‘Milestone' treatment could reshape future leukaemia care

A UK trial has found that a chemotherapy-free approach to treatment may lead to better outcomes for some leukaemia patients, in what scientists are calling a "milestone".
The groundbreaking UK-wide trial could reshape the way the most common form of leukaemia in adults is treated.
Researchers from Leeds assessed whether two targeted cancer drugs could perform better than standard chemotherapy among patients with chronic lymphocytic leukaemia (CLL).
Chronic lymphocytic leukaemia is the most common form of leukaemia in adults, with about 4,000 new cases recorded in the UK every year.
The Flair trial, which took place at 96 cancer centres across the UK, saw 786 people with previously untreated CLL randomly assigned to receive standard chemotherapy; a single targeted drug, ibrutinib, or two targeted drugs taken together, ibrutinib and venetoclax, with treatment guided by personalised blood tests.
Researchers found that after five years, 94 per cent of patients who received ibrutinib plus venetoclax were alive with no disease progression.
This compares with 79 per cent for those on ibrutinib alone and 58 per cent for those on standard chemotherapy, according to the study, which has been published in the New England Journal of Medicine and presented to the European Haematology Association congress in Milan, Italy.
Meanwhile, 66 per cent of patients on the new combination had no detectable cancer in their bone marrow after two years, compared with none of the people who received ibrutinib alone and 48 per cent on chemotherapy.
Ibrutinib is a type of drug known as a cancer growth blocker, which works by stopping signals that cancer cells use to divide and grow, and venetoclax blocks the functions of a protein found in CLL cells.
Experts said that the new treatment regime was also tolerated better than traditional treatments.
Dr Talha Munir, consultant haematologist at Leeds Teaching Hospitals NHS Trust, who led the study, said the Flair trial is a 'milestone'.
'We have shown that a chemotherapy-free approach can be not only more effective but also more tolerable for patients,' she said.
'By tailoring individualised treatment based on how well the cancer responds, we're moving into an era of truly personalised medicine.'
Catherine Whitfield, 63, from Farnley, West Yorkshire, was diagnosed with CLL in 2018 after she noticed symptoms including bleeding gums, constant illness and neck pain.
She signed up for the trial, which was coordinated by the Leeds Cancer Research UK Clinical Trials Unit at the University of Leeds and sponsored by the University of Leeds.
'After three years of treatment, I am still MRD negative – that means no cancer cells,' she said.
'I lost my husband to cancer. I have seen how hard it could be.
'My first thought after my diagnosis was, I will never see my grandchildren being born and growing up.
'Now I have two grandchildren, Drew and Alaia, and they are a delight and highlight the joys of a healthy life'.
Ms Whitfield added: 'The way this trial was explained, it just made sense. Also, the thought of chemotherapy was scary to me. The trial felt right. And it was.'
Many people who have chronic lymphocytic leukaemia do not have any symptoms, but the main ones include:
swollen glands, usually in your neck or under your arms
losing weight
getting ill a lot
feeling tired even though you've had a good night's sleep
a rash that looks like small bruises or bleeding under the skin and does not fade when you roll a glass over it, similar to meningitis
bleeding or bruising for no reason
looking unusually pale and feeling breathless
a high temperature even though you're not unwell
aches and pains that will not go away
sweating at night
Dr Iain Foulkes, executive director of research and innovation at Cancer Research UK, which funded the trial along with AbbVie, and Johnson and Johnson, said: 'The results of the Flair trial show that we can provide kinder, more targeted treatment for chronic lymphocytic leukaemia, which gives people with CLL more precious time with their loved ones.
'We're hopeful that the results of the Flair trial will power new treatment options for leukaemia and other blood cancers, thanks to the efforts of researchers at in Leeds and across the UK working together on this trial.'

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The main value in this research letter was a kick in the butt to go back to the original evidence for this FFR-CT business, the publication of the ADVANCE registry in the European Heart Journal in 2018. First author Fairbairn. This will be a trigger warning because this is one of those things you can't unsee or unhear. ADVANCE registry included about 5000 patients with symptoms concerning for CAD and atherosclerosis on CCTA. The authors recorded the basic info, symptoms, CCTA and FFR-CT findings were recorded along with treatment plans. They also had 90-day outcomes. For each enrolled patient, a clinical management review committee used data from coronary CTA to determine the management plan using the following criteria: (a) optimal medical therapy, (b) percutaneous coronary intervention (PCI), (c) coronary artery bypass graft surgery (CABG), or (d) more information required. The primary endpoint of the registry is the reclassification rate between the management plan based on coronary CTA alone vs CTA plus FFR-CT. Two teams came up with the original plan based only on CTA. A site team and a blinded core team from Duke. The primary endpoint was the reclassification of the treatment plan from the CT-FFR results. The primary results were that it changed management in about two-thirds of the cases. It was hard for me to see a pattern in the reclassification. The authors tell us later that the majority of subjects were safely deferred to medical management alone, and only a minority required 'further testing.' A second finding was that rate of no significant disease at angiography was significantly lower in patients who had a positive FFR < 0.8 (about 15%) vs > 0.8 (44%). Odds ratio for no significant disease was 0.19 for a positive FFR (that is < 0.8) A third finding was that 19 MACE events happened in the 90 days after the study, 10 of them were death, and all happened in the FFR < 0.8 category — 19 vs 0. The authors concluded that FFR-CT was great. It guided management, helped predict no disease, and even had a strong association with MACE events. They noted this: 'FFR-CT led to a recommendation of invasive coronary angiography (ICA) in only 40% of subjects in a cohort with an anatomic obstructive disease rate of 72%, and subjects referred for ICA downstream were significantly more likely to have obstructive disease at ICA if they had a positive FFR-CT.' And this: 'Importantly, a negative FFR-CT was associated with an excellent short-term prognosis, as none of the 1600 subjects with negative FFR-CT experienced death, MI, or unplanned hospitalization for ACS and urgent revascularization.' A colleague in imaging advises me that this was one of the major studies cited to establish FFR-CT. My gosh, this is terrible. What a mess. First of all, the study was sponsored by HeartFlow. It was a late-breaker at ESC in 2018. I must have had jet lag because I missed it. Much of my criticism follows a Twitter thread from my friend Venk Murthy at University of Michigan. A primary endpoint in change in management in a voluntary registry sponsored by the company is about as weak an endpoint as you can get. Why isn't this a measurement of clinical psychology? What if you chose, say, in a non-industry-funded study, a doctor team skeptical of FFR-CT. I bet few would be swayed by the CT-FFR results. Another problem was that most of the FFR-CT values were abnormal in the left anterior descending artery (LAD) and were between 0.7-0.85. We know this from the IQR values. But now I will cite a study from Christopher Cook in Darrell Francis' group published in JAMA Cardiology 2017. 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If we wanted to know about FFR-CT, it's simple: you randomize people to care with the HeartFlow FFR-CT vs those without. Then you measure outcomes — MI, CV deaths, even urgent revascularization. But this was not done. Instead, FDA approves the HeartFlow, proponents and key opinion leaders speak highly of it, these studies are not highly criticized, and CT scans get $1500 added to them. HeartFlow was approved de novo in 2014 but received a 2019 clearance for 'virtual modeling.' When I asked my AI friend Claude to explain the difference between the two designations — 2014 and 2019 — one of the 'significant' points was a business model expansion wherein the original FFR-CT was a one-time diagnostic test, but the 'planner (the virtual modeling) creates additional revenue opportunities for each patient who needs intervention.' And then this: the 2019 decision Expands HeartFlow's market from diagnosis into treatment planning. My AI program Claude must not know I am a critical appraiser because it then wrote: Physicians can now use HeartFlow for the entire patient journey: diagnosis → treatment planning → post-intervention assessment. This creates much stronger physician adoption and stickiness. And it makes the cost–benefit analysis more favorable since one CT scan can support multiple clinical decisions. The 2019 Planner approval was huge for HeartFlow because it transformed them from a diagnostic company into a comprehensive coronary care platform. Instead of just answering "Does this patient need a catheterization?", they can now answer: "Exactly how should we treat this patient's disease?" This is why HeartFlow's valuation and market penetration accelerated significantly after 2019. They weren't just competing with stress tests anymore; they were competing with the entire invasive workup process. I had no idea this stuff was happening. What a tragic waste of money. This may be one of the lowest value medical interventions I have seen. And you think I am wrong to be hopeful about FDA new leadership. Regulators should have required an RCT. Since they did not require and RCT, physicians should. Companies are not nefarious. They simply jump over the bar we hold for them. In this case the bar was ridiculously low. Speaking about lax FDA regulation, JACC has published a sobering research letter on the transcatheter tricuspid valve replacement called the EVOQUE valve. This one is also really scary. On this I hardly need commentary; I can just tell you the data. First author was Lior Lupu. FDA approved the valve in February 2024. This was based on the pivotal TRISCEND II trial, which was driven quality-of-life measures, not hard outcomes, and was not blinded. Thus, placebo effects were surely present. The group of authors from Washington, DC used the MAUDE database at FDA, which stands for Manufacturer and User Facility Device Experience. It contains information about device malfunctions, injuries, and deaths associated with medical devices that have been reported by manufacturers, healthcare facilities, and users. The main weakness of MAUDE is that there is no denominator and it's voluntary. In the year since approval, the research team found 150 reports on EVOQUE that describe 158 events. 1. Bradycardia or high degree atrioventricular (AV) block was most common (n = 70 or 44%) and there were 2 deaths. 66 of the 70 required pacemakers. Most were detected at the implant however a third were seen later between days 3 and 90. 2. Device malposition, migration, or embolization occurred in 33 patients (20.9%), causing 6 deaths. Most events were diagnosed within 3 months: 76% intraprocedurally, 14% within 2 days, and 7% between 3 days and 3 months. Management included transcatheter valve-in-valve implantation in 10 cases (eg, SAPIEN-in-Evoque), with 2 requiring a second valve for optimization. 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To me, this was quite lax regulation. First, there should have been a trial with a sham procedure. Quality-of-life metrics are meaningless when one group gets a procedure and the other group gets bland white tablets. Second, there should have been more patients in the trial. And third, the approval should have been contingent on a required database, such as that with TAVR. This report is really scary given the number of deaths. In fact, mortality from tricuspid valve surgery is the main reason transcatheter techniques were designed. In the transcript, I highlighted in orange font the number of deaths. I counted 14 deaths and 5 cases of ventricular tachycardia/cardiac arrest. Proponents may cite the learning curve, but I doubt it because I read that the company did a slow rollout where centers who were part of the trial were first. And you wonder why I am a medical conservative and slow adopter.

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