iwCLL started as a small international working, the “iw” in the acronym iwCLL, group that held meetings around the world and now has grown to a meeting of 1,400 attendees that reviews all the latest research in chronic lymphocytic leukemia. I believe that the high attendance number was helped by the smart move to hold the 2019 meeting in beautiful Edinburgh, Scotland.
At iwCLL 2019, I interviewed Dr. Tom Kipps from UCSD who has been my personal doctor for over 14 years and what a wild ride that has been. Treatments are so much better now. Today we have many safe highly effective non-chemo choices.
It is interesting that when I asked Dr. Kipps, MD, PhD about how he approaches a new patient that need treatments, he homed in on fixed duration therapies, mostly those based on venetoclax.
Takeaways:
- Venetoclax based therapies are very effective in both frontline and later lines of therapy for CLL.
- The Murano trial of the combination of venetoclax and rituximab led to approval of that combination second line in CLL. See this on that big news.
- The more recent trial that proved venetoclax combined with obinutuzumab (VenG) was superior to chlorambucil and obinutuzumab led to approval of VenG as a frontline option for treatment naïve patients in May 2019.
- This is was the first non-chemo fixed duration therapy approved. Patients could stop all drugs at 12 months.
- By using the obinutuzumab first, the tumor burden is reduced, so there is less cancer to kill when the venetoclax is added later, leading to less risk of tumor lysis syndrome (TLS) that occurs when too much cancer is killed too quickly, overwhelming the kidneys’ ability to cope with the changes in the electrolytes, especially potassium. This can be fatal and is why we slowly ramp up the venetoclax as it is such a powerful CLL killer. For more on what you need to know if you plan to take venetoclax, you can read our pharmacist, Tom Henry’s helpful article.
- New combinations may make fixed duration therapy possible with ibrutinib and other drugs too.
Conclusions:
As Dr. Kipps wisely admonishes us, it is important not to get complacent. CLL is not solved and even though we have great drugs, they don’t always work. Very few CLL patients are cured, but more of us are living longer and longer.
How we sequence the therapies is hardly worked out either. Even the timing of when to use the venetoclax and when the obinutuzumab in combination is unclear. Dr. Hillmen suggests that it might make sense to start the venetoclax first. Dr. Skarbnik has research that questions the benefits of adding rituximab to venetoclax.
Not everyone agrees that fixed duration is the best way forward.
So many unanswered questions, but through active research we are finding answers and the Gestalt is that it is getting better all the time.
Please enjoy my brief interview with Dr. Kipps at iwCLL in Sept. 2019 in Scotland.
Stay strong.
We are all in this together.
Brian Koffman
