Precision Therapy Versus Standard Therapy in AML and MDS in Elderly

Overview

This is a randomized clinical trial that randomizes between treatment principles. The study will investigate if precision therapy determined by a tumour board is better than standard treatment for acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS) in elderly. The tumour board will decide the precision therapy based on identified genetic changes that can guide customized therapy. There are currently 40-50 targeted therapies approved for various cancers in Norway. The precision therapy will be given in addition to the standard treatment. The primary study objective will be to evaluate the cost-effectiveness of a precision therapy strategy compared with standard treatment. Other objectives will mesaure efficacy and satety of the treatment, and impact on life quality of the patients.

Acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS) in the elderly are not curable since elderly patients usually do not tolerate intensive chemotherapy and allogeneic stemcell transplantation. Next generation sequencing (NGS) of DNA can find changes in tumor DNA that can be targeted by new drugs, so called "precision therapy". Precision therapy drugs are usually less toxic than standard treatment, and thus may be particularly well suited for elderly. Precision therapy is principally different from today's standard therapy since it will be individualized based on NGS from the tumor, while in standard therapy all patients receive the same treatment. It is unknown how a precision therapy strategy will perform compared with standard therapy in AML and high-risk MDS in the elderly. A Clinical Tumour Board will decide on the precision therapy. Study design: This is a prospective, open label, single centre, randomized phase II clinical trial. The study randomizes between standard treatment and precision therapy in unfit elderly patients with AML and high-risk MDS. Importantly, this study design is not a randomization between treatments as in a traditional clinical trial, but a randomization between treatment principles. This means that patients in the standard treatment arm will receive the same treatment, while patients in the precision arm will receive different treatments based on the profiling of the tumor cells. Since most of the precision therapies will be experimental, the study is designed so that the patients in both arms receive a period of standard treatment before randomization. This is to reduce the risk of patients not receiving effective treatment, so that the precision therapy can be tested safely. The standard treatment for AML and high-risk MDS in elderly may change during the study, therefore "standard treatment" is defined as the recommended treatment in Norway at any time point. This means that MDS patients and AML patients may have different standard therapy. Diagnostic sampling and genomic profiling will be done on the bone marrow of all included patients before start of treatment and compared with germline DNA from buccal swab taken at the bone-marrow. Treatment with hydroxyurea prior to the initial standard treatment is allowed to get leukocytes below 30. While the patient receive two initial 28 day cycles of standard treatment, NGS of the bone marrow samples are done and assessed in the diagnostic pipeline, followed by bioinformatics analysis. The information is then interpreted by a Clinical Tumour Board consisting of pathologists, haematologists, oncologists, molecular biologists and bioinformatician, the treating hematologist and study nurse. The Clinical Tumour Board makes the decision on targeted treatment. After initial standard therapy bone marrow samples will be evaluated for response to treatment. Patients with progressive disease as defined by the European Leukemia Net will go out of the study and receive treatment according to investigators choice. Notably, the results from the Clinical Tumour Board will be available for these patients to provide best possible treatment. Patients without disease progression are randomized in a stratified manner 2:1 after the initial treatment with standard therapy to either precision therapy advised by the Clinical Tumour Board or continuous standard therapy.