Understanding the Timing of Therapy in CLL



Nicole Lamanna, M.D.: One question that comes up quite commonly now in light of these newer therapies, such as ibrutinib, is should individuals start therapy earlier than they did before? We used to initiate therapy for patients when their good counts got bad. So if the doctor tells you you’re anemic, your red blood cell count is lower, your platelet count is low, or if you have big and bulky lymph nodes, that’s usually when we would start individuals on therapy. In light of these newer drugs, patients always ask, “Should we wait, should we still wait?” Or “Should we start these therapies earlier, will that change the disease course for me?”

Those data we don’t have yet. There is a study that was randomized to look at patients with high-risk features or aggressive features to their disease, whether waiting as they normally would until they needed therapy or starting them earlier with drugs like ibrutinib will make a difference. Those data are not yet available. So for now we are not recommending patients to start therapy earlier than they would even if they got chemoimmunotherapy. So you still wait until you really do need treatment.

And I think there’s a benefit to that. I think that until we show that starting you on an agent earlier will make your survival so much better than if you waited until you really needed treatment, it is important because all agents potentially have toxicity. If we don’t have to give you any therapy for a few years and you don’t need it earlier, why should you start it, unless there are very good data to say that it absolutely changes the disease course, then we’ll be in for it. But for now, we don’t start even these novel agents sooner than we would otherwise.

Now what about if you get a drug like ibrutinib. How long can you go? Right now when we start these novel agents, at least currently, when you start a drug like ibrutinib you’re going to take it indefinitely. So it’s sort of chronic therapy similar to other medications that you might take for diabetes or high blood pressure or a cardiac problem. You’re going to take this indefinitely unless you’re having side effects that are intolerable, that you can’t manage with your physician, or if the drug stops working. And that can be variable. So there are individuals who can spend years on ibrutinib without needing other therapies who are doing well. If you have a side effect that’s unmanageable, that could happen early on or that can happen later. So it’s very variable how long somebody may be on ibrutinib, and that depends on the patient’s course.

When it comes to other therapies, obviously venetoclax is a new therapy that’s also been approved for patients with relapsed CLL. So if you’ve had prior therapy, this is another oral agent that you can take. Right now you would take it indefinitely. However, there are many strategies that have looked at venetoclax in shorter durations, depending upon somebody’s response to the therapy.

So I think for patients, the field is evolving, and you all should be aware that we’re looking forward to the fact that you might be looking at different combinations of these oral therapies with other agents, that we can then stop that therapy, and that you may not be on them indefinitely, depending upon your response to the therapy. So I think even if you’re on one of these agents now, you may be able to stop them at some point soon, or your doctor may tweak that. And so I think the good news is the field is continuing to evolve.

Transcript Edited for Clarity

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