Nicole Lamanna, M.D.: The initial therapy for patients with CLL has evolved quite dramatically. I think patients have many more options available today than they ever did before. Ibrutinib is now standard therapy, although we can discuss how there are maybe patient characteristics indicating folks who may not want to be on ibrutinib, depending [on] their comorbidities. And I think that’s something that patients need to discuss with their doctors.
In the era of traditional chemoimmunotherapy we used to use for CLL, fludarabine, cyclophosphamide, and rituximab, or FCR; and bendamustine and rituximab, or BR, were the prior therapies that many individuals may have received. I think there have been very good advances going forward, and ibrutinib has enhanced those, has improved both survival of patients with ibrutinib versus perhaps the older therapies.
However, I think there are still a select group of individuals or patients who may prefer to receive chemoimmunotherapy, which is not unreasonable. However, I think that if somebody has high-risk features to their disease, so if there are adverse chromosomal abnormalities, like a 17p or a p53, we would steer those individuals away from chemoimmunotherapy in favor of ibrutinib. Patients who have an unmutated IGVH—and again, these are sophisticated tests your doctors should run before getting therapy—we would steer those individuals away from chemoimmunotherapy.
I think if you have favorable characteristics and you do not want to go on a drug like ibrutinib for a variety of reasons, then chemoimmunotherapy is still OK. But I think there are very good data for all individuals with CLL, whether you’re older or you’re younger. And even with comorbidities, that ibrutinib is very manageable and acceptable. So I do think that you have options, but more favoring these newer agents such as ibrutinib than before.