Understanding Chronic Lymphocytic Leukemia

Transcript:

Kristie L. Kahl: Should patients be getting retested if or when their disease recurs?

Dr. Susan O’Brien: There are some tests that we should be repeating anytime we’re considering a new treatment, that includes the FISH test which looks at chromosomal abnormalities inside the CLL cell as well as an important protein abnormality called the p53 mutation. A p53 mutation is a gene that can be mutated and the reason it’s super important to know about these chromosomes and the p53 status is that those patients should never receive chemo or chemo-immunotherapy because they don’t respond very well to it. But even with the small molecule therapies that we have nowadays, patients with those abnormalities can do better on one drug than another. So in other words, it’s important to know that because it may affect the physician’s choice of treatment.

Kristie L. Kahl: Outside of testing, are there other factors that should be considered when it comes to determining the next line of treatment?

Dr. Susan O’Brien: When you have treatment options, which we do nowadays, you want to look at the side effect profile. If you have a patient who has a history of atrial fibrillation or an irregular heart rate…maybe in that patient you want to go towards one of the other drugs. (Venclexta [venetoclax]) can cause tumor lysis so someone with a high-volume disease maybe you would be a little bit more cautious about using that. So you want to look at the side effect profile.

The other thing that’s important is that for some of these small molecules, the length of time that the patient is on the drug is different. So what do I mean by that? With (Imbruvica [ibrutinib]) or (Calquence [acalabrutinib]), the drug is given indefinitely. So once the patient starts on it they just continue on it unless they have a side effect which makes them stop or unless x number of years later the disease starts to come back and is then resistant to the drug. With venetoclax-based therapy, the regimen that’s approved for relapse is venetoclax with the antibody (Rituxan [rituximab]) and that’s a time limited therapy. So the rituximab is given for the first six months only and then the venetoclax is given daily for two years. So that treatment actually stops at two years and that may or may not be important to the patient if they have a time-limited therapy and that may or may not be important to the patient in terms of whether continuous therapy is a problem or time limit is more attractive.

We all know that in the states with oral agents there are copays and so in some senses having a limited time duration might be attractive. On the other hand, there are some patients who say well wait a minute if I’m responding to the drug you’re going to stop it anyway and they don’t like that idea so they actually would prefer to have an indefinite therapy as long as they’re tolerating it and it’s working.

So, I think you have to look at the side effect profiles of the drugs, that they’re different durations of time and then what the patient preferences might be or what’s most important to them.