Wednesday, December 5, 2012

ASH Abstract: Long-Lasting Responses with Lenalidomide As Initial Therapy of Elderly Patients with Chronic Lymphocytic Leukemia (CLL)

Here's another abstract from ASH, # 3932.

I need to be reminded that most patients with CLL are elderly. The median age at time of diagnosis is about 71 or 72. I tend to be in touch with a skewed population sample as I suspect that those who follow my blog and are active on a list serve or Yahoo group might be a younger bunch. There are of course many many exceptions.

Our bone marrow becomes less resilient as we age (doesn't everything), so the standard approach of FCR can be hard and persistently dangerous low blood counts can delay or even prevent a full course the chemo-immunotherapy. And some elderly may not tolerate the adverse events as well, especially those who have picked up co-morbidities during their long lives.

That is why it is encouraging to see non chemo approaches to CLL, this time with the immune modulator, lenalidomide (the son of the infamous thalidomide that caused so many birth defects).

No-one is quite sure how it works, but that is a topic for another post.

The old good news is that it is a pill (no infusion needed) and the response rate is high with two out of three patients responding and a whopping 88% alive at two years. What is new this year that is being presented at ASH 2012 is that the researchers continued to follow this cohort and now three full years out (or longer) 31 of 60 are still responding. 29 of those 31 are in a CR (complete remission) with 4 MRD negative (minimal residual disease negative) CR. Very nice durable responses in a little over half of the patients for  at least 36 months! 

The median dose was low, only 5 mg a day, with a range of 2.5-10. That's good. This is one drug that is cheaper and safer at lower doses. Side effects that led to stopping the drug were the usual suspects: DVT (deep vein thrombosis) fatigue, secondary cancers (skin), and neuropathy.

Neutropenia resolved in 83% patients within a year. Hgb (100%), platelets (77%) and even immune globulin (IGG, IGM and IGA levels were higher than baseline in those who were long term survivors. T cell counts increased, More good news and a very different story than told by most chemo drugs.

The bad news is that it doesn't work for those who need it the most. Long term survivors "were more likely to have lower baseline levels of beta2-microglobulin, IL6, IL8, IFNγ and MIP1α and intermediate or favorable cytogenetic abnormalities."

In other words, those whom are favorable to treat, are favorable to treat. Those of us with poor prognostic factor live up to our billing, at least with this drug.

Remember also that everything has its price Lenalidomide is associated with potentially fatal blood clots, tumor lysis syndrome, painful and potentially fatal tumor flares, secondary cancers, suppressed blood counts, profound fatigue, diarrhea, neuropathies, and serious infections, so use with caution.

Still for half the population, this looks like a fine option. Better than chemo.

For the others. let's check for the news of trials of the tyrosine kinase inhibitors in the elderly.

On a personal note, my blood chemistries remain remarkably unremarkable with kidney and liver function all in the very healthy range. Low LDH and uric acid are also reassuring that nothing sinister is brewing in my blood.

Tonight, I am off to the beach, where there is no WIFI, but my cell phone works. I have mixed feeling about that.

From there I leave for ASH in Atlanta on Friday.  Much to share.

Life is good.

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