SOHO 2023 | Factors to consider when selecting initial therapy in CLL: patient features & preference

Selection of initial therapy for CLL has become a little more complicated in a way, because a lot of it actually depends potentially on patient preference. The two main choices include continuous BTK inhibitors, and if you’re using acalabrutinib, you might add obinutuzumab- so plus or minus a CD20 antibody- or one year time-limited therapy with venetoclax-obinutuzumab. We do take into account some patient features. For example, patients with 17p deletion or p53-aberrant disease do have a longer initial progression-free survival with the BTK inhibitor regimens. We don’t know if that could be overcome down the line by retreating with the time-limited regimens, and that data is still to emerge, but for now, if they’re not enrolling on a trial, we tend to favor continuous BTK for those patients. In terms of IgHV status, the mutated IgHV patients, we know if they achieve undetectable MRD, they can have very long durations of remission off therapy. So, I tend to favor a little bit more of the time-limited venetoclax-obinutuzumab regimens for those patients. But, there’s still a huge amount of patient preference in terms of are the patients willing to come in for the visits, for the infusions, for the escalation of venetoclax. It’s a lot more work for the patient to start on venetoclax-obinutuzumab than it is to start on a continuous BTK inhibitor. So we do find some of the older patients in my practice in particular, though I have also heard this from others, may not want to come in that much, and they’re just fine taking the continuous BTK inhibitor, especially now that we have the next generation drugs, which are much better tolerated than ibrutinib.