Expert Point of View: Richard Furman, MD

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“These results are interesting, important, and relevant for maintenance post chemotherapy, but if we are not using chemotherapy, they may not be relevant,” said Richard Furman, MD, of Weill Cornell Medical College, New York Presbyterian Hospital, New York. He said that newer drugs such as ibrutinib (Imbruvica), idelalisib (Zydelig), venetoclax (Venclexta), and obinutuzumab (Gazyva) have all been approved for chronic lymphocytic leukemia (CLL), and the probability is that the shift in the United States will be toward these targeted therapies.

“In some European countries, there is limited access to drugs like ibrutinib or venetoclax, and lenalidomide (Revlimid) maintenance will be useful for those patients are treated with chemotherapy,” Dr. Furman said.

Dr. Furman said that 5-year data on single-agent ibrutinib, presented at the American Society of Hematology (ASH) Annual Meeting & Exposition by Susan O’Brien, MD, of the University of California at Irvine, showed that in the relapsed setting, in patients over 65 years of age, 92% of patients demonstrated freedom from progression, with those whose disease progressed demonstrating a 17p deletion. In those patients who tolerate it, ibrutinib might be all they need for long-term survival. For those patients with 17p deletion, venetoclax offers an excellent treatment option if their disease progresses on ibrutinib.

Clinical Implications

Dr. Fink, who presented the results from the CLL M1 study, agreed that novel targeted agents are likely to replace chemotherapy as first-line treatment. However, she noted, fludarabine/cyclophosphamide/rituximab (Rituxan) is still standard of care for young, fit patients. “It is difficult to know how the standard of care might change with these new chemoimmunotherapy-free agents,” Dr. Fink admitted.

The CLL-13 trial will compare each of the new targeted therapies vs chemoimmunotherapy. The ­ALLIANCE 3-arm trial will compare ibrutinib, ibrutinib/rituximab, as well as bendamustine and rituximab as first-line therapies. The results of those trials should further inform clinical practice. ■

Disclosure: Dr. Furman reported no potential conflicts of interest.

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