Ask The Doctor Q4 2020: CAR-T Edition
By Brian Koffman, MDCM (retired), MS, Ed.
MRD-specific questions submitted by readers and answered by the CLL Society Medical Advisory Board
Remember that we cannot give medical advice and any suggestions should be reviewed with your treating doctors.
By Brian Koffman, MDCM (retired), MS, Ed.
I was diagnosed in 2013 as a 17P/TP53 and began a trial at MDA under Dr. Susan O’Brien (presently Dr. Jain) with Ibrutinib & Rituxin. For 4-1/2 years my markers were fantastic but the Ibrutinib was showing signs of diminishing effectiveness. Dr. Jain prescribed Venetoclax & Rituxin and for the last 2 years I have had tremendous success with zero side effects. Two weeks ago I returned to MDA for blood, SCAN & bone aspiration and it was determined that I am MRD negative. The big decision for me was whether to remain on Venetoclax for another year or go off treatment until my blood markers indicated needed treatment. I chose to remain on Venetoclax. Based upon my 17P situation, did I make the right choice?
Answer from Dr. Koffman: The truth is we don’t know the answer to this question. Some doctors would repeat the MRD testing after 90 days or so, and if confirmed the U-MRD, then stop the venetoclax. This is an important discussion to have with your doctor and Dr. Jain is one of the best.
I have been on ibrutinib for 3 years and all my counts are normal including my absolute lymphocyte count, but I am not uMRD in my blood. Should I worry?
Answer from Dr. Koffman: When drugs such as ibrutinib, as well as acalabrutinib, idelalisib and duvelisib are used on their own, uMRD is rarely reached, but the good news is that is doesn’t seem to matter. In the vast majority of patients that do well long-term on ibrutinib, the drug with the most years of data available (over 7 years in some studies), most have detectable MRD and that does not portend any problems.
I am uMRD in the blood? Do I need a bone marrow biopsy?
Answer from Dr. Koffman: The usual answer in no as there is a strong but not 100% correlation between the results in the blood and the marrow. The exception might be in the months right after use of a monoclonal body that might clear all the CLL out of the blood, but leave some residual cancer cells in the marrow. The role of a bone marrow biopsy in monitoring MRD is evolving and overall diminishing outside of clinical trials.
I am 60 years old with CLL and started a venetoclax and gazyva combination last February. I will be ending fixed duration treatment in January of 2021. What treatment are you seeing patients are getting to keep the MRD at low level?
Answer from Dr. Koffman: I am not sure I understand the question. If you reach uMRD, then many, but not all, doctors would stop all drugs and just monitor you. If you have detectable MRD, the choice is more complicated and beyond the scope of a simple online answer. Discuss this with your doctor and consider a second opinion. Look at our free expert access program: https://cllsociety.org/cll-society-expert-access/
Dr. Brian Koffman, a well-known retired doctor, educator, and clinical professor turned patient has dedicated himself to teaching and helping the CLL community since his diagnosis in 2005. He serves as the Executive Vice President and Chief Medical Officer of the CLL Society Inc.
Originally published in The CLL Society Tribune MRD Special Edition.
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