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Journal of Clinical Oncology, Vol 20, Issue 10 (May), 2002: 2429-2440
© 2002 American Society for Clinical Oncology

Randomized Controlled Trial of Azacitidine in Patients With the Myelodysplastic Syndrome: A Study of the Cancer and Leukemia Group B

By Lewis R. Silverman, Erin P. Demakos, Bercedis L. Peterson, Alice B. Kornblith, Jimmie C. Holland, Rosalie Odchimar-Reissig, Richard M. Stone, Douglas Nelson, Bayard L. Powell, Carlos M. DeCastro, John Ellerton, Richard A. Larson, Charles A. Schiffer, James F. Holland

From the Mount Sinai School of Medicine and Memorial Sloan-Kettering Cancer Center, New York, and State University of New York School of Medicine at Syracuse, Syracuse, NY; Cancer and Leukemia Group B, Statistical Center, Duke University Medical Center, Durham, and Wake Forest University Bowman Gray School of Medicine, Winston-Salem, NC; Dana-Farber Cancer Institute, Boston, MA; University Medical Center–S. Nevada Community Clinical Oncology Program, Las Vegas, NV; University of Chicago, Chicago, IL; and Wayne State University, Detroit, MI.

Address reprint requests to Lewis R. Silverman, MD, Mount Sinai Medical Center, Division of Medical Oncology, Box 1129, One Gustave L. Levy Place, New York, NY 10029; email: lewis.silverman{at}mssm.edu

PURPOSE: Patients with high-risk myelodysplastic syndrome (MDS) have high mortality from bone marrow failure or transformation to acute leukemia. Supportive care is standard therapy. We previously reported that azacitidine (Aza C) was active in patients with high-risk MDS.

PATIENTS AND METHODS: A randomized controlled trial was undertaken in 191 patients with MDS to compare Aza C (75 mg/m2/d subcutaneously for 7 days every 28 days) with supportive care. MDS was defined by French-American-British criteria. New rigorous response criteria were applied. Both arms received transfusions and antibiotics as required. Patients in the supportive care arm whose disease worsened were permitted to cross over to Aza C.

RESULTS: Responses occurred in 60% of patients on the Aza C arm (7% complete response, 16% partial response, 37% improved) compared with 5% (improved) receiving supportive care (P < .001). Median time to leukemic transformation or death was 21 months for Aza C versus 13 months for supportive care (P = .007). Transformation to acute myelogenous leukemia occurred as the first event in 15% of patients on the Aza C arm and in 38% receiving supportive care (P = .001). Eliminating the confounding effect of early cross-over to Aza C, a landmark analysis after 6 months showed median survival of an additional 18 months for Aza C and 11 months for supportive care (P = .03). Quality-of-life assessment found significant major advantages in physical function, symptoms, and psychological state for patients initially randomized to Aza C.

CONCLUSION: Aza C treatment results in significantly higher response rates, improved quality of life, reduced risk of leukemic transformation, and improved survival compared with supportive care. Aza C provides a new treatment option that is superior to supportive care for patients with the MDS subtypes and specific entry criteria treated in this study.




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