Front-Line Therapy Decision Criteria

Key opinion leaders consider the decision criteria for selecting a front-line therapy for patients with chronic lymphocytic leukemia (CLL).

Cody Steeves, PharmD, BCOP: What are some of the front-line therapy decision-making criteria that you see, and how do you present treatment options to the patients with factors such as patient factors, disease factors, and mutation status?

Alison Duffy, PharmD, BCOP: I think the criteria used to be far more rigid in terms of patients that were frail or unfit, those that were older, maybe younger with comorbidities, and those that were young and fit. Previously, if you're familiar with the guidelines, those that are listening in, there used to be very stringent buckets such as no-go, slow-go, and go-go. So historically, we've had these stringent boxes. I think there's a number of factors still to consider, and it is a very patient-centric shared decision.

Some of the things that I would think about would be age, fitness, comorbidities such as atrial fibrillation, and renal function if we're going to give something like fludarabine within the FCR regimen. Cytogenetics might be important, but mutation status can be really helpful, as well.

So patients that have immunoglobulin heavy chain variable, or IgHV-mutated CLL, those patients do seem to do better with chemo-immunotherapy, so for our young, fit patients, the fludarabine, cyclophosphamide, rituximab, or the FCR regimen, still seems to be the best for those patients.

In addition, I think patient preference and clinical experiences are important. Not every patient is a great candidate for oral therapy because of access, finance, or just comfort level and adherence challenges—and transportation also might be a barrier to getting IV [intravenous] chemotherapy.

So I think some of the other chemo-immunotherapy options could be a patient where they want a defined period of therapy. Those are the types of things that I would consider looking at. What about you, Dr. Steeves? Anything?

Cody Steeves, PharmD, BCOP: No, I certainly agree. I think the oral therapies and their success rate in those patients with 17P-deletion, has been a big factor in changing the landscape of this treatment.

So moving forward, it's positive to see that the outcomes, when they're stratified by those patients with the deletions, still tend to trend in the positive direction, for those patients with these newer oral therapies we've had over these last 5 or 6 years.