Treatment of Frontline CLL has dramatically evolved in the last decade. As the number of novel options and strategies available to us continues to grow, treatment decisions have become increasingly complex. In this segment of the CLL Discussion series Dr. Versha Banerji (CancerCare MB) discusses current standards and how recent data will impact treatment decisions in frontline CLL moving forward.
What is your current approach for determining optimal frontline treatment strategy?
- First and foremost is molecular stratification
- IGVH status, p53 mutation status, and FISH status Mutational status allows for patient categorization into high- or low-risk
- Other factors are fitness and age to determine which options may be best in terms of tolerability
- This can include whether they have other medical conditions, are on other medications, what is the travel time for them to get the regimen, or whether they can take it independently.
- Current recommendations:
- in younger, low-risk patients: FCR
- in older, low-risk patients: time- limited, non-chemo strategies (i.e. Ven-O or Clb-O)
- in high-risk patients: BTKi (IB or Acala)
What factors do you believe are most important to discuss with patients prior to making a treatment decision?
- Main goals for me to achieve are things that maximize QoL
- It is important to ask what they want to accomplish with treatment and get a sense of what their short- and long-term goals are (i.e. improvement in QoL, ability to maintain activities of daily life, if they want to travel, etc.)
- I also want to understand what support is available to them for things like travel for treatment and what worries them about the treatments that we are offering.
What recent data in the frontline setting do you anticipate will impact your approach moving forward?
- Exciting updates in the Canadian environment that will impact practice now include recent funding of Ven-O for elderly, unfit patients and acalabrutinib (based on the ELEVATE-TN study)
- Multiple recent studies have shown promising results for time limited treatment with combinations of novel agents (i.e. Ven+ a monoclonal antibody, or Ven+ BTKi).
- The FLAIR study (FCR vs IR in young, fit patients) reported on at ASH 2021 supports use of FCR in this population.