Efficacy of azacitidine compared with that of conventional care regimens in the treatment of higher-risk myelodysplastic syndromes: a randomised, open-label, phase III study
Open accessAbstract
Background Drug treatments for patients with high-risk myelodysplastic syndromes provide no survival advantage. In this trial, we aimed to assess the effect of azacitidine on overall survival compared with the three commonest conventional care regimens.Methods In a phase III, international, multicentre, controlled, parallel-group, open-label trial, patients with higher-risk myelodysplastic syndromes were randomly assigned one-to-one to receive azacitidine (75 mg/m(2) per day for 7 days every 28 days) or conventional care (best supportive care, low-dose cytarabine, or intensive chemotherapy as selected by investigators before randomisation). Patients were stratified by French-American-British and international prognostic scoring system classifications; randomisation was done with a block size of four. The primary endpoint was overall survival. Efficacy analyses were by intention to treat for all patients assigned to receive treatment. This study is registered with ClinicalTrials.gov, number NCT00071799.Findings Between Feb 13, 2004, and Aug 7, 2006, 358 patients were randomly assigned to receive azacitidine (n=179) or conventional care regimens (n=179). Four patients in the azacitidine and 14 in the conventional care groups received no study drugs but were included in the intention-to-treat efficacy analysis. After a median follow-up of 21.1 months (IQR 15.1-26.9), median overall survival was 24.5 months (9.9-not reached) for the azacitidine group versus 15.0 months (5.6-24.1) for the conventional care group (hazard ratio 0.58; 95% CI 0.43-0.77; stratified log-rank p=0.0001). At last follow-up, 82 patients in the azacitidine group had died compared with 113 in the conventional care group. At 2 years, on the basis of Kaplan-Meier estimates, 50.8% (95% CI 42.1-58.8) of patients in the azacitidine group were alive compared with 26.2% (18.7-34.3) in the conventional care group (p<0.0001). Peripheral cytopenias were the most common grade 3-4 adverse events for all treatments.Interpretation Treatment with azacitidine increases overall survival in patients with higher-risk myelodysplastic syndromes relative to conventional care.
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Hypomethylating agents such as azacitidine and decitabine yield complete remission rates of approximately 15%-20% in patients with either TP53-mutant or wild-type MDS.
“Hypomethylating agents (HMAs), such as azacitidine and decitabine, yield statistically similar complete remission (CR) rates of approximately 15%-20% in patients with either TP53-mutant or wild-type MDS.12-14”
From Eprenetapopt (APR-246) and Azacitidine in <i>TP53</i> -Mutant Myelodysplastic Syndromes (2021) · cites this paper as [14]
The Results (page not provided) report complete remissions with azacitidine in patients with higher-risk MDS. The cited paper does not report remission rates by TP53 mutation status or test whether those rates are statistically similar; its trial did not include decitabine. The available Results passage also does not give a 15%–20% complete-remission rate. (LLM, conf=0.83)
Experimental — accuracy not yet measuredAdverse events with eprenetapopt plus azacitidine were similar to those reported for azacitidine or eprenetapopt monotherapy.
“Adverse events were similar to those reported for azacitidine or eprenetapopt monotherapy, with the most common grade ≥ 3 adverse events being febrile neutropenia (33%), leukopenia (29%), and neutropenia (29%).”
From Eprenetapopt (APR-246) and Azacitidine in <i>TP53</i> -Mutant Myelodysplastic Syndromes (2021) · cites this paper as [14]
The Results (page unavailable) report adverse events in patients receiving azacitidine alone, including grade 3–4 peripheral blood cytopenias. The paper compares azacitidine with conventional care, not with eprenetapopt or the combination, so it cannot establish the claimed similarity between their adverse-event profiles. (LLM, conf=0.85)
Experimental — accuracy not yet measuredResponse rates of up to 60% to azacytidine have been reported in MDS.
“Whilst response rates of up to 60% to azacytidine have been reported in MDS 125,129 ,”
From The roles of DNA, RNA and histone methylation in ageing and cancer (2019) · cites this paper as [129]
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Self-citationOutcome of High-Risk Myelodysplastic Syndrome After Azacitidine Treatment Failure
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“This raises interesting issues regarding possible effects of AZA, including, as suggested by others, a possible modification of the MDS natural history.(11,24) A variety of salvage regimens were administered to patients in the current cohort, although information regarding salvage treatment was missing for many of the…”
BackgroundResultSelf-citationEprenetapopt (APR-246) and Azacitidine in <i>TP53</i> -Mutant Myelodysplastic Syndromes
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“PRD (63-97) DBD (102-292) TET (323-356) REG (363-393) TAD2 (43-62) TAD1 (1-42) CR mCR + HI mCR HI SD PD NR/NE”
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Self-citationThe mutational landscape of adenoid cystic carcinoma
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BackgroundMethodInfluentialHealthy Effects of Plant Polyphenols: Molecular Mechanisms
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BackgroundInfluentialTargeting epigenetic modifications in cancer therapy: erasing the roadmap to cancer
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BackgroundSelf-citationA Comparison of Azacitidine and Decitabine Activities in Acute Myeloid Leukemia Cell Lines
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“4 months) compared with conventional care regimens [14], DAC did not demonstrate a statistically significant improvement in survival in a similar clinical trial [15].”
ResultEpigenetics-targeted drugs: current paradigms and future challenges
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BackgroundMDS and secondary AML display unique patterns and abundance of aberrant DNA methylation
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Self-citationDeregulated gene expression pathways in myelodysplastic syndrome hematopoietic stem cells
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“TAD1 (1-42) TAD2 (43-62) PRD (63-97) DBD (102-292) TET (323-356) REG (363-393)”
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“1;q22), CBFB- MYH11”; “acute myeloid leukemia with minimal differentiation”; “acute myeloid leukemia without maturation”; “acute myeloid leukemia with maturation”; “acute monoblastic and monocytic leukemia”; “acute myeloid leukemia with myelodysplasia- related changes”; “acute myeloid leukemia, t(8;21)(q22;q22) RUNX1-…”
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The Role of DNA Methylation in Cancer
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Diagnosis and Treatment of Myelodysplastic Syndromes
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Epigenetics and cancer treatment
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“5-azacitidine has been studied in higher-risk MDS in two major randomized multicenter trials: CALGB 9221(136) and AZA-001.(86) In the CALGB 9221(136) study, 191 patients with MDS were randomized between 5-azacitidine (75 mg/m(2)/day for 7 consecutive days every 28 days) and best supportive care (BSC).”
BackgroundResultInfluentialOncometabolites in renal cancer
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Germline DDX41 mutations define a significant entity within adult MDS/AML patients
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Self-citationMyelodysplastic syndromes: 2018 update on diagnosis, risk‐stratification and management
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“Blum et al have indicated that a 10-day schedule of decitabine has significant activity in AML.120 Similar results have been reported by other groups in recent years.18 5-azacitidine has been studied in higher-risk MDS in two major randomized multicenter trials: CALGB 9221121 and AZA-001.”
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DNA methyltransferase expression in triple-negative breast cancer predicts sensitivity to decitabine
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“5-Aza-2 ′ -deoxycytidine (decitabine) is a demethylating agent that is approved by many international regulatory agencies, including the US FDA and the European Commission (EC), for treating hematological malignancies (8–10) and that has become a standard of care for patients with higher risk myelodysplastic syndrome…”
InfluentialBraun, T., Itzykson, R., Renneville, A., Renzis, B. D., Dreyfus, F., Laribi, K., Bouabdallah, K. K., Vey, N., Toma, A., Récher, C., et al. (2011) · Blood · doi:10.1182/blood-2011-05-352039 · Cited by 201 · see citing works
“Median platelet number, g/L (range) 81 (12-560)”
Self-citationTherapeutic targeting of tumor suppressor genes
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“The ribonucleoside azacitidine is an analogue of cytosine, which is important for DNA and RNA synthesis [55].”
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Incidence, survival and prevalence of myeloid malignancies in Europe
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“The international phase 3 trial AZA-001 established that the cytidine nucleoside analog azacitidine significantly prolonged median overall survival by >9 months and significantly delayed median time to AML transformation by >6 months compared with conventional care regimens.(3) Azacitidine was also associated with sig…”
MethodResultInfluentialSelf-citationTiu, R. V., Gondek, L. P., O’Keefe, C. L., Elson, P. J., Huh, J., Mohamedali, A. M., Kulasekararaj, A. G., Advani, A. S., PAQUETTE, R. L., List, A. F., et al. (2011) · Blood · doi:10.1182/blood-2010-07-295857 · Cited by 194 · see citing works
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- Authors
- Fenaux, P., Mufti, G. J., Hellstrom-Lindberg, E., Santini, V., Finelli, C., Giagounidis, A., Schoch, R., Gattermann, N., Sanz, G., List, A., Gore, S. D., Seymour, J. F., Bennett, J. M., Byrd, J., Backstrom, J., Zimmerman, L., McKenzie, D., Beach, C., & Silverman, L. R.
- Affiliations
- Université Sorbonne Paris Nord (FR)
- King's College Hospital (GB)
- Azienda Ospedaliero-Universitaria Careggi (IT)
- University Hospital Schleswig-Holstein (DE)
- Düsseldorf University Hospital (DE)
- Hospital Universitari i Politècnic La Fe (ES)
- Moffitt Cancer Center (US)
- Johns Hopkins University (US)
- Karolinska University Hospital (SE)
- University of Rochester Medicine (US)
- The Ohio State University (US)
- Celgene (United States) (US)
- Icahn School of Medicine at Mount Sinai (US)
- Corresponding author
- Fenaux, Pierre
- ORCID
- Venue
- The Lancet Oncology
- Publisher
- Elsevier BV
- Published
- 2009-03
- Volume
- 10
- Issue
- 3
- Pages
- 223-232
- ISSN
- 1470-2045 (ISSN-L)
- PMC
- PMC4086808
- OpenAlex
- W2118771330
- Cited by
- 2,663
- References
- 45
- Citations by year
- 2026: 80 · 2025: 99 · 2024: 103 · 2023: 153 · 2022: 149 · 2021: 182 · 2020: 148 · 2019: 149 · 2018: 132 · 2017: 164 · 2016: 178 · 2015: 173 · 2014: 201 · 2013: 182 · 2012: 178
- FWCI
- 124.66
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- The Lancet Oncology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Florence Research (University of Florence) (submittedVersion)
- IRIS UNIMORE (University of Modena and Reggio Emilia) (submittedVersion, cc-by)
- Research Portal (King's College London) (submittedVersion)
- Funders
- Celgene
- National Cancer Institute (K24CA111717)
- Topics
- Health Sciences › Medicine › Hematology › Acute Myeloid Leukemia Research
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Retinoids in leukemia and cellular processes
- Health Sciences › Medicine › Hematology › Hematopoietic Stem Cell Transplantation
- Keywords
- azacitidine, myelodysplastic syndrome, high-risk myelodysplastic syndrome, overall survival, low-dose cytarabine, intensive chemotherapy, best supportive care, hypomethylating agents, treatment efficacy comparison, hematologic malignancies
- MeSH terms
- Adult, Aged, Aged, 80 and over, Antimetabolites, Antineoplastic, Azacitidine, Female, Humans, Male, Middle Aged, Myelodysplastic Syndromes, Proportional Hazards Models
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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