First-Line Treatment Selection in CLL

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The frontline treatment of patients with chronic lymphocytic leukemia (CLL) has undergone a dramatic transformation in the past year. Treatment selection has shifted from the more standard chemoimmunotherapy regimens, such as fludarabine and cyclophosphamide with rituximab (FCR) or bendamustine with rituximab (BR), to the newer anti-CD20 antibodies, including ofatumumab and obinutuzumab, notes Thomas J. Kipps, MD.

These newer agents—each in combination with chlorambucil—are helping to make CLL treatment more targeted and more tolerable. In addition, the BCR inhibitor ibrutinib is transforming care for patients with CLL for whom chemotherapy may not be a viable option.

As a result of these newer therapies, clinicians are reassessing whether less aggressive therapy should be the only treatment administered to patients with the more favorable karyotypes—the low-risk group, John C. Byrd, MD, suggests. Based on studies from MD Anderson and the German CLL Study Group, IgVH mutated, 13q deletion, and trisomy 12 patient groups respond well to FCR. At 10 years, there’s a 65% plateau in the progression-free survival curve, suggesting that 6 months of aggressive therapy is beneficial in low-risk patients with CLL, Byrd notes.

Still, the other panelists recommend exercising caution when looking at these data, and stress that the efficacy of aggressive treatments, such as FCR, must be weighed against their toxicities. They debate the efficacy, safety, and appropriate patient population for BR versus FCR.

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