LRF Brooklyn, NY report - Part 2 TX strategy

[Guest guest]

The CLL/SLL breakout session from the LRF Conference was

conducted by Dr. Bruce Cheson of town Univ. It struck

me how heavily slanted his program talk was toward frontline

use of Bendamustine & Rituximab. Having read Terry Hamblin's

critique of the Clinical Trial which was largely the basis

for Bendamustine approval by the FDA wherein Bendamustine

was compared to an inferior patient dosage of Chlorambucil,

asked Dr. Cheson to comment and he flat out denied that

Chlorambucil had been under dosed " Not true " he said and

took another audience question. I asked about his opinion

for appropriate usage of Chlorambucil, as in an older

patient population. His answer was " We do not use

Chlorambucil - Period "

This got me to thinking about how Wait & Watch members are

to navigate the uncertainty surrounding the all important

question of what therapy to begin with when the time comes

for 1st TX. Situations for each patient are as different as

our cancer behaves. A variety of factors influence treatment

choices based on country of origin, insurance coverage, age

and co-morbidities not to leave out access to CLL Dr.

expertise. While having at least one consultation with a CLL

expert is important the patient should be aware that Experts

often are prejudiced by the therapy that they will

recommend, are most familiar with and or have their careers

dependent on. So, do you pick " The Doctor " or do you pick " a

treatment " you believe may give you a better chance. If you

go with picking a Doctor, do you go with the conservative

who may push Wait & Watch and use less toxic frontline

therapies or do you go for the Doc who is more aggressive

and want to treat earlier and with more toxic regimens with

the goal of getting one a longer and deeper first TX

remission? How do these differing approaches play out in a

rapidly changing era where newer less toxic therapies are

being tested in Clinical trials?

It is not my place to argue the case for or against

frontline BR or the motives of Dr. Cheson but it left me

with the impression that more patients who choose to go to

Dr. Cheson will be channeled toward BR use in a frontline

setting as opposed to say FCR or FR. Needless to say he

might become the authority on who would most likely benefit

from BR use and who might be mostly likely to fail. This is

not knowable now.

In a general session Q & A I asked Dr. Cheson about data for

side effects, primarily MDS (MyeloDysplastic Syndrome) and

secondary cancers with Bendamustine or BR. He indicated that

much of the data had been on BR usage as a salvage/second

line therapy and it was too early to evaluate BR side

effects based on frontline usage. Fair enough but those

contemplating frontline use of BR should see themselves as

in a Clinical Trial of sorts. For younger patients, the

question for use of BR should be: " Because Bendamustine is

considered more of an alkylating agent than a purine analog,

will the long term use or protracted time from first use

reflect side effects seen in other alkylating agents like

Cyclophosphamide? "

To further your knowledge: T. Hamblin's recent article

" Chlorambucil - Still not bad: a reappraisal &

http://mutated-unmuated.blogspot.com/2011/02/bendamustine-is-it-better.html

's excellent review in CLL Updates -

http://updates.clltopics.org/3919-br-in-relapsed-patients

The bottom line and ironically for this LRF Coneference, I

was sitting next to a guy who had switched to a CAL-101

Trial after a reaction to BR nearly killed him. Dr. Cheson

cannot predict who these folks will be and the only way to

eliminate some of the uncertainty in Treatment choice is to

push for comprehensive DNA sequencing and comparative

analysis to begin development of predictive drug reaction &

response road maps for all Docs to make better therapy

outcomes for their patients.

WWW

[Guest guest]

Hi Wayne,

I understand what you are saying and believe highly targeted

therapies are the ideal treatment choices. You write

" the only way to eliminate some of the uncertainty in

Treatment choice is to push for comprehensive DNA sequencing

and comparative analysis to begin development of predictive

drug reaction & response road maps for all Docs to make

better therapy outcomes for their patients. "

DNA sequencing and compatative analysis as part of trial

design?

Then DNA sequencing for all patients?

And who needs to be pushed: NCI, FDA, Drug companies,

doctors, researchers,, or all? And how?

Great posts!!

Q

[Guest guest]

An important aspect of this comment, which is very eloquent

in its assessment, is that the patient who receive BR

upfront will definitely require subsequent therapy. So when

asking about myelodysplastic syndrome after BR, whether it

is upfront or in relapse is irrelevant, as patients will

eventually need both.

Rick Furman

Wayne Wells wrote:

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