CLL Care: Does FCR Still Have a Role? | Transcript | Chronic Lymphocytic Leukemia | Patient Power


CLL Care: Does FCR Still Have a Role?

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Andrew Schorr:          

Help us understand – FCR has been used for years. I was 45, which in CLL, is actually seen as younger. I was fit. I didn’t have diabetes or a heart condition or anything else. Is FCR still used? That’s two chemotherapy drugs combined with what we’ll learn about monoclonal antibodies. Is it still used? 

Dr. Sharman:              

So, I said 2014 represents the olden days and everything in front of 2014, the new days. If you were gonna label the next important year, it would be 2018 was clash of the titans. The reason I picked that is because at our annual meeting for hematology this year, we had a bunch of data sets that were really goose bump-type data sets where the new was directly compared to the old. 

I would say the field is moving rapidly away from chemotherapy. I will say chemotherapy still fulfills a role, although I’ve been a part of debates where even very seasoned experts in the field debate this. There are some key opinion leaders who feel very passionately that chemotherapy shouldn’t be used anymore and there are also key opinion leaders who feel there is a defined role in space for chemotherapy. 

So, amongst the experts, there’s debate. This list of trials that the young, fit, IgHV mutated, if there’s a place for chemo-immunotherapy, that’s probably the most pertinent place, but literally, this week a new regimen was approved with these combinations that you could argue might displace some of that. So, a very dynamic environment. 

Andrew Schorr:          

And the big news was that people could have ibrutinib as a first line therapy versus FCR or another chemo-immunotherapy regimen, bendamustine (Bendeka) plus rituximab (Rituxan) and it was just as good, right? 

Dr. Sharman:              

Yeah. There were two major studies that were presented at the American Society of Hematology, a third study maybe under that, and then a fourth one that should have been presented but we just got the abstract for ASCO this week and FDA approval this week that should have been at ASH. 

 The two big studies were ibrutinib versus bendamustine-rituximab and ibrutinib versus FCR. Now, we’ll leave the discussion about Rituxan for a different point. But amongst the patients who have unmutated CLL, it really does appear that the ibrutinib in that setting is a more safe and efficacious choice. For those patients who are mutated, they’re generally gonna get more bang for their buck out of chemo-immunotherapy.

 So, with ibrutinib (Imbruvica) being an indefinite therapy with a cost that is—we’re gonna have a discussion later today on financial toxicity and goals of therapy. So, as we talk about potentially being on a long-term oral medication versus short-term chemo-immunotherapy, that debate, I think, is far more relevant and pertinent in the patients who are mutated than in the patients who are unmutated. 

 So, FCR is a bigger bang for your buck, higher toxicity, higher risk, but higher reward. Bendamustine-rituximab tends to be easier on patients, although I wouldn’t say easy. What I like to do is address the patients’ goals and say, “Here are your choices. Which of these makes most sense in your life? Let’s work through this together.”

Andrew Schorr:          

Okay. Dr. Menashe, one of the drugs mentioned there is chlorambucil or Leukeran. It’s been around like 40 years. Probably you’ve known it through your practice many years. Is it still used? You have more powerful medicines now. 

Dr. Menashe:              

It has a small niche, I would say. There are people, for a variety of reasons, who don’t fit into really any of these categories. They might be extremely elderly and you’re trying to palliate some symptoms and sometimes you can do that with Leukeran Chlorambucil as a single agent. There’s also some data in people who are older, 65 or older, with the obintuzumab (Gazyva), which people have used. 

Andrew Schorr:          

That’s obinutuzumab.  

Dr. Menashe:

Especially with Leukeran, although I think it’s a rare scenario to include that in the discussion. 

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 August 20, 2019