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ERIC 2020 | The treatment and management of CLL across the globe

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Robin Foà

Robin Foà, MD, Sapienza University of Rome, Rome, Italy, discusses the management and treatment of chronic lymphocytic leukemia (CLL). Immunochemotherapy, in the right context, is still a valid option for treatment. In some countries, novel drugs are less available and immunochemotherapy is the only option. Additionally, the way treatment is paid for in different countries has a big impact on how CLL is managed. This interview took place during the European Research Initiative on CLL (ERIC) International Virtual Meeting 2020.

Transcript (edited for clarity)

Well, CLL, if I go back to in the old days, was a disease for a bunch of aficionados, because nobody really was interested. A few decades ago, CLL disease of the elderly in those days, chronic, indolent, etc. Now it changed dramatically, everybody’s interest CLL and the change has been really substantial. So, I think the themes that will covered or, I think what important now, if we will look at frontline treatment...

Well, CLL, if I go back to in the old days, was a disease for a bunch of aficionados, because nobody really was interested. A few decades ago, CLL disease of the elderly in those days, chronic, indolent, etc. Now it changed dramatically, everybody’s interest CLL and the change has been really substantial. So, I think the themes that will covered or, I think what important now, if we will look at frontline treatment. One theme that will be covered, I know because we had a conference call recently to discuss these points is, for instance, has chemoimmunotherapy still have, does it still have a role in frontline treatment of CLL? And I remember saying that this has to be seen in a rather broader context. ERIC put together colleagues from, theoretically, all parts of the world. And as you know, as we both know, the world is very heterogeneous.

So, you can ask a colleague maybe from the US and he, or she will answer, I will start with the new drugs. You can ask a colleague in, I won’t mention which country, but let’s say less resourced parts of the world, less lucky. And the answer would be completely different. So, I think we have to put it in a context on what can be done and the realities are enormously different in terms of treatment, but also prognostic workup because, as you know, CLL has changed and now we have a number of prognostic markers that should be tested, they are in the guidelines. So, at the time of treatment, you should test at least for FISH sequencing, p53 and immunoglobulin genes.

And how many patients are tested around the world? This is not trivial. We do it, obviously the lucky countries do it, but the lucky countries are always less. And I would say it now it’ll be even worse with the disaster we’re witnessing everywhere. So I think these are key points, what will be used frontline and chemoimmunotherapy still, as I see it, has a role. And in fact, there’ve been many studies showing that chemoimmunotherapy is still a very valid option if you have good prognostic markers. That leads again to the fact that you have to test for these markers. As an example, a fit patient who has mutated for immunoglobin, does not have 17p, does not have 11q, does not have a PFD mutation, could safely be given a short course of chemoimmunotherapy. And this patient may even be cured because this patient may become MRD negative. Other issue with that will be discussed at ERIC a lot is MRD, minimal residulal disease, should be an endpoint? And the answer is no, outside of clinical trials.

So these, I think are the topics: what can be done and who’s paying for what; that’s another issue because in many parts of the world, if you can pay, you can be treated differently. And that goes, for instance, another issue that I think is very important, is treatment off-label or not. In Italy, we could not give a drug off-label frontline, in other part of world, if you pay, you can get it. So this makes a big, again, a big difference in the management of patients. So I think they’ll be many topics and I stress that I hope, and I told the organizer, it’s important to know who is in the audience. And in fact, they want a session they will ask upfront, who is there, who is listening from which parts of the world, because I think we should always keep this in mind when we give a talk, whether it’s just in presence or virtual, but it’s very important to know who’s on the other side and what they can do in their country or region even.

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