SOHO 2026 | Avoiding common pitfalls when managing patients with ALL outside of specialist centers

I think the places where we need to improve how we engage community physicians, in ALL specifically, is one, the timeliness of the referral. I don’t think we need to own the care. So if there’s a concern about patient retention, and again, all these, I hate to say it, it’s still a business for, you know, our community colleagues. We can still focus on retention, focus on, you know, local management. I’m perfectly fine with that. But that early referral to set the stage of, hey, this is how I would recommend you approach this person based on you’re in one of these now, what, 30, 40 different types of ALL? And the types of ALL keep, it seems like, increasing. This rare disease that gets getting diced and diced smaller. This is our advice for managing KMT2A rearranged, right? We’re thinking mid and early. This is our advice for PDGFR rearranged leukemia. We’re thinking about efforts to tolerate the PDGFR or the FGFR, you name it. This is our guidance for how to move forward so we can avoid that relapse. Get them in early. The early referral also helps with transplant referral and helps with clonal ID. And if their MRD positive post-induction gets us thinking down a whole different path, how are we going to clear the MRD? How are we going to cure the patient? That can be early incorporation of CAR-T. That’s our trial, which I’m still very excited about. It could be, though, that you do something like a blina or something else in that NGS MRD positive setting. Again, the tool is going to be informed by the, you know, again, what we’re doing at diagnosis genetically, molecularly to inform some of those questions. Also asking who’s the patient, right? It may be a very different answer for someone who’s 78 than it is for someone who’s 28. So all of this we can try to address with the early referral piece. So I think that’s a key. The second thing in terms of, I wouldn’t call it getting wrong, but how we can better engage our community partners is for those bigger hospitals, how do we use the tools that we have in hand, the blinas, the inos, the CARs, again, the menins, the TKIs. How do we think about the optimal use there in that situation so we can avoid untoward toxicity? And I would say one of the sort of more common things that I see is maybe a little bit too much of a dependence on inos. And let me be very clear what I mean by that. Great drug, but you have to understand that once you get beyond that, call it two and a half milligram per meter squared threshold, you’re going to see liver tox, like meaningful liver tox. This is not a drug you want to push for six or eight or more cycles. And this says nothing of the marrow damage that occurs in that setting, right, where we’re enriching now for MDS and AML and so on. So I think that I’m picking on ino, not because it’s an ino issue, but because it’s a bigger issue of how do we employ the agents we’re employing? I also wouldn’t want someone giving blinatumomab indefinitely. Again, I know the label, but you’re just going to enrich for extramedullary relapse if you’re pushing to cycle nine and 10 and 12 and so on. And I say that from experience because that’s what we were doing in the beginning and we learned that lesson. And so we want to make sure that we communicate some of these lessons to our partners. But all of that gets addressed. Again, coming back full circle, how do we educate? How do we build these novel regimens that can be employed in community settings? And how do we partner for the care of our patients so bad things don’t happen.

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