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Why Is Watch and Wait Necessary?

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Published on June 25, 2015

Why is the watch-and-wait period necessary for many people with chronic lymphocytic leukemia (CLL)? Dr. Javier Munoz, from Banner MD Anderson Cancer Center, explains the reasoning behind this phase, which occurs prior to treatment. Dr. Munoz discusses how understanding a patient’s individual disease affects the decision to treat and why treating early does not always lead to an improved outcome.

Sponsored by the Patient Empowerment Network, which received educational grants from AbbVie and Genentech. 

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Banner MD Anderson Cancer Center CLL Global Research Foundation

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Transcript | Why Is Watch and Wait Necessary?

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.

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. 

Carol Preston:

You’re with Banner, is that correct?

Dr. Munoz:          

Correct. Banner MD Anderson Cancer Center. I have been here for almost three years.

Carol Preston:   

Excellent. And I actually go to the other cancer center, the small one in Houston.  Anyway, so it’s a pleasure to meet you. And I just would like to ask you because we focused a lot this morning on the clinical and the technical.  But in terms of the patients you see day to day, what are the common issues from them that bubble to the surface?

Dr. Munoz:          

Absolutely. I think that watch and wait, as we were discussing, is a concept that sometimes is a pathway that is difficult to follow for some patients because it’s difficult to say that we have cancer, but we’re not going to treat it.

But as we were saying, we favor strongly, if possible, to stay with watch and wait for as long as possible.

Carol Preston:   

And why is that different from other cancers? Why is that with CLL? Because everybody wants that cancer out.

Dr. Munoz:          

Absolutely. So treatment sometimes can be worse than the disease. And I think that is key to comprehend. The original trials, they showed that treating early CLL will not necessarily improve your outcome. So you could be getting the toxicity from the drugs without the benefit from it.  So that is why we favor watch and wait. 

Carol Preston:   

And when you explain that to your patients, what is the response from them?  I mean, do they get it? Are they still feeling the Damocles sword is hanging over their heads?

Dr. Munoz:          

I think we’re all different. But most of our patients are relieved that they do not need chemotherapy, that they do not need treatment.  I do think there’s a small subset of patients that anxiety sets in, and there’s more watch and worry instead of watch and wait. 

But that is why we work as a team, and we take our time to explain things to patients. And hopefully, we can all work together towards a good outcome. 

Carol Preston:   

I had a question from an online patient a while back who said let me stir the pot a little bit. He was a watch-and-waiter. And he said, “But what I’m wondering is what if, instead of watch and wait, and then waiting for this thing maybe to explode suddenly with skyrocketing white blood cell counts and so on, what if there was a very really titration, slow and low dose of something to prevent an explosion of the disease?”  Is that research underway?  

Dr. Munoz:          

Well, yes.  In many conditions, even beyond chronic lymphocytic leukemia, we have been trying to see if treating early would make an impact. For example, there is something called smoldering myeloma, a precursor of myeloma.

People are looking into the question if we should treat these patients. But as we said, one size does not fit all.  We think that CLL, myeloma, lung cancer, they are all—it’s not one disease. It’s a combination of multiple subsets of diseases. So you truly need to understand why some patients behave so well or why some patients with CLL the disease misbehaves so abruptly.  And even nowadays, I think that we go back to the basics that is symptoms, fevers, night sweats, weight loss, swollen lymph nodes. We take a look at the blood. If the patient is getting progressively anemic and is developing low platelets.

And we look at the disease tempo. We see the doubling time of the lymphocytes to see if it is a fast paced disease or a slow growing disease. And then we make decisions appropriately.

Carol Preston:   

No, I’m a nearly 9-year CLLer, so, of course, I’m very interested in research and specifically the research you are working on. So what is in your laboratory these days?

Dr. Munoz:          

Well, we’re just so happy to have so many novel agents available like ibrutinib (IMBRUVICA®) and idelalisib (Zydelig®). And in the near future, we’re going to have more available in the clinic, as they said, probably perhaps the ABT-199, the BCL-2 inhibitor that is going to be available as well. Personally, we have several clinical trials available definitely in the mother ship, as you said, in Houston MD Anderson. And we are starting to bring some here.  We have, for example, a clinical trial for relapsed diffuse large B-cell lymphoma combining lenalidomide (REVLIMID®) and ibrutinib, two drugs that we had been talking about earlier on today.  So I definitely… 

Carol Preston:   

…yes, it was suggested if I relapse, that might be my clinical trial. I’m just inserting that in there. But indeed that could be it.

Dr. Munoz:          

And again, it’s a non-chemotherapy platform.  None of those agents are chemotherapy. And I think that we’re strongly trying to follow that lead, trying to find concoctions that would not include chemotherapy. 

Carol Preston:   

Dr. Munoz, thank you for your time and also for the work that you’re doing.

And we’ll look forward to hearing more from you this afternoon. 

Dr. Munoz:          

Nice to meet you. Thank you very much.

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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