In the setting of relapsed chronic lymphocytic leukemia, Nicole Lamanna, M.D., considers the patient and disease factors that affect her selection of therapy.
PUBLISHED December 27, 2018
Nicole Lamanna, M.D.: If somebody has received therapy for their CLL [chronic lymphocytic leukemia] and their disease comes back, what happens at that point in time? And there are many things that your doctor has to take into consideration. You should be retested for your chromosomal abnormalities. So if you had no abnormalities or you started off as having a deletion 13q, which is a favorable thing, but then you’ve gotten some form of therapy and you relapse again, it’s important to retest that at that time. And the reason being is because it is not uncommon for patients, when they relapse time and time again, to eventually acquire other chromosomal abnormalities.
So there are other adverse features that you might not have presented with initially, and the doctor may choose therapies that might be more beneficial for you depending upon that. And it also tells the doctor something about the kinetics of your disease. So if you acquire a 17p or a p53 abnormality at that time, then for sure the doctor is going to be choosing something that’s a novel agent. If you had already gotten ibrutinib, then they’re likely going to go to venetoclax or a venetoclax combination. So it really does depend. So it’s important for you to have retesting done at the time that you need treatment again. And so that’s, I think, a very important part of this.
Now, how long then will that next therapy last? And that does partly depend on a lot of different things. So one is your first-line therapy, how long did that work for? For some individuals, if that worked for years, then the likelihood is a subsequent line of therapy may also work for years. However, what if the kinetics of your disease have changed and now you acquired some of these aggressive features? That’s different. So in part, how long the next line of therapy works does depend a little bit on how your disease might have changed and what your response was to whatever frontline therapy you might have gotten. And so we always have to consider those conversations when a patient is relapsed. We’re considering both as your physician and trying to figure out what the best therapy is, depending upon your disease at the present time and what you responded to initially and for how long. And that helps in the selection process as well.
Of course, in addition you might be older and have more medical problems, and we have to take that into consideration too. You might be on many more medications than when you started five, 10 years ago. And so those are in consideration when we talk about different therapies and options for therapies as well. So all of that will be a part of the discussion when you’re then talking about your second-line treatment or your third-line treatment.
Similarly, when we talk about subsequent therapies for folks with CLL when they re-present with disease, we’re thinking about, how fit are you now? What are your comorbidities? These things affect your performance status, and some of that may play a role in the type of therapy that your physician may choose for you at that point, depending upon what other medicines you’re on, what you are able to take, and if are there any drug-drug interactions among these medications. And so that will all play a role as well in addition to what your disease is doing or how the features of your disease may have changed as well. And so your doctor has to take all this into consideration when choosing a future treatment option.