Combining and Sequencing New Agents in CLL

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The treatment of chronic lymphocytic leukemia (CLL) is poised to undergo a dramatic transformation as multiple new agents begin to gain approval in the relapsed/refractory setting. The question that remains unanswered is how these agents will be sequenced. As of now, John C. Byrd, MD, believes that ibrutinib will be used in the first-line setting while idelalisib will be used second-line, predominantly as a result of side effects.

Since these therapies are so effective with low toxicity in the relapsed/refractory setting, studies are being designed to explore them in asymptomatic patients with CLL who show high-risk characteristics, such as 17p deletions, Brad S. Kahl, MD, notes.

As combination therapies advanced, they will likely use obinutuzumab rather than rituximab, Byrd believes, due to the dramatic benefit demonstrated for obinutuzumab over rituximab in the CLL11 study. The improvement in survival with obinutuzumab was the first to be shown in elderly patients with CLL for quite some time, representing an exciting new option that will be explored across other types of blood cancer and in combinations, Byrd notes.