: Numbers of Protocols Opened
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 (proj)
0
1
2
3
4
5
6
7
8
02010202
01010102
030203030401
030104020501
04030502*0704*
0601060306040703*
0701
0702 08030801 0804*0802 0805*
09010902
09031101
11021202120312041205
BMT CTN Yearly & Cumulative Accrual All Protocols, 2004-2012
BMT CTN TRIALS Protocol Categories
All Trials Phase II Phase IIIDonor/Graft Source 12 6 6GVHD 5 3 2Infection 3 2 1Disease Control 12 6 6Regimen Toxicity 4 2 2QOL 7 2 5TOTAL 28 14 14
BMT CTN Publications Summary
2012: 7 peer-reviewed papers (+1 in press)
28 total: 10 primary results papers: 0101, 0102,
0202, 0301, 0302, 0303, 0401, 0601, 0603/0604, 0704 (100104)
8 other protocol-related papers 3 methodology papers 7 other Network publications
BLOOD & MARROW TRANSPLANTATION2nd State of Science Symposium
- BMT CTN organized and led- June 7-8, 2007 @ Ann Arbor, MI- Goal: identify key transplant-related issues- Propose critical trials to address these issues
- may be sequential phase II III- may require cooperative oncology group or
other participants- trials should be ready to start quickly
BLOOD & MARROW TRANSPLANTATION2nd State of Science Symposium
1. Optimal donor and graft source – C. Anasetti
2. Regimen-related toxicity – E. Stadtmauer
3. Graft-versus-host disease – J. Antin
4. Infection & immune reconstitution – J. Wingard
5. Late effects/quality of life – S. Lee
6. Pediatrics – K. Schultze, J. Levine
BLOOD & MARROW TRANSPLANTATION2nd State of Science Symposium (con’t)
7. Leukemia – F. Appelbaum
8. Lymphoma – R. Negrin
9. Plasma cell myeloma – S. Giralt
10. Non-malignant disorders – C. Bredson
11. Gene and cell therapy – H. Heslop, D. Kohn
12. Cinical trial design – M. Horowitz
April 2006 Committees named and chargedJune-Dec 2006 Committee conference callsDec 2006 Committee in-person mtgs @ ASHFeb 2007 Committee in-person mtg @ TandemMay 2007 Document dueJune 2007 SOSS
JL Ferrara, BMT CTN. Biol Blood Marrow Transplant 13: 1268-1285, 2007
BLOOD & MARROW TRANSPLANTATIONTimeline: 2nd State of Science Symposium
1. GVHD: Phase II trial calcineurin-free regimen – 0402
2. QOL: Phase III study stress management – 0902 3. Myeloma: Phase III comparison tandem HCT vs. consolidation and maintenance – 0702
4. AML: Phase III chemotherapy vs. URD HCT – SWOG 1203
5. AML: Phase III full intensity vs. RIC HCT - 0901
6. Ph+ ALL: Phase III chemotherapy vs. Allo HCT – S0805
BLOOD & MARROW TRANSPLANTATION2nd State of Science Symposium: Conclusions
7. CLL: Phase II RIC Allo HCT for high risk CLL – 0804
8. Lymphoma: Phase II RIC Allo HCT in T cell lymphoma – NA
9. HLH: Phase II RIC for children with HLH – planning
10. Non-malignant: Phase II auto HCT in Crohn disease – NA
11. Cell Therapy: Phase II viral-specific CTL adenovirus - NA
BLOOD & MARROW TRANSPLANTATION2nd State of Science Symposium: Conclusions
MAJOR SCIENTIFIC PUBLICATIONSPotentially Practice-Changing
BMT CTNDonor Graft Source Questions
Blood versus Marrow
Extremely complex undertaking;Dual consent: donor and recipient
C Anasetti, BMT CTN. N Engl J Med 367: 1487-96, 2012.
BLOOD vs MARROW GRAFT SOURCEMatched Unrelated Donors (MUD): Engraftment
C Anasetti, BMT CTN. N Engl J Med 367: 1487-96, 2012.
BLOOD vs MARROW GRAFT SOURCEMatched Unrelated Donors (MUD): GVHD
C Anasetti, BMT CTN. N Engl J Med 367: 1487-96, 2012.
BLOOD vs MARROW GRAFT SOURCEMatched Unrelated Donors (MUD): Relapse & TRM
C Anasetti, BMT CTN. N Engl J Med 367: 1487-96, 2012.
BLOOD vs MARROW GRAFT SOURCEMatched Unrelated Donors (MUD): Survival
BMT CTN 0401Reduce Relapse After Autograft: NHL
DLBCL: BEXXAR-BEAM vs Rituximab-BEAM
No differences in patient outcome except increased mucositis
Randomized to Bexxar/BEAM or Rituxan/BEAM
Day -19
Day -12
Day -6Days -5 to -2Days -5 to -2Day -1
Day 0
Bexxar 75 cGy TBD
Bexxar 5 mCi Rituxan 375 mg/m2
Rituxan 375 mg/m2
Infusion of mobilized hematopoietic cells
BCNU 300 mg/m2
Etoposide [VP-16] 100 mg/m2 BID (8 doses)Ara-C [Cytarabine] 100 mg/m2 BID (8 doses)Melphalan 140 mg/m2
Day +5 G-CSF 5 µg/kg daily until ANC >500/mm3 x 3 days
Within 3 mo of mobilization
dosimetry
Prob
abili
ty, %
Months0 12 24 48
100
0
20
40
60
80
90
10
30
50
70
0
100
20
40
60
80
90
10
30
50
70
6 18 30 36 42
Rituxan/BEAM (N=113)
Bexxar/BEAM (N=111)
Bexxar/BEAM @ 2 yr: 48.6% p=0.65Rituxan/BEAM @ 2 yr: 49.0%
BMT CTN 0401Autograft BEXXAR-BEAM vs Rituximab-BEAM
Probability Progression-free survival (PFS)
JM Vose, BMT CTN. J Clin Oncol 31: 1662-1668, 2013.
Prob
abili
ty, %
Months0 12 24 48
100
0
20
40
60
80
90
10
30
50
70
0
100
20
40
60
80
90
10
30
50
70
6 18 30 36 42
Rituxan/BEAM (N=113)
Bexxar/BEAM (N=111)
Bexxar/BEAM @ 2 yrs: 60.1% p=0.29Rituxan/BEAM @ 2 yrs: 66.3%
BMT CTN 0401Autograft BEXXAR-BEAM vs Rituximab-BEAM
Probability Survival
JM Vose, BMT CTN. J Clin Oncol 31: 1662-1668, 2013.
BMT CTNRelapse Prevention Questions: Myeloma
Tandem Autograft vs Autograft-Allograft
A Krishnan, BMT CTN. Lancet Oncol 12: 1195-203, 2011.
TRANSPLANTATION IN MYELOMATandem Autograft vs Autograft-RIC Allograft
Autografts: Melphalan 200 mg/m2
Allograft: TBI 200 cGy
A Krishnan, BMT CTN. Lancet Oncol 12: 1195-203, 2011.
TRANSPLANTATION IN MYELOMATandem Autograft vs Autograft-RIC Allograft
Standard-risk
A Krishnan, BMT CTN. Lancet Oncol 12: 1195-203, 2011.
TRANSPLANTATION IN MYELOMATandem Autograft vs Autograft-RIC Allograft
High-risk
BMT CTNRelapse Prevention Questions: Myeloma
Post-Autograft Maintenance Therapy
AUTOGRAFT IN MYELOMAPost-Transplant Lenalidomide vs Placebo
PL McCarthy, BMT CTN. N Engl J Med 366: 1770-81, 2012.
Joint BMT CTN and CALGB study
Median TTP 46 mo
Median TTP 27 mo
88% @ 3 yr
80% @ 3 yr
AUTOGRAFT IN MYELOMAPost-Transplant Lenalidomide vs Placebo
PL McCarthy, BMT CTN. N Engl J Med 366: 1770-81, 2012.
Risk 2nd maligancy
BMT CTNNovel GVHD Prevention Strategies
T Cell Depletion and Other Strategies
HEMATOPOIETIC CELL TRANSPLANTAllograft & High-dose Rituximab in FCC NHL
IF Khouri, MD Anderson. Blood 111: 5530-5536, 2008
Survival
Graft-vs-Host Disease
BMT CTN 0701Allograft & High-dose Rituximab in FCC NHL
Rituximab 375 mg/m2 (day –13)Rituximab 1,000 mg/m2 (day – 6)
Fludarabine + Cyclophosphamide conditioning
Tacrolimus+ Methotrexate (GVHD prophylaxis)
Rituximab 1,000 mg/m2 day +1 and +8Blood allograft infusion (matched-related or MUD)
PK studies for rituximab blood concentration
Accrual completed: awaiting DSMB recommendations
GRAFT-VS-HOST DISEASEProphylaxis: T Cell Depletion
• Decades of failure• Engraftment failure• Prolonged immune incompetence• viral, opportunistic infections
• High relapse rates
VT Ho, RJ Soiffer. Blood 98: 3192-204, 2001.
GRAFT-VS-HOST DISEASEProphylaxis: AML CR1 & T Cell Depletion
S Devine, BMT CTN. Biol Blood Marrow Transplant 17: 1343-51, 2010
• Multi-center BMT CTN trial: CD34 selection, Miltenyi device• Few AML CR2; early follow-up
Grade 3-4 Acute GVHD Chronic
GVHD
GRAFT-VS-HOST DISEASEProphylaxis: AML CR1 & T Cell Depletion
S Devine, BMT CTN. Biol Blood Marrow Transplant 17: 1343-51, 2010
Relapse
No engraftment failures
Survival
AML CR1 ALLOGRAFTS: BMT CTNT Cell Depletion vs Immune Suppression
MC Pasquini, BMT CTN. J Clin Oncol 30: 3194-3201, 2012
GVHD-Free Survival
Survival
N=44 T Cell Depletion; N=88 Immune Suppression
Relapse
GRAFT-VS-HOST DISEASEProphylaxis: Combination
C Cutler, BMT CTN. Blood 120: 2012 (abstract #739).
Myeloablative conditioning: Cy or VP-16 plus TBI > 1200 cGyMobilized blood graft Median (range) age 44 (13-59) yr
Sirolimus/tacrolimus:No advantage in 114-day acute GVHD-free survival• 2 and 3 days faster neutrophil and platelet engraftment• Reduction in acute GVHD
8% absolute II-IV, p = 0.17 7% absolute III-IV, p = 0.05
• More chronic GVHD 9% absolute , p = 0.05
• Less mucositis but more endothelial injury (all p 0.05)Acceptable alternative to tacrolimus/methotrexate
BMT CTN GVHD PROPHYLAXISSirolimus/Tacrolimus vs Tacrolimus/Methotrexate
BMT CTNRegimen-Intensity Questions
Acute Leukemia and MDS
ACUTE MYELOID LEUKEMIA CR1Reduced-Intensity Conditioning in Elderly
ACUTE MYELOID LEUKEMIA CR1Reduced-Intensity Conditioning in Elderly• CALGB & BMT CTN: N=123 @ 21 centers • Median age 65 (60-74) yr• N= 58 matched-related donor; N=65 MUD• 82 intermediate cytogenetics; 25 adverse cytogenetics• Fludarabine + busulfan ± ATG
SM Devine, CALGB, BMT CTN. Blood 120: 2012 (abstract #230).
Event Incidence @ 2 Yr
Treatment-related mortality
14%
Acute GVHD gr 3-4 3.4% @ 100 days
Chronic GVHD 26%Relapse 47%
Overall survival 46%
ACUTE MYELOID LEUKEMIA CR1Prospective Randomized: RIC vs Myeloablative
M Bornhäuser, German AML. Lancet Oncol 13: 1035-1044, 2012.
German AML Study Group: small series
ACUTE MYELOID LEUKEMIA & ALLOGRAFTMyeloablative vs Reduced-Intensity Conditioning
BMT CTN 0901
BMT CTNAlternative Donor Graft Source Questions
No Matched-Related or MUD Available
GRAFT-VS-HOST DISEASEPost-Transplant Cyclophosphamide
L Luznik, Hopkins. Blood 115: 3224-30, 2010.
N=117; Bu/CYT-replete marrowCY 50 mg/kg/d T+3, T+4
Chronic GVHD
Acute GVHD
BMT CTN Protocol 1101
Multi-center, Phase III, Randomized Trial of Reduced Intensity Conditioning and Transplantation
Of Double Unrelated Umbilical Cord Blood versusHLA-Haploidentical Related Bone Marrow for
Patients with Hematologic Malignancies
Followup to 2 independent BMT CTN phase II studies BMT CTN 0603 and 0604
45%31%
54%
CG Brunstein, BMT CTN. Blood 118:282-288, 2011
Patient ≥ 18 and ≤70 yrAcute leukemia or lymphoma
Adequate organ functionPerformance score ≥70
No sibling or matched unrelated donor available, BUT:• Double umbilical cord blood (UCB) graft • Haploidentical related donor marrow (Haplo-BM)• No donor specific anti-HLA-Ab
RandomizationStratified by Transplant Center
Double UCB
Haplo-BM
BMT CTNStudy Design Protocol 1101
BMT CTN Protocol 1101
Minnesota Protocol (0604)
Hopkins Protocol (0603)
Eliminate alloreactive T cells
Haploidentical
BMT CTN Manuscripts in Preparation
0402 – Sirolimus vs methotrexate (in combo with tacrolimus) to prevent acute GVHD : NO BENEFIT
0403 – Etanercept for Idiopathic Pneumonia Syndrome: NO BENEFIT
0501 – Single vs double UCB transplant in children: MORE GVHD with double; NO ADVANTAGE engraftment or survival
0502 – RIC HCT for older AML adults: GOOD RESULTS
0802 – MMF as initial therapy for AGVHD: NO BENEFIT
BMT CTN Future
• Continued accrual enhancement• Continued publications in high-impact journals• Repository trials: GVHD blood biomarkers
BMT CTN Protocol 1202
Prospective Multi-Center Cohort for the Evaluation of Biomarkers Predicting Risk of Complications and Mortality
Following Allogeneic HCT
1,500 allogeneic patients over 4 yr: HCT only @ US centers Samples collected for DNA, RNA, and proteins: R24Building upon University of Michigan data and other sourcesData collection for post-transplant complications
Biomarker Approach Sample No.
PtsPre-
ConditioningPre-HCTDay -1 or
0
Days post-HCT
7±2
14 ± 2
21 ± 2
28 ± 2
42 ± 3
56 ± 3
90±10
GeneticDNA17mL blood
1500 X
ProteomicSerum(10 mL blood)
1500 X X X X X X X X
Gene Expression
PAXgeneLysates-(20 mL blood)
240 X X
Recipient SamplesBMT CTN Protocol 1202
BMT CTN Future (con’t)
• Partnering with other groups:• IFM• Canadians• Germans
• Increased companion translational trials: obesity• 3rd State of the Science Symposium
IFM/DFCI 2009Phase III: Untreated Myeloma
Arm A RVD Cycles 2-3 HD Cytoxan; collect cells RVD Cycles 4-8 Maintenance lenalidomide(Melphalan + HCT @ relapse)
Arm B RVD Cycles 2-3 HD Cytoxan; collect cells HD Melphalan + HCT RVD for 2 more cycles Maintenance Lenalidomide
RANDOMIZE
• Symptomatic myeloma with measurable disease<65 yrs and transplant-eligible; ECOG <2 (KPS ≥60%)
1° Endpoint: PFS
2° Endpoints: relapse, TTP, survival, QOL, economics, genetic prognostic
Initial Therapy
RVD Cycle 1
RVD=lenalidomide; bortezomib; dexamethasone
BMT CTN Future (con’t)
• Partnering with other groups:• IFM• Canadians• Germans
• Increased companion translational trials: obesity• 3rd State of the Science Symposium
Myeloma patients within 9 months of diagnosis
Single autograft +/- consolidation versus tandem autograft and maintenance
N=750 patients (250 each arm)
Uniformity of treatment:
Melphalan 200 mg/m2 IV plus autograft
Accrual nearly reached
COOPERATIVE ONCOLOGY GROUPSObesity and Myeloma: BMT CTN 0702
Myeloma is an obesity-driven disease
Critical questions- What is impact of obesity on treatment and disease?
- If obesity has detrimental effects, what are the mechanisms & how can these be addressed & improved?
- If obesity has beneficial effects, how can these be identified and used to enhance therapeutic outcomes?
COOPERATIVE ONCOLOGY GROUPSCompanion Investigation: Example
OBESITY AND MYELOMA
Limitations of BMI (body mass index) Anthropomorphic measures of abdominal adiposity
correlate with cardiovascular and cancer mortality: independent of BMI
Which anthropomorphic measurements are better? Waist:Hip measure better indicator of visceral fat better correlation with incidence colon & ovarian cancer
C Zhang, et al. Circulation 117: 1658-1667, 2008YC Wang, et al. Obesity 15: 2855-2865, 2007
OBESITY AND MYELOMA
Opportunity to study prospectively other biologic measurements
Identify mechanisms by which obesity impacts therapy
Identify mechanisms by which obesity affects disease progression
Identification of potential markers and mediators to impact disease progression
Companion translational obesity study to transplant trial
Investigators:HM LazarusE CampagnaroNA Berger
Anthropomorphic measures at frequent intervalsAnalysis of prospectively collected/archived blood samples
COOPERATIVE ONCOLOGY GROUPSClinical Investigation: Example
Measure Hip & Waist Circumference
OBESITY AND TRANSPLANTMyeloma: BMT CTN 0702
Waist:Hip measurement
Plasma biomarkersAdipokines/cytokines:• adiponectin, leptin, IL-6, TNF-αHormones: • insulin, C-peptide, pancreatic peptide (PP), peptide YY (PYY)Growth factors: • IGF-1, IGFBP-3
BMT CTN Future (con’t)
• 3rd State of the Science Symposium• February 24-25, 2014 @ Grapevine, TX