Published on September 1, 2020
What are the Latest Treatment Options for Adult Acute Lymphoblastic Leukemia?
Treatment of leukemia in adults with ALL has improved dramatically for older acute lymphoblastic leukemia patients. Dr. Gail Roboz from Weill Cornell in NYC joins Patient Power host and advocate Ruth Fein to explain the current treatments available to Adult ALL patients and future treatments on the horizon. Dr. Roboz emphasizes the importance of understanding your ALL subtype and how those subtypes can dictate treatment. Watch to hear the full discussion.
Transcript | Current Treatments for Adult Acute Lymphoblastic Leukemia
Treatment Developments for Adult ALL Patients
Hi, welcome to Patient Power, I'm Ruth Fein, a patient advocate and I've been living with an MPN, which is a myeloproliferative neoplasm for more than 25 years. Today, we're here with Dr. Gail Roboz to talk about another much more acute blood cancer, adult ALL, which is acute lymphoblastic leukemia, or sometimes called lymphocytic leukemia. Dr. Roboz is Director of the Clinical and Transitional Leukemia Program at Weill Cornell Medical Center in New York. So, welcome Dr. Roboz.
Thank you very much, very nice to be here. So, ALL is the most common subtype of leukemia in children, but it's more rare in adults. The bone marrow is a super important organ that makes white blood cells, red blood cells and platelets. And what happens in acute leukemias is that the bone marrow actually gets completely clogged up, within this case, abnormal lymphoblasts which completely wipe out the normal bone marrow function and actually prevent production of normal white blood cells, red cells and platelets which results in bone marrow failure.
Let's talk about where we are today in treatments for adult ALL. So, I know there are lots of clinical trials going on. There's targeted therapy, there's STEM cell transplants, Of course there's the exciting potential of CAR-T therapy, which we can talk about. So, what does the treatment landscape look like right now?
Well, I mean, I have to say it's actually - the last decade or so has been completely transformational. So first, you had how come adult patients are doing poorly with ALL and kids are getting cured? 70, 80, sometimes in subgroups, 90% of kids are getting cured. We hadn't been seeing anything like that in the adult landscape. So, the first thing is, divide up the disease biology correctly. There are Philadelphia chromosome positive patients, so PH positive ALL is one subgroup. There are PH like signatures in ALL, that's another subgroup. And then again, using cytogenetics and other molecular information, and also T-cells and B-cells, T-cell ALL and B-cell ALL, first thing is get your subgroup right. Then, we can start getting into treatment landscape, treating the targeted patients, the PH positive patients with targeted inhibitors.
Those patients used to actually always die from their disease and now the combination of tyrosine kinase inhibitors (TKI) with chemotherapy, the cure rates are so much better and without STEM cell transplant. That was a group of patients who always had to be transplanted. Now, we are seeing five year cures, real cures without STEM cell transplant. Then, in addition to that, how come the kids are doing better and the adults aren't? Well, there's intensification of therapy, which very much was using old drugs; things like steroids and asparaginase, older therapies but intensifying them so that adults up to 40, 42, 45, depending on where you are, are actually getting those intensified pediatric regimens with cure rates again at five years that are going up and that are questioning the need for transplant in those patients. So, we are trying for that group of patients to use the intensified pediatric regimen without a transplant.
And then, there's the whole new group of new therapies. So, if you have leftover disease, MRD, measurable residual disease, don't just keep piling on chemotherapy but thinking of drugs, like for example, blinatumomab (Blincyto) or inotuzumab (Besponsa). These drugs are difficult to say but these are novel therapies that are antibody-based treatments that can be used either with chemotherapy in combination or after chemotherapy in the setting of MRD positivity to try to wipe out those extra lymphoblasts that might be left over. And then, there's the whole discussion that you brought up of CAR T-cells.
CAR T-cell therapies are approved for patients up to 25 years old and there are some cures. And then, there's a whole bunch of new CAR T-cell therapies that are investigated to try to get some of the older patients included in who can receive CAR T, and to also look at allogeneic versus autologous CAR T-cells. So, autologous means the patient's making the T-cells and allogeneic means you're getting them off the shelf from a donor, which would be a fantastic thing to increase access to that therapy.
You mentioned the full gamut of treatments. If you had to speak to one thing that you're most optimistic about, what would that be?
I have to say, I have a lot of optimism about the direction of ALL therapy because we were doing so badly. Adult patients had so few options and older patients in particular, we just couldn't get patients in their sixties and seventies, we couldn't get them into the intensive chemotherapy regimens. And now, the reduction in intensity of standard chemotherapies, plus introduction of some of the novel agents, some of the antibody-based therapies, has actually revolutionized our ability to get those 60 and 70 plus year old patients treated.
So I have to say, I have a lot of optimism about the direction of ALL patients in general, and I think that a lot of that is also based on sub-grouping them correctly. So again, Philadelphia chromosome positive patients get treated differently. Older patients are getting less of the standard chemotherapy and more for example, blinatumomab, or inotuzumab is being incorporated in. And then, we are actually using less allogeneic STEM cell transplant than in the past because of the ability to intensify the therapy for younger patients, younger adult patients.
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