Clinical Data Update: The Transitioning Role of Chemoimmunotherapy in CLL Care

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Topics include: Treatment

Is chemotherapy being cut from the frontline? As part of our 2018 American Society of Hematology (ASH) coverage in San Diego, CA, chronic lymphocytic leukemia (CLL) experts Dr. Nicole Lamanna, from Columbia University Medical Center, and Dr. Jeff Sharman, from The US Oncology Network, share updates on frontline and retreatment research. The panel also discusses the role of chemo in CLL care and how mutational status can influence treatment decisions.

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Transcript

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Esther Schorr:          

What we really want to know is what has got you guys excited about what you're hearing at ASH this year, especially versus last year, because there were some cool things last year as well? What's the update?

Dr. Lamanna:           

Well, there are lots of updates. I think for a highlight probably not very new news for folks who do CLL but finally some presentations comparing chemoimmunotherapy to ibrutinib (Imbruvica). And, again, not surprising to some of us but obviously the data really finally highlighting randomized data, large sets of patients looking at chemoimmunotherapy versus an ibrutinib or ibrutinib and rituximab (Rituxan), again, highlighting the importance of ibrutinib as front line therapy. And so I think as a major take-home I think we're gonna be for the majority seeing probably less chemoimmunotherapy, although there are subsets that I think it's certainly still relevant for, but I think these were nice, randomized studies really highlighting the impact of Ibrutinib as frontline therapy, whether you're old or young and whether you have high-risk features or not.

Esther Schorr:          

So, cutting out chemotherapy as a frontline?

Dr. Lamanna:           

For the majority. I think there are still a subset of patients, if they have favorable disease characteristics, they're mutated, I think chemoimmunotherapy is still a relevant conversation for that subset of patients. But I really think that finally this is the data that many oncologists were looking for is just randomized data showing is this better than chemoimmunotherapy, that unanswered question for years, even if we were adopting it differently in different practices? This really was finally data that was put out there.

Andrew Schorr:       

Let's just be a little more specific. Patients for years have heard about FCR or BR, so being cyclophosphamide and rituximab. That's that chemo.

Dr. Lamanna:           

One chemoimmunotherapy.

Andrew Schorr:       

Another one would be bendamustine (Treanda) and rituximab. Okay, so that's FCR or BR. Are you saying now we're talking about IR for example?

Dr. Lamanna:           

If you look at the data a little bit more closely, the question of whether or not monoclonal antibodies such as rituximab adds a significant impact to ibrutinib therapy. And so I think that many of us feel that adding rituximab to ibrutinib may not add that much. And so some of these randomized studies that looked at bendamustine-rituximab versus ibrutinib versus ibrutinib-rituximab that there was really no different between the ibrutinib and the ibrutinib-rituximab arms. I think that many of us don't feel that you necessarily need the rituximab as part of ibrutinib therapy. They were both equally efficacious.

Lee Swanson:           

You know going into FCR it's a six-month regimen, and you're out. If you're on ibrutinib now instead frontline, are you there forever?

Dr. Lamanna:           

I think that there are obviously many questions this raises. Obviously, we're gonna talk a little bit more about indefinite therapy versus not. I think what Jeff and I are really just saying is this is at least the first real randomized data showing the importance of a BTK inhibitor or ibrutinib in this case versus chemoimmunotherapy. So, when we look at these therapies, obviously, like Jeff said, there was a lot of data and presentations that made this year extremely exciting for CLL at ASH like it did many years ago when ibrutinib first got approved. So, we have, obviously, a lot of exciting combinations and things that are going on, but at least this was some maturity of data that we had of ibrutinib versus chemoimmunotherapy.

Will that stay that way? No, I don't necessarily think it will, but at least I think it solidifies that the novel agents, there are better responses. And chemoimmunotherapy is fading a little bit more in the background with maybe some very select groups. What Jeff was highlighting about the mutational status is very important for patients to know, because I think many of us had already felt that data participating in these clinical trials that those individuals really shouldn't be treated with just chemoimmunotherapy that the un-mutated IgVH patients really should be treated with novel agents. And so that's very an important take-home point.

Dr. Sharman:

There's a very simple point I want to make that I think would be useful. I cannot as of today envision a situation where a patient who's previously had chemotherapy would be appropriate for retreatment with chemotherapy.

Andrew Schorr:       

And that's changed.

Dr. Sharman:

That's a change. For the people who are listening, if somebody's saying, yeah, we gave you FCR before, we're gonna give you BR, that to me would be a red flag just in very simple terms. Do you agree with that, Nicole?

Dr. Lamanna:           

Are you putting me on the spot?

Dr. Sharman:

I'm putting you on the spot.

Dr. Lamanna:           

I'm just kidding. Yeah. I think that's a fair statement.

Esther Schorr:          

The chemo wouldn't be used twice in all these.

Dr. Sharman:

No.

Dr. Lamanna:           

We did do that years ago, but we didn't have anything else. It's changing.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on March 20, 2019