Nicole Lamanna, M.D., provides insight on how the management of chronic lymphocytic leukemia (CLL) might progress as new therapeutic agents are introduced or matched together.
PUBLISHED December 27, 2018
Nicole Lamanna, M.D.: With many of these new therapies that have become available for patients with CLL, one of the questions that many of you may ask or read about is, how well do these new therapies work for my disease? This is very interesting. If you look at responses to ibrutinib, you can have somebody who’s been on ibrutinib for years. But if you test their bone marrow, they still have disease. Technically they’re not in a complete remission because there’s still evidence of the CLL in their bone marrow. But their numbers may be great, they may have no more lymph nodes, and they’re doing fine. There’s nothing wrong with that.
As we are looking at some of these newer therapies, though—for example, venetoclax, which is a BCL2 [B cell leukemia 2] inhibitor—we know that with that drug we can eradicate or get rid of your disease and your bone marrow a little bit better than if you’re on ibrutinib as a single agent. And so we can mop out the bone marrow and individuals can achieve a complete remission, at least at a higher frequency than patients who are on ibrutinib monotherapy. So in other words, ibrutinib has lower complete remissions than venetoclax. Does that mean it’s a worse drug? We don’t know that because patients are doing well for years, and it has transformed and improved survival.
But when we talk about drugs like venetoclax, what we’re looking at is can we combine venetoclax with drugs like ibrutinib or with other drugs? Can we get individuals off these oral therapies? So we were talking about taking ibrutinib indefinitely until you have a side effect or your disease progresses. With some newer agents or combinations of these agents can we get individuals off the pills so they don’t have to take them indefinitely.
That’s where we’re using this detection: They call it minimal residual disease and are looking at finer levels of leukemia cells that might be floating around in your body. Can we use the detection of how much leukemia is in your body as a way to stop these therapies? And so this is where the field will be moving toward. So for those of you who are taking some of these therapies right now, you might now be taking them indefinitely. But our goal is to see whether or not we can look at truncating or fixing the duration of your therapies so that you can get a break, as long as it works and you have a nice response to therapy. So I think the field will be moving forward in that direction.
This is an exciting time for patients with CLL. I think for individuals listening to this, it is a hopeful time. There are many active therapies available now. We’re looking at ways to make them better, safer, less costly I hope, and less toxic. And hopefully more limited as well. So the field is really drastically moving forward at such [a] heightened pace compared with the days of chemoimmunotherapy. I think you all have a lot of reasons for hope. Keep the dialogue open with your physicians. If you have questions, ask your physicians. If your physicians can’t answer them, there are others who can. Seek comfort. For those of you who like to get involved in patient advocacy groups, or at least reading, there are many groups available to patients. There are many support groups available to patients with CLL. So take advantage of that. Or for the caregivers of patients with CLL, I think that’s very important as well. But you have many reasons to hope and many things to look forward to.