Nicole Lamanna, MD: Now what about a patient who’s already had treatment for their disease? We call them relapsed patients. So, a patient who needs treatment again. There are 2 different categories in that. We talk about relapsed patients, and sometimes we’ll even categorize somebody as a refractory patient. A refractory patient is someone who has really gotten a lot of therapy, and they’re not really responding to treatment any more. So, let’s talk about relapsed patients.
In general, it depends on what they might have gotten for their first line of therapy, and how long that response lasted. When you choose alternative second lines of therapy, it really depends on side effects that they might have had with their first treatment, responses to their first treatment, and how long that response lasted.
What’s really important for patients to know is that when they get retreated, they should be tested, again, for these chromosomal abnormalities. In most patients, 17p is not very commonly identified in a newly diagnosed patient. Only about 6% of patients get diagnosed with 17p deletion. But for patients who, through the years, get multiple treatments, that frequency of a 17p deletion increases. So, if they haven’t had ibrutinib, and it’s even relevant if they have had it, when they get retreated in subsequent lines of therapy, you want to retest them. If they have a 17p deletion, that may impact what you’re going to do for them in terms of treatment. If they got chemoimmunotherapy as frontline therapy, and they now have a new 17p deletion, in second-line therapy, for sure, you’re absolutely going to use ibrutinib or a novel agent like ibrutinib. So, that’s important information to know.
If they’ve had ibrutinib as frontline therapy, because many patients are now getting ibrutinib as their first treatment whether they have 17p or not, the question is, can you go to chemoimmunotherapy? This is an area where we don’t have a lot of data. There are some clinical trials that are looking at this question. We just don’t have enough patients who’ve had ibrutinib in the frontline setting to know what to do with them in the second-line setting. There is a new BCL-2 inhibitor, venetoclax, that got approved. It’s approved, first, in relapse, for 17p deleted patients.
There’s data that’s now being presented at the ASH Congress that will show its benefit in relapsed patients as well. So, you will likely see that this may get approved, as well, in relapsed patients. This might be an area where, if somebody had ibrutinib in the frontline setting, venetoclax, as a second treatment, is certainly very appealing and effective. But the question, can you go to chemoimmunotherapy, is there as well. We just don’t have the right answer. If you get ibrutinib in the frontline setting, what do you do in the second-line setting? I think venetoclax is a great option. But certainly, chemoimmunotherapy might still be applicable. So, it just depends. It also depends on the features of your disease.
In relapse, you absolutely need to be retested, to look at the features of your disease. And then it depends on what you might have gotten, or potential side effects that you might have had, that will determine what type of therapy you’ll have in relapse.