Will chemotherapy remain the cornerstone of CLL management?
Prof Clemens Wendtner - Klinikum Schwabing, Munich, Germany
Would you please tell us a bit about your research and what you presented today?
Today we had an interesting discussion at the iwCLL in Sydney about the role of the so-called new agents in CLL. We have seen a change in the treatment options in CLL since the last few years; we are just moving from a solely chemotherapy driven therapy in CLL to treatment that makes use of so-called novel drugs, small molecules that interfere very specifically with the signalling cascade of the CLL cell. So the question is, is there still a role for so-called old-fashioned chemotherapy or should we just skip it and just move to the new agents. I think we should not discard the chemotherapy too early. Our study group, but many other study groups worldwide, in the UK, in the US, in Australia, have conducted fantastic trials proving major benefits for subgroups of patients just based on chemo-immunotherapy, meaning a combination of chemotherapy plus monoclonal antibodies. The new agents they’re developing, they offer treatment choices, especially in the relapsed refractory setting. They’re offering treatment choice for especially elderly patients, not being able to experience too much toxicity. But we have to stress that continuous therapy on novel oral agents might not be a thing patients are wishing to receive. It also might not be good for quality of life to think on a daily basis about therapy so a defined period of treatment, even chemo-immunotherapy, might be better and the efficacy is very, very good for subgroups of CLL patients.
What about your research into the future, what have you got planned?
The German CLL Study Group, nevertheless, wants to explore more on these novel agents. There are PI3 kinase inhibitors, delta, gamma delta, alpha delta, so different subgroups. We are exploring on BTK inhibitors, on BCL2 inhibitors and we try to put them into place. So one line of research, clinical research, is to, for example, debulk patients first then offer for a limited period of time, in this case six months, an induction of a combination of different kinase inhibitors plus antibodies. Then the peculiar and interesting thing follows, meaning the maintenance. We want to have a limited maintenance, so a discontinued maintenance, a paradox. But this is not random, this is based on assessment of minimal residual disease, for example by PCR flow. So we’re defining patients that got rid of the disease by these modern techniques and you’ve observed them for another three months, for example, then you take them off these new drugs that usually should be given continuously but we discontinue them. So that’s an ongoing line of research.
And do you have a take home message?
For especially also patients watching this, I think we have now a very luxury time, finally, in leukaemia research. So in some cases you also can call it an agony of choice. So if a very efficient frontline treatment does not work we can rescue most of the patients with new combinations, with new drugs I just mentioned and there is significant progress. I always tell my patients we just should wait, the future is bright and the future is working for you.
