Considerations in Selecting Treatment in Resistant CLL
Posted: Monday, August 26, 2019
As treatment of chronic lymphocytic leukemia (CLL) has dramatically improved over the years, with the development of effective chemoimmunotherapy regimens and mechanism-driven agents, physicians now have a catalog of options to treat patients with relapsed or refractory CLL. In an editorial published in the Mediterranean Journal of Hematology and Infectious Diseases, Antonio Cuneo, MD, of the University of Ferrara, Italy, and Robin Foà, MD, of Sapienza University, Rome, discussed the available treatment approaches and the financial sustainability of therapy.
Drs. Cuneo and Foà explained that “a progressive lack of efficacy is observed with chemoimmunotherapy regimens in patients with multiple relapses,” indicating that there is a marginal role for chemoimmunotherapeutic agents in advanced phases of disease. Data still support the use of bendamustine plus rituximab for a limited subset of patients who desire second-line treatment of a short duration.
Treating physicians must also establish whether a patient with relapsed or refractory disease is a candidate to receive continuous treatment at relapse or if they would benefit from a fixed-duration course of therapy. Continuous use of mechanism-driven agents with or without CD20-directed monoclonal antibodies is an effective option for some patients with CLL, the authors noted. The most actively investigated drug, ibrutinib, offers durable efficacy; however, certain patients may not tolerate a long duration of exposure.
Alternatively, therapy with venetoclax and rituximab is currently the only chemotherapy-free approach for relapsed or refractory disease with a fixed duration schedule of up to 24 months capable of “inducing deep responses in the majority of cases.” As for safety, this option appears to have a lower incidence of treatment-related adverse events compared with continuous therapy.
Finally, Drs. Cuneo and Foà stressed that physicians “cannot disregard the growing problem of sustainability.” Employing effective regimens for a fixed duration may decrease the cost of treatment. Also, they added, regulatory agencies should take action to negotiate fair prices.
Disclosure: The study authors’ disclosure information may be found at mjhid.org.