Nicole Lamanna, MD: There are several unmet needs in chronic lymphocytic leukemia that have changed over time. Initially, the biggest unmet need happened to be in the patients with the 17p deletion. Since the advent of ibrutinib and agents like ibrutinib–other B-cell receptor agents and the BCL-2 inhibitors–this really has transformed treatment for that subgroup, entirely. However, we still need to work out other therapies for patients with the 17p deletion. But clearly those patients do very well on the new therapies. And so, we’re very excited about that.
There’s a small proportion of patients with CLL, about 10% of patients–probably in the literature the number is between 5% and 15%, and I think we underreport it because a lot of patients don’t get evaluated for this–who have what they call Richter’s transformation. That’s when a subset of an area of your CLL cells can transform to more aggressive lymphoma. The most common lymphoma is a large cell lymphoma, but we can also see Hodgkin’s lymphoma, and even what they call PLL, or prolymphocytic leukemia. Those are much rarer. For the majority of patients, it is diffuse large cell lymphoma. And so, that absolutely is an unmet need.
Traditionally, we treat those folks with lymphoma-based therapies that are large cell lymphoma-based regimens. But invariably, they are not successful. It is just not a good treatment option. So, we’re looking at checkpoint inhibitors. We’re looking at newer agents for patients with Richter’s. This is clearly an unmet need because it’s not so common. We’re looking at pooled analyses, trying to do clinical trials that are multicenter to gather those patients and put them on novel agents. Standard lymphoma-based therapy just doesn’t cut it. And so, that’s a definite unmet need for CLL.
When we talk about other unmet needs, no doubt, an area that has come up is supportive care for a CLL patient. Is this an unmet need, or just something that needs to be discussed? I think that because it’s a chronic illness, it requires a team. In my practice, I have a team. I have a nurse practitioner. I have a nurse. I have a research staff. We teach our CLL folks to call us and guide them with a little more hand holding. Health care maintenance is important for patients with CLL. Screening for other cancers is important. There’s a higher incidence for other cancers, so I’m always bugging my patients to be good about skin cancer screenings, mammograms, and Papanicolaou tests. Do all of the colonoscopies. Do all of your age-appropriate screenings. Follow up on those cancers. Those are curative, right?
An unmet need, I think, has to do with the support of CLL patients. I think CLL patients sometimes get pushed off because the doctor may be busy seeing other cancers that are actively being treated. CLL patients don’t necessarily need treatment. So, they’re like, “You’re fine. Your blood counts are good. Move on. I’ve got to see my 20 other patients with breast and lung and colon cancer.” No doubt, CLL folks may feel like they’re a little bit in an isolated category. So, we need better education and support for both the physicians and the CLL folks. It’s a chronic illness. They become a part of your practice as if you were in an internal medical practice. They’re with you for years. So, I think there are some emotional, psychological, and physical unmet needs that are probably inherent with just having the disease, itself.