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ASH 2024 | Updates to the ESMO clinical practice guidelines for CLL
Carsten Niemann, MD, PhD, Copenhagen University Hospital, Copenhagen, Denmark, comments on the recent updates to the European Society for Medical Oncology (ESMO) clinical practice guidelines for chronic lymphocytic leukemia (CLL). He highlights the addition of assessing comorbidities and mutational status to allow for personalized treatment decisions. This interview took place at the 66th ASH Annual Meeting and Exposition, held in San Diego, CA.
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Transcript (AI-generated)
So the recent update on the ESMO guidelines was based on the development and publication of a number of different clinical trial results. But it also changed the paradigm in terms of how to assess frailty or comorbidity, where we now have gone from a situation beforehand where it was just a combined frailty that would divide patients into slow-go or go-go patients that could be treated with intensive or less intensive chemotherapy or not at all...
So the recent update on the ESMO guidelines was based on the development and publication of a number of different clinical trial results. But it also changed the paradigm in terms of how to assess frailty or comorbidity, where we now have gone from a situation beforehand where it was just a combined frailty that would divide patients into slow-go or go-go patients that could be treated with intensive or less intensive chemotherapy or not at all. Now we are in the situation where different targeted agents may have differences in terms of toxicity profile and thus we need to look at cardiac comorbidities, could be hypertension, type 2 diabetes, maybe even the frequency of infections prior to starting treatment and use that to inform what would be the best treatment, both in terms of weighing the risk of toxicity, adverse events, and efficacy. So on top of the molecular subgroups, with TP53 mutations and deletion 17p and IGHV unmutated status still being high risk factors, drawing the patients towards either continuous BTK inhibitors or maybe combination of BTK inhibitors and BCL2 inhibitors. We also need to look at frailty, whether patients have higher risk of specific adverse events, could be on BTK inhibitors with cardiac events, but it could also be the logistics for the patient that they would actually not be able to go for long-term venetoclax treatment because they would come in frequently during the ramp-up period, and that might be tough if you’re living five or ten hours drive from the hospital. So bringing that together, we have really good options for treatment, and we divide it based on IGHV mutational status and TP53 aberrations and the comorbidity, ending up with having time-defined treatment as the best option, whether being venetoclax obinutuzumab or venetoclax ibrutinib for patients, except for the ones with TP53 aberrations, where we may still consider indefinite BTK inhibitors.
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