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CLL Treatment in Community Oncology

Insights From: Tara Graff, DO, MS, Mission Cancer + Blood
Published: Friday, Feb 28, 2020



Transcript:

Tara Graff, DO, MS: We’re in a really exciting time right now with CLL [chronic lymphocytic leukemia]. I think chemoimmunotherapy is a dying art, which is insane to say, because when Rituxan [rituximab] came out, we started paring it with other chemotherapy drugs. It changed the landscape. It was the hot new item on the block. To see where we’ve come—from FCR [fludarabine, cyclophosphamide, rituximab] and BR [bendamustine, rituximab] to now looking at, in some cases, oral therapy or using MRD to determine, “OK, you can go off [those drugs] now.” It’s fascinating. As time goes on, possibly even in the next year, we’re going to know that 3 drugs—you know, AVO [acalabrutinib, venetoclax, obinutuzumab] is better than VO [venetoclax, obinutuzumab] is better than acalabrutinib by itself.

We have so many options now. If you are a medical oncologist specifically in the field of CLL, or anything else, for that matter, with the changes going on, you know that you will go to a meeting and come back supercharged because you have all these other options to offer your patients that you didn’t have just 18 months ago. It’s a great time.

CLL is changing constantly. It’s hard to keep up. You could go to the guidelines every 3 weeks, and a different drug is probably going to change on the ladder. We’re at a good holding point right now. We’re pretty set with the selection order of drugs, such as acalabrutinib plus or minus obinutuzumab or venetoclax plus obinutuzumab. But if you don’t spend time going to meetings, or if you don’t spend time reading all the emails we get with updates or going to the NCCN [National Comprehensive Cancer Network] Guidelines, it’s really hard to know what to choose. Especially when you’re in a community oncology practice, where you’re seeing 15 different cancers, it’s really hard to know the newest and the latest and greatest data on every single disease you’re treating.

My advice, specifically, would be to really know your patients. We know that a majority of our patients—I believe the statistics say that 89% of newly diagnosed CLL patients are going to have at least 1 major comorbidity. So vascular disease, atrial fibrillation, high blood pressure. Do they have an existing rheumatologic disorder? Do they have pain every day already? You need to know those things.

In day-to-day practice, when you are seeing 25-plus patients in clinic, you sometimes forget the little details of your patient. You need to know your patient and know what their other medical issues are when you’re looking at your selection of medicine.

The other thing is, cytogenetics. Fortunately, we know that acalabrutinib is highly successful in the high-risk cytogenetic groups. But it’s really important, especially with some pathology labs, to know that they’re not routinely testing all the different genetic mutations. That’s really important to know, especially when you’re looking at overall response rate and which drugs you’re choosing. You don’t want to choose FCR [fludarabine, cyclophosphamide, rituximab] if they have a deletion 17p.

Now, most doctors are not choosing FCR [fludarabine, cyclophosphamide, rituximab] anymore, but bendamustine-Rituxan still gets selected. You need to know the data. You need to know the efficacy when you’re looking at the other drugs. But you’ve got to know your patients. Listen to your patients. Know their other medical issues. If you know that, it will guide you toward the best treatment for them.

Transcript Edited for Clarity
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Transcript:

Tara Graff, DO, MS: We’re in a really exciting time right now with CLL [chronic lymphocytic leukemia]. I think chemoimmunotherapy is a dying art, which is insane to say, because when Rituxan [rituximab] came out, we started paring it with other chemotherapy drugs. It changed the landscape. It was the hot new item on the block. To see where we’ve come—from FCR [fludarabine, cyclophosphamide, rituximab] and BR [bendamustine, rituximab] to now looking at, in some cases, oral therapy or using MRD to determine, “OK, you can go off [those drugs] now.” It’s fascinating. As time goes on, possibly even in the next year, we’re going to know that 3 drugs—you know, AVO [acalabrutinib, venetoclax, obinutuzumab] is better than VO [venetoclax, obinutuzumab] is better than acalabrutinib by itself.

We have so many options now. If you are a medical oncologist specifically in the field of CLL, or anything else, for that matter, with the changes going on, you know that you will go to a meeting and come back supercharged because you have all these other options to offer your patients that you didn’t have just 18 months ago. It’s a great time.

CLL is changing constantly. It’s hard to keep up. You could go to the guidelines every 3 weeks, and a different drug is probably going to change on the ladder. We’re at a good holding point right now. We’re pretty set with the selection order of drugs, such as acalabrutinib plus or minus obinutuzumab or venetoclax plus obinutuzumab. But if you don’t spend time going to meetings, or if you don’t spend time reading all the emails we get with updates or going to the NCCN [National Comprehensive Cancer Network] Guidelines, it’s really hard to know what to choose. Especially when you’re in a community oncology practice, where you’re seeing 15 different cancers, it’s really hard to know the newest and the latest and greatest data on every single disease you’re treating.

My advice, specifically, would be to really know your patients. We know that a majority of our patients—I believe the statistics say that 89% of newly diagnosed CLL patients are going to have at least 1 major comorbidity. So vascular disease, atrial fibrillation, high blood pressure. Do they have an existing rheumatologic disorder? Do they have pain every day already? You need to know those things.

In day-to-day practice, when you are seeing 25-plus patients in clinic, you sometimes forget the little details of your patient. You need to know your patient and know what their other medical issues are when you’re looking at your selection of medicine.

The other thing is, cytogenetics. Fortunately, we know that acalabrutinib is highly successful in the high-risk cytogenetic groups. But it’s really important, especially with some pathology labs, to know that they’re not routinely testing all the different genetic mutations. That’s really important to know, especially when you’re looking at overall response rate and which drugs you’re choosing. You don’t want to choose FCR [fludarabine, cyclophosphamide, rituximab] if they have a deletion 17p.

Now, most doctors are not choosing FCR [fludarabine, cyclophosphamide, rituximab] anymore, but bendamustine-Rituxan still gets selected. You need to know the data. You need to know the efficacy when you’re looking at the other drugs. But you’ve got to know your patients. Listen to your patients. Know their other medical issues. If you know that, it will guide you toward the best treatment for them.

Transcript Edited for Clarity
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