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ALL Treatments, Transplants and Testing

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Published on January 27, 2020

Key Takeaways

Acute lymphoblastic leukemia experts Dr. Eunice Wang from Roswell Park Comprehensive Cancer Center and Dr. Hetty Carraway from the Cleveland Clinic discuss hope and progress in treating pediatric and adult patients.  Dr.’s Wang and Caraway address patient outcomes and the role of minimal residual disease (MRD)  testing and ALL genetics in understanding options. The experts also explain why certain therapies may be more beneficial for different patient populations, like transplant for those with a more aggressive form of the disease, and give updates on immunotherapy as an up and coming treatment option for ALL.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Transcript | ALL Treatments, Transplants and Testing

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Andrew Schorr:

Hello.  Andrew Schorr here talking about acute lymphoblastic leukemia, and with me are two experts in the field.  And over here is Dr. Eunice Wang from the Roswell Park Cancer Institute, right?  

Dr. Wang:

Right.

Andrew Schorr:

In Buffalo, New York.  And Dr. Hetty Carraway from the Cleveland Clinic in Cleveland, Ohio. 

So we've been at a large medical meeting for hematologists, and ALL, we have more to talk about now.  Now, certainly we have children with ALL, and I think we're often familiar with that, but we have adults with ALL.  So, Dr. Wang, where are we now with really new hope for people with this acute condition? 

Dr. Wang:

Well, I know that for adults we have for many years really been looking enviously at our pediatric hematologist‑oncologist colleagues as they have achieved 90 to 95 percent cure rates in patients with acute lymphoblastic leukemia.  Now, many older adults, particularly those between the ages of 50 and 70, we're really—we're getting about 30, 40, 50 percent survival, very low, low survival rates.  

And what we've been doing is kind of adapting from our counterparts, and for patients that are a little bit younger, you know, between the ages of 18 and 39, just sort of that adolescent, young adult population, we've been adopting some of those high‑dose and highly effective chemotherapy strategies that we've seen work in pediatric patients

The pediatricians have also looked at this parameter that's called minimal residual disease or measurable residual disease, and so when patients go into what we think is a complete remission, we can't see their disease, a lot of times in adult leukemia therapy we will stop therapy.  We will say let's take a watch‑and‑wait approach. 

But I think that another way to look at that is to say not all of those remissions are long-lasting.  Not all of them represent cures.  Some of them are just the cancer cells lying in wait until we stop the therapy and then them coming back very aggressively and then not being able to cure those individuals.  So our ability to measure that minimal or measurable residual disease has actually led us to try to be aggressive about treating that MRD and preventing that overt relapse. 

Andrew Schorr:

Not stopping treatment but continuing treatment… 

Dr. Wang:

Right. 

Andrew Schorr:

…but keep trying to knock it down to the lowest.  

Dr. Wang:

Right.  But non-toxic therapy, the therapy that's designed to eradicate or eliminate that low‑level disease but not in a way that's going to make our patients really horribly sick. 

Andrew Schorr:

Okay.  Dr. Carraway, what about transplant?  So that's been around quite a number of years now and has been used in ALL, right?  So what about now?  

Dr. Carraway:

Yeah.  Transplant has been used for patients with ALL particularly those that we worry that chemotherapy is not enough to cure it.  The patients that fit into those categories are patients that have particular genetic signals that tell us chemotherapy won't be enough, and the reason we know that is just because of patients that we've treated in the past and what those outcomes have looked like. 

And as Dr. Wang alluded to, the older patients are, the more we worry that their type of leukemia has patterns that tell us that they won't be cured only by chemotherapy.  Some of them are genetic mutations that we find or chromosome changes, and some of them are just gene expression profiles that teach us that those leukemias will be more resistant to chemotherapy. 

And then we also just recently talked about what we call minimal residual disease where we can measure small amounts of disease even though we can't see disease under the microscope when we look with a slide.  And in some of those patients, we worry that a transplant will be less beneficial in those patients, because they're more likely to relapse. 

So not only are we using novel therapies to see if we can eradicate that amount of disease prior to going to transplant, we're also using different ways to make sure transplant works better and is less toxic to patients.  So there's work in all of these areas to try and improve outcomes for our older patients with ALL.  

Andrew Schorr:

Okay.  In many areas of hematology now we're starting to see‑‑take multiple myeloma or going back over a few years, CML, more is more medicines, in ALL lots of medicines.  Where are we now in ALL, in the range of treatments you have?  We still have a ways to go, it sounds like. 

Dr. Wang:

Well, we've really entered the world of immunotherapy really for acute lymphocytic or lymphoblastic leukemia.  We have two different antibodies.  One is specifically what we call a bispecific antibody.  It interacts with the tumor cell but brings it in contact with the T cells of the patient's host immune system and activates the immune system to direct those T cells to destroy the leukemia cells.  We have antibodies attached to chemo drugs bringing the chemo drugs specifically into touch.  

Andrew Schorr:

It has that payload.   

Dr. Wang:

Payload, yes. 

And then we, of course, have chimeric antigen receptor T cells.  Now, those are approved for individuals with ALL up to the age of 25, and there have been ongoing studies investigating those CAR-T cells in adults with relapsed and refractory setting.  We're hopeful that those studies in adult ALL patients above the age of 25 are going to hopefully become something that we have available to our older adult patients in the near future. 

Andrew Schorr:

Okay.  Dr. Carraway, so maybe I misspoke.  It sounds like you've got a few things when patients come to see you and it's a scary diagnosis.  I had a friend once it was like, boom, she was in the hospital.  She did have a transplant.  She had a twin, and she's alive today many years, and it's worked out well.  But you have more to talk about with people and with precise testing. 

Dr. Carraway:

That's true.  And I think again a lot of the similar things that we talk about in acute myeloid leukemia are relevant here especially in our adults with ALL that we really want to think about clinical trials for our patients so that we can potentially use agents that we think are active, but we haven't yet proven efficacy in the up-front setting to show that it helps to keep disease away in a long, durable way, whether it's with chemotherapy alone or getting that patient ready to go to transplant or some alternative therapy like CAR‑T therapy.  

Andrew Schorr:

Okay.  So as we always say, have consultation whether you, your doctor, get to a clinic if you can where there's an ALL specialist.  Have your doctor consult with one of these leaders so that in this acute situation you have really the broad range of both what's approved therapies and also what may be investigational but could make a real difference. 

Dr. Eunice Wang, from Roswell Park in Buffalo, thank you for being with us. 

Dr. Wang:

Thank you, Andrew. 

Andrew Schorr:

And also Dr. Hetty Carraway, from the Cleveland Clinic, thank you. 

Dr. Carraway:

Thank you.  

Andrew Schorr:

Andrew Schorr on location in Orlando where we get to meet all these super‑smart doctors.  Remember, knowledge can be the best medicine of all. 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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