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Your CLL Questions Answered!

Your CLL Questions Answered!
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Published on August 27, 2020

CLL Expert Answers Patient Questions

Do I need treatment now, or can I watch and wait? Is it safe to get treated during the coronavirus pandemic? How do I know if my treatment is working?

In a Patient Power "Ask The Expert" webinar earlier this month, Dr. Richard Furman, director of the CLL Research Center at Weill Cornell Medicine in New York City, fielded numerous questions from chronic lymphocytic leukemia (CLL) patients and Patient Power Co-Founder Andrew Schorr.

Here are Dr. Furman’s answers to questions ranging from BTK inhibitors and CAR T-cell therapy to a COVID-19 vaccine and whether it will be safe for CLL patients.

Dr. Richard Furman, MD

Dr. Richard Furman, MD

What Are the Best CLL Treatments Right Now?

“We all have our biases and I actually do believe that BTK inhibitors, long term, have better outcomes than the other oral agents, and the truth is, we do have seven-year data for ibrutinib (Imbruvica), which I do believe is equivalent to the other BTK inhibitors. So, I speak to them all as a class. But I do think BTK inhibitors, by and large, are more efficacious, so, they're often my first choice. Some patients though prefer what might be offered by venetoclax (Venclexta) in terms of the fact that it's usually a fixed duration. It's a once-a-day pill, whereas acalabrutinib (Calquence) and zanubrutinib (Brukinsa) tend to be twice-a-day. So, there are a lot of subtleties and also other comorbidities that may direct the physician and patient in one direction versus the other.

One thing I do want to mention and report on is, currently, venetoclax is approved for use in combination with either rituximab or obinutuzumab (Gazyva) for durations of one or two years. You know it's important for patients to remember, that we really don't know, what is the ideal ratio of treatment. The way I phrase it is, we don't know if stopping treatment after one year is not necessarily depriving the patient of some of the benefits. So, I've always been very cautious, and I always warn patients that just because that's the way the regimen was approved doesn't mean that's the best way to use the drug.

Now as it turns out, with regard to other oral agents, we also have the BLC2 inhibitor, venetoclax. We have the PI3K inhibitors, idelalisib (Zydelig) and duvelisib. So being resistant to one or having one first and then progressing doesn't preclude the use of any others. So, these are not cross-resistant and, unlike chemotherapy, progressing on one, doesn't necessarily predict for being more resistant to the others.”

What is Watch and Wait for CLL?

“It's important to remember that watch and wait was developed during the 1970s. And, so, it was based upon 1) having very core agents to use, primarily chlorambucil and prednisone, and 2) not really being able to discern who are those people that are likely to progress from those who are not. So, I do think watch and wait is very antiquated, but it still is standard of care to not treat a patient until they meet the established criteria.”

Is CAR T-Cell Therapy for CLL Right for Me?

CAR T-cell therapy is not much more expensive than actually any of the BTK inhibitors. The difference is whether or not it's annualized over a couple years or whether it's paid all at once. As a physician, I really believe that we have to offer patients the best things that we can, and I actually do prefer BTK inhibitors because they are, I think, more efficacious and far safer than CAR-T cell therapy. One area where I think CAR T-cell therapy may still play a role in CLL are in those people who aren't in transformation, so the people that develop Richter’s, which really don't respond to the BTK inhibitors but still could respond to CAR T-cell therapy.”

How Do I Know if My CLL Treatment is Working?

“Progression-free survival really is what's most important. So, I have patients who have been on ibrutinib for 10 years now who haven't yet achieved MRD (minimal residual disease) negativity. They’re fine. They're on the drug. They’re tolerating it well and they continue to respond. And so, really progression-free survival. And that translates into overall survival, (which) is the most important endpoint. So, a drug like venetoclax, which achieves MRD negativity more quickly than ibrutinib or other BTK inhibitors, doesn't necessarily afford any advantage.”

What Do CLL Patients Need to Know About COVID-19?

It's important to keep in mind that the biggest risk factors for having a severe COVID infection are going to be age, obesity and lung disease. And being immunodeficient or having CLL does translate into an increased risk having a complication from COVID-19, but it is far less impactful than any of those other three. That being said, I always mention this, 40-year-old healthy adults have died of COVID. So, the key still is to be smart and not get infected.

Will a COVID-19 Vaccine Be Safe for CLL Patients?

All COVID-19 vaccines that we're developing in the United States, they’re not live vaccines. So, they will be safe for CLL patients. Whether or not CLL patients respond to them is another separate question that's obviously very important. The good news is that for any vaccine, the estimated herd immunity that's necessary to sort of protect everyone is 70%. And so that's why everyone should get vaccinated if it's a non-live vaccine, which it will be.

To learn more from Dr. Furman, watch Part 1 of the 4-part series: Latest News on BTK Inhibitors for CLL.

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~Megan Trusdell

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