Moshe Talpaz, MD, discusses best practices in monitoring patients with CML and applying multidisciplinary care.
Moshe Talpaz, MD: We need to define the objective. What is our objective in third line [treatment]? Is it really complete molecular remission? Maybe, in some patients. But in many patients, when we get to the third line, we should be very happy with a complete cytogenetic response.If we also get the major molecular responses, that's an excellent achievement. The monitoring of the patient doesn't differ much from the monitoring of patients in earlier stages of the disease or those who are treated in first line or second line. However, if they develop resistance and don't respond well to the third line, I would resolve to repeat the mutation analysis within the BCR-ABL1 gene to see if there are new mutations that render resistance to the current therapy. Otherwise, I would continue the quantitative follow-up of checking the level of disease with PCR (polymerase chain reaction) testing every 3 months.Once we have a desirable remission, we can reduce the frequency.
The physician who monitors the patient is essential but insufficient. In my team, I have a physician assistant, a nurse, and sometimes a social worker, if needed, who is on-demand. Why do I need a nurse? A nurse is needed for longitudinal follow-up of the patient and to check a patient’s blood. Even if we are considering that many of these patients come from long distances, and the routine blood tests can be done locally, and sometimes even the molecular tests, we need a person who will monitor all of those, because as a single individual, I may miss it. The same role goes with the PA (physician assistant). Both the nurse and the physician assistant have to alert me to issues that pertain to compliance, tolerance, and adverse effects and to discuss whether the adverse effects are severe or not. It's important to emphasize that unlike a clinical study, where we measure grade 3 adverse effects as a reason to stop treatment, that's not the case once a drug is approved to be used in the clinic. Some of the patients may have a grade 2 toxicity, which will interfere with their quality of life and is a good enough reason to switch drugs. Collecting information on toxicity on a longitudinal basis, collecting information on compliance, collecting information on loss of response needs more than 1 individual. And my team is very educated when it comes to the management of CML (chronic myeloid leukemia). Furthermore, because there are also financial issues with the use of CML drugs, my team and the social worker have established an elaborate system to get support from the various pharmaceutical companies that develop CML drugs as well as other agencies that can help patients.
Transcript edited for clarity.