Dr. Wierda on Frontline Management of Patients With CLL

William G. Wierda, MD, PhD, medical director of the Leukemia Center at The University of Texas MD Anderson Cancer Center, discusses the management of patients with chronic lymphocytic leukemia (CLL) in the first-line setting.

According to Wierda, this is a very rapidly evolving area. Up until a few years ago, chemotherapy and chemoimmunotherapy were the only frontline treatment options for patients with CLL. More recent data, though, have opened the doors for small molecule inhibitors, such as ibrutinib (Imbruvica), which demonstrated efficacy in the RESONATE-2 trial.

This randomized phase III study investigated frontline therapy for patients over 65 years old, who received treatment with either chlorambucil or ibrutinib. The study was positive and showed an improvement in progression-free survival, as well as overall survival for patients who received ibrutinib as their primary therapy. Specifically, patients with a 17p deletion—a small subset totaling about 5% to 8%—are considered excellent candidates for ibrutinib, and should not receive chemotherapy or chemoimmunotherapy. Questions remain regarding whether all patients should receive ibrutinib in the first-line setting, or if only certain subsets of patients derive benefit from this therapy.

As of now, there are dozens of new drugs being investigated for the treatment of patients with CLL. Many of these drugs are targeted at specific parts of cancer cells, while others perform more similar to standard chemotherapy drugs. For example, oblimersen (Genasense) has been given along with chemotherapy, and was shown to be more associated with increased remission rates versus chemotherapy alone.