Background : Ibr is an established standard of care in CLL and is the only once-daily Bruton tyrosinekinase inhibitor with significant overall survival benefit in randomized phase 3 studies in first-line CLL(RESONATE-2; ECOG1912). The synergistic combination of Ibr + Ven (oral inhibitor of BCL2) hasbeen shown to mobilize and clear CLL cells from multiple disease compartments leading to deepresponses, providing a rationale to evaluate time-limited treatment (Jain et al. NEJM 2019). CAPTIVATE(PCYC-1142) is a multicenter phase 2 study (NCT02910583) of first-line Ibr + Ven with 2 cohorts: MinimalResidual Disease (MRD) and Fixed-Duration (FD). For both cohorts, patients (pts) received 3 cyclesof Ibr lead-in followed by 12 cycles of combined Ibr + Ven. Pts in the MRD cohort were randomized byMRD status to placebo or further treatment. In the pre-randomization phase of the MRD cohort, Ibr +Ven resulted in high rates of undetectable MRD (uMRD) in both peripheral blood (PB; 75%) and bonemarrow (BM; 72%), with concordant uMRD results in 93% of pts with matched samples (Tam, ASH 2019).We present primary results from the MRD-guided randomization phase of the MRD cohort, evaluatingwhether this regimen allows for treatment-free remission in the setting of uMRD.Methods : Pts <70 years with previously untreated CLL/SLL requiring therapy received 3 cycles of Ibrlead-in followed by 12 cycles of Ibr + Ven (Ibr 420 mg/day PO; Ven ramp-up to 400 mg/day PO). Pts withConfirmed uMRD (defined as uMRD serially over ≥3 cycles, and in both PB and BM) after 12 cycles ofIbr + Ven were randomized 1:1 to receive double-blind treatment with placebo or Ibr; pts who did notmeet the definition of Confirmed uMRD were randomized 1:1 to receive open-label treatment with Ibror continued Ibr + Ven. Primary endpoint was 1-year DFS rate in the Confirmed uMRD pts randomizedto placebo vs Ibr; DFS was defined as survival without progression or MRD relapse. Key secondaryendpoints were rates of uMRD (<10-4 by 8-color flow cytometry), response per iwCLL, progression-freesurvival (PFS), and adverse events (AEs).Results : 164 pts were enrolled in the MRD cohort. Median age was 58 years (range, 28-69); baselinehigh-risk features included del(17p) in 16% and del(11q) in 17%; del(17p) or TP53 mutation in 20%;complex karyotype in 19%; and unmutated IGHV in 60%. Median time on study was 31.3 mo (range,15.0-41.0). 90% of pts completed planned treatment with 3 cycles of Ibr lead-in followed by 12 cyclesof combined Ibr + Ven. Of 149 randomized patients, 86 (58%) with Confirmed uMRD (100% uMRDin PB and BM) were randomized to placebo (n=43) or Ibr (n=43). 63 of 149 pts (42%) did not achieveConfirmed uMRD as defined above and were randomized to Ibr (n=31) or Ibr + Ven (n=32); uMRDrates at randomization in this group were 48% in PB and 32% in BM. In the Confirmed uMRD group, 1-year DFS rate was not significantly different for pts randomized to placebo (95.3%; 95% CI 82.7-98.8)versus Ibr (100%; 95% CI 100-100) (P=0.1475; Figure). In the group without Confirmed uMRD who were
randomized to continue Ibr or Ibr + Ven, uMRD rates improved to 57% in PB and 54% in BM during theoverall study period. 30-mo PFS rates were >95% across all randomized arms (Table). Full results ofendpoints by randomized arms will be presented. The median duration of treatment was 28.6 mo (range,0.5-39.8) with Ibr and 12.0 mo (range, 0.8-34.1) with Ven. AEs were primarily grade 1/2 and mostlyoccurred in early cycles of Ibr + Ven, with modest differences by randomized treatment arm. During theoverall study period across all-treated pts (with median treatment duration 29 mo), most common grade3/4 AEs (≥5% of pts) were neutropenia (36%), hypertension (10%), thrombocytopenia (5%), and diarrhea(5%).Conclusions : First-line Ibr + Ven treatment is an all-oral, once-daily, chemotherapy-free regimen thatconfers high rates of PB and BM uMRD in pts with CLL, and a 90% reduction in high-risk TLS monitoring(Siddiqi, EHA 2020). The 1-year DFS in pts randomized to placebo after Ibr + Ven combination wassimilar to that of pts continuing Ibr, supporting a fixed-duration treatment that offers treatment-freeremissions in pts with CLL/SLL. The depth of response achieved with this regimen is reflected in the 30-
mo PFS rate of ~95% across all treated pts. The safety profile of Ibr + Ven was consistent with knownAEs for Ibr and Ven, and no new safety signals emerged.
- first-line treatment
- chronic lymphocytic leukemia (CLL)
- small lymphocytic lymphoma (SLL)
- Disease-Free Survival (DFS)
- Tyrosine kinase inhibitor