Infection Risk With Continuous Acalabrutinib in ELEVATE-TN

Danielle M. Brander, MD, of Duke University School of Medicine, turns to the ELEVATE-TN trial in chronic lymphocytic leukemia (CLL), which compared continuous acalabrutinib monotherapy with acalabrutinib plus 6 cycles of obinutuzumab. With 6-year follow-up, infection was the most common cause of death in both arms, though patients remained on treatment much longer than in fixed-duration trials. She asks how much infection differences should drive the choice between a fixed-duration combination and continuous single-agent therapy. Marc J. Braunstein, MD, PhD, of NYU Grossman Long Island School of Medicine, says his first considerations are expected benefit, whether the patient prefers continuous or time-defined treatment, and whether the molecular profile matches the AMPLIFY or ELEVATE-TN populations. Infection is always a consideration but not the main driver over efficacy, because prophylactic measures can reduce risk. He recommends addressing vaccination, before treatment starts or at diagnosis, since vaccine responses fall once therapy begins.