ASH 2016: Which Patients With Chronic Lymphocytic Leukemia (CLL) Become Resistant to Ibrutinib

This week I'm posting the final installment of my 3-part interview with Dr. Adrian Wiestner from the NIH where we discussed which CLL patients are more likely to relapse when being treated with ibrutinib and the options that are available if that happens. You can read my summary, and watch the interview here: cllsociety.org/2017/06/cll-...

TOMORROW, the 2nd 2017 issue of The CLL Tribune will be published. Watch your email and set aside some time to read the fantastic articles in this issue, written by both patients and CLL experts. Very cool

Stay strong.

We are all in this together.

Brian

Ibrutinib failure as a result of progressive chronic lymphocytic leukemia (CLL) or Richter's Transformation.

This week I'm posting another interview that took place at ASH 2016 with Dr. Adrian Wiestner from the NIH where we discussed ibrutinib failure as a result of progressive CLL or Richter's Transformation. You can view my summary, and watch the interview here: http://cllsociety.org/2017/06/ibrutinib-failure-prog-cll-rt/ 

We have posted interviews and articles about research that is being conducted to study treatment options for patients with relapsed or refractory CLL. On occasion we will make our readers of a clinical trial that is starting that might be of interest. Today we have posted some information about a trial for patients with relapsed refractory CLL who have received 2 or more prior treatments, including treatment with a BTK inhibitor such as ibrutinib or acalabrutinib. You can read more about it here: http://cllsociety.org/2017/06/new-clinical-trial-rr-cll/

Stay strong

We are all in this together

Brian

More good news about my CLL (chronic Lymphocytic leukemia)

Let me set this up.

My  particular flavor of CLL has a complex karyotype and a deletion of the short arm of the 17th chromosome. And a clonal Notch1 mutation- This is all bad.

What that means is that my CLL is unstable and has a tendency to mutate. These mutations can lead to more aggressive clones of CLL that are resistant to therapy, or in worse cases transform into nastier blood cancers.

That last process is called Richter's Transformation.

I have now been on ibrutinib for over four years and 8 months.

Most Richter's Transformation happens in the first two years of treatment so I am well past the high risk period for that life threatening development. For that I am deeply grateful.

I do have a recognized mutation that does confer resistance to ibrutinib in PLCƔ2. This mutation can turn back on the signaling blocked by ibrutinib, essentially rendering the drug impotent. 

My small subclone of CLL that has the PLCƔ2 mutation has been slowly growing for about two years now. That is until my last blood test that showed it had stabilized over the last 84 days, and had in fact dipped a tiny amount.

For that I am also grateful.

This is quite unusual as the usual pattern is a relentless climb in the number of resistant cells.

Why it happened and what I can do to keep it going down is a mystery. I would like to think it is because I have been exercising more, but that is a wild conjecture. But after I finish this post, I will work-out, just in case.

I know this might be just a pleasant respite on the road to relapse, but I'll take this sweet repose. And wish for more

For those whose CLL is more tame, the news is nearly always good, but most folks with my nasty mix of genetic freakiness have already progressed a long time ago.

While I was at the 2016 ASH meeting in San Diego last month, I had the opportunity to sit down with Dr. George Follows to talk about real world data on 300+ CLL patients being treated with ibrutinib compared to clinical trial data. You can view our interview here on the CLL Society website.

This is important as too often the data is much better in the clinical trials than in the community, but for ibrutinib, this does not appear to be the case. And for those without bad markers, the results are very encouraging. 

ASCO 2016: Dr. O'Brien on what happens when we fail ibrutinib for our CLL (chronic lymphocytic leukemia)

Last week in the Conference Coverage section, we’ve posted another interview with Dr. Susan O’Brien out of UCI where we discussed an important paper that cleared up some confusion about what happens when patients fail on ibrutinib. You can view that interview here. http://cllsociety.org/2016/09/asco-2016-prior-therapy-ibrutinib-outcome/

This is a really important topic that has been badly misunderstood and highly recommend you take a look at the interview.

We are pleased to announce that a new CLL Patient & Caregiver Support and Education Group will be starting in partnership with the Levine Cancer Institute – Morehead in Charlotte, North Carolina. The first meeting will take place on Tuesday, October 18th at 6:30 PM. Patients and family caregivers are welcome. Find out more about dates and registration here.

Another NEW CLL Patient & Caregiver Support and Education Group will be starting in Tampa this fall: Tentative Meeting Date November 1^st at Moffitt Cancer Center. Stay tuned for details!

From time to time, we will make you aware of in-person meetings coming up for those of us affected by CLL and lymphoma, specifically:

·      Monday, September 19^th at 10 AM at The Grand Central Hotel in Glasgow, Scotland: The CLL Support Association (CLLSA) is hosting a 2016 Glasgow Members Conference. Dr. Alison McCaig a consultant in the haematology department of the Royal Alexandra Hospital will be the featured speaker. You can find out more information and register here. Lunch and refreshments will be served and there is no charge to attend for members.

·      Wednesday, September 21st at 6 PM at the New York Marriott East Side in New York City: The Lymphoma Research Foundation will be hosting Updates on Chronic Lymphocytic Leukemia / Small Lymphocytic Lymphoma as part of their Ask the Doctor series. Rick Furman from New York Presbyterian – Weill Cornell Medical (also part of the CLL Society Medical Advisory Board) is the featured speaker. You can find out more information and register here. Dinner will be served and there is no charge to attend.

·      Saturday, October 8^th at 9 AM at the Teaneck Marriott at Glenpointe: The Leukemia and Lymphoma Society will be hosting their New York/New Jersey Metropolitan Area Blood Cancer Conference. Dr. Anthony Mato from the Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA will be speaking during the CLL breakout session. You can find out more information and register here. Breakfast and lunch will be served and there is no charge to attend. Parking is also complimentary.

Heads Up! The CLL Society has become aware of a series of unbranded patient meetings coming up in September and October (with a few more to come in November and December). CLL patients will share their personal stories, and local CLL experts will be providing a talk on the basics of CLL. A complimentary meal will be provided and parking is free. You are welcome to bring a guest.

One member of the CLL Society will be at each meeting to show a brief video and give a talk about the impact support and education groups have had on their CLL journey. We will provide practical tips and support for setting up a local CLL group and will stay afterwards to meet with attendees who may be interested in participating in a support group in those areas. We look forward to meeting you there. After tonight’s meeting, the next 9 confirmed meetings are:

·      Saturday, September 17^th in Long Island, NY. More details in the flyer. Access it here.

·      Wednesday, September 21^st in Madison, WI. More details in the flyer. Access it here.

·      Saturday, September 24^th in Framingham, MA. More details in the flyer. Access it here.

·      Thursday, September 29^th in Portland, OR. More details in the flyer. Access it here.

·      Tuesday, October 4^th in Phoenix, AZ. More details in the flyer. Access it here.

·      Thursday, October 6^th in Park Ridge, NJ. More details in the flyer. Access it here.

·      Tuesday, October 11^th in Bloomington, MN. More details in the flyer. Access it here.

·      Tuesday, October 25^th in Golden, CO. More details in the flyer. Access it here.

·      Saturday, October 29^th in San Francisco, CA. More details in the flyer. Access it here.

In the meantime….

Stay strong.

We are all in this together.

Brian Koffman, MD

http://cllsociety.org

Personal Update on my CLL: I am doing well with a near normal MR and no evidence of resistance to Ibrutinib at 42 months

I had MR imaging of my abdomen and pelvis earlier this week at St. Jude. The results were compared to my CT scans done on June 30, 2014 at Ohio State, about 16 months ago. 

I am now on my 42nd month on ibrutinib as part of the OSU clinical trial.

The abdomen showed no adenopathy. No abnormal nodes. None. No big nodes! 

WOW!

My pelvis did show one plump node in the left external iliac area (drains the lymph from the left side of GU tract) that was borderline enlarged and probably 2 millimeters bigger than it was before. 

Different techniques, different doctors, different times. I don't think the 2 mm. means anything and either does Dr. Byrd so I refuse to worry.

I switched to the less precise technique of MR to avoid the potential cancer causing risks of ionizing radiation of the many CT scans that are part and parcel of clinical trials.

When relapses happen with ibrutinib, they often start in the nodes. And that clearly is not happening in my case. And that is great news.

The other great news was that my blood tests done at OSU for the two common mutations that can lead to resistance to ibrutinib were negative, namely the downstream gain of function mutation of PLCγ2 or the C481S mutation at the BTK binding sites that prevents ibrutinib from irreversibly (covalently) binding. Either one of these mutations could turn back on the signaling. Blocking BTK signaling is the key to the success of ibrutinib in handling the CLL clone, so if the blockade is broken than will lead to resistance and eventually relapse

It is not a perfect test, but I had neither one at detectable levels.

Tomorrow I go for IVIG for my still dismal levels of immunoglobulins and to keep my auto-immune ITP at bay. I will also have routine labs drawn, but I am not expecting any surprises

A week later I am back at OSU for my 3 month check-up.

Flying to Ohio in the late fall and all winter is not predictable, but what I can predict is good care and what I can anticipate is more good good news as I am heading towards 4 years on ibrutinib.

UPDATE: My CBC at the infusion center Nov. 12, 2015 was basically normal. Hemoglobin was really normal at 14.5 so no anemia, platelets were very slightly above normal at 458,000 due to my splenectomy, ALC was at the low end of normal at 1.0 and that makes me most happy and my ANC was a healthy 8.1.  

All good. YEAH!

Hope to see you at our after ASH educational bash at City of Hope on Dec 12. Click here for the details.

ESH 2014: Dr. Cathy Wu Explains TUMOR HETEROGENEITY and CLONAL EVOLUTION in CLL (Chronic Lymphocytic Leukemia)

This is taken from the first of a two part interview with Dr. Cathy Wu in Greece where I spoke on the patients' perspective at a meeting of the Greek Hematology Professional Congress.

It is also a teaser of what is to come in the new website of the nonprofit The CLL Society. That CLL specific education and support site should launch in the next few weeks. It will offer much deeper and broader information and be more searchable than is possible with a blog. 

Be assured that my blog is not going away but may revert back to more of a personal blog and the place where I continue to host my candid and occasionally combative opinions and commentaries. 

Truth is that the plethora of news and emerging therapies in CLL have outgrown the capacity of my time linear blog to keep up. This new format also will offer the chances to hear other patient voices in what will be the only patient driven physician curated place on the web for CLL support and education.

I and the team of fellow volunteers are pretty excited. It's been a ton of work, but our mission is to address the unmet needs of the CLL community and we believe this new website will be a helpful piece of that effort. There is great information out there and we want to help everyone find it and explain it in our soon to be born strong and friendly CLL focused website.

Honestly, my efforts to help launch our nonprofit 510c3 and its website has consumed me, leaving less time to post here.

While we are still building phase 1 of the new website, I plan to continue to post news and interviews like this one here modified for this blog. The website will offer more links, a glossary, some surprise, and a whole lot more.

Stay tune, but I digress.

This clonal heterogeneity discussion is very important stuff on how our cancer evolves and what it means when we consider therapies.

TAKE AWAY POINTS:

·     Cancer by its nature is genomically unstable.
·     Over time it acquires more mutations.
·     New clones and sub-clones can arise over time.
·     Therapy can influence the balance and evolution of the clonal and sub-clonal populations.
·     Those changes may have significant implications for how to best manage our cancer.

PREFACE:

Hematology in general and CLL specifically are full of jargon and acronyms that can be both overwhelming and daunting.  With time and experience, you'll become familiar with the terminology and acronyms.  We will try to explain each medical term the first time it appears in an article, but we will use the true terminology so that you gain comfort and familiarity with the medical terms that you will see in your lab reports and in medical articles. We will also provide a glossary for your reference.

CLONAL HETEROGENEITY:

Dr. Cathy Wu out of Dana-Farber starts at the basics.

In the first of our two part interview from the International Conference on New Concepts in B Cell Malignancies: From molecular pathogenesis to personalized treatment in Greece in November 2014 she reminds us that while the concept that any cancer is made of multiple populations of different cells dates back to the 70s, it is our recent ability to look deeply and quickly at the genome with next generation genetic sequencing that has really cracked open our understanding of how huge a factor this is in one’s particular CLL aggressiveness and its ability to become resistance to therapy.

We now know that questions about the presence or absence of a good or bad prognostic indicator often should not be answered with a simple yes or no.

More importantly we know that our population of our cancer cells evolves over time. Hence the need to repeat FISH and other tests when the contemplating therapy.

An analogy: In most good movies the lead protagonist has an arc to his or her character. We see how he or she changes and evolves in response to the support received or the challenges faced.

So too it is with our cancer. Unfortunately CLL is much more like a movie than a snapshot. Dr. Wu explains our cancer may evolve over time in response to therapy and other selection pressures.

Please enjoy our video interview with Dr. Cathy Wu.

If you want to dig deep, take a look at this Blood Journal abstract or this abstract from ASH 2014 or this older full text from the Journal of Clinical Oncology or this on the evolution of resistance to BTK inhibitors such as ibrutinib as just a few of the many examples of the explosion of research in this field.

Our understanding of this complicated concept is itself evolving.

I believe it is critical research with enormous implications for how we should treat our cancer. 

More to come.

ASCO 2014: Dr. Furman Gives us Perspective on Resistance with Ibrutinib in CLL (chronic lymphocytic leukemia)

More of My Son, Ben's Mural Work

ASCO 2014 was only a few months ago, but happily the CLL world is a fast moving place.

Since this video interview with Dr. Rick Furman of Weill Cornell, recorded and edited by Andrew Schorr and his team at Patient Power, idelasilib has been approved for CLL (see this post for discussion of its labeled indication) as predicted by Dr. Furman, and ibrutinib was approved for frontline therapy in 17p deleted patients (see this post).

YEAH to both!

Also in the intervening months, new mathematical models that consider evolution of resistant sub clones have been published by Dr. Burger out of MDACC and a high powered mathematical team headed by Dr. Natalia Komorova out of UCI. (I plan to interview Dr. Komorova as we are practically neighbors in Orange County, CA). Similar research, but this time using deep genetic analysis of the cancer's evolution over time by Dr. Cathy Wu from Dana Farber was presented at AACR 2014 Hematologic Malignancies Conference last week. (I also plan to post on her important research soon.)

The issue of ibrutinib resistance may be becoming an increasingly important issue. More and more of us are doing great with our BTK inhibited, but we still have residual disease and if you are similar to me with bad markers such as clonal diversity, 17p deletion, 11q deletion, and have a history of having been heavily pretreated (I have the first three for sure and many would say the 4th with my bone marrow transplant), then the fear of a resistant sub clone starting to act out, while still not the case for most of us even with the worst of the worst disease, is based on a growing reality of a droopy Kaplan-Meier (KM) Curve. Below are KM plots from OSU published in NATURE at the start of the year that show the downward drift in progression free and overall survival for those of us that are 17p deleted. As you can see the curves are way better than anything else out there, but they are hardly perfect.

This whole resistance issue might be largely obviated in the future by moving the new therapies up to frontline status. Dr. Furman and I both agree that is the direction we need to encourage with appropriate trials and struggles with insurers to pay for these drugs in all treatment naive patients.

Dr. Furman also mentions two exciting new BTK inhibitors, ACP-196 and ONO-4059. Click on the drugs' names to be linked to their phase 1 trials. We are just in the first chapters, but it is looking that the stories they will tell should have very happy endings. Please consider trials that offer these drugs among your treatment options.

Here is my ASCO 2014 interview with Dr. Rick Furman.



As there is a small but significant cohort of FCR patients that do great for years and years, there is a much much larger cohort of patients taking ibrutinib and other small molecules, now based on more than on more than four years of data, that should continue to do well year after year.

I am so happy for all these patients.

But I worry about the minority who won't do well, who will relapse. I am not giving up on my plea: Don't leave us stranded on 3rd base- Get us to the home plate of a cure with a follow up therapy.

We discuss obinutuzumab and ABT-199 as mop up therapies and I think those are smart choices. Maybe it will be cirmtuzumab, a new ROR1 mAB discussed in my recent post with Dr. Kipps from the very same meeting. We will only find out with clinical trials.

Dosing of Ibrutinib and Other Oral Agents

"Poison is in everything, and no thing is without poison. The dosage makes it either a poison or a remedy."

PARACELSUS

Recently there has been some discussions among those of us who hang out at online at CLL forums such as ACOR and CLLSLL Yahoo Groups about the dosing of ibrutinib.

I am a strong believer in the power of these online communities to help us cope with our disease.

The problem inherent in peer to peer counsel is not the inaccuracy of the advice given as that also sadly too often occur in professional to patient counsel. The problem is more the lack of authority afforded any particular response. That said, if respect is earned, several regular contributors have earned my respect with their well reasoned and researched frequent comments online.

Often, especially with cutting edge therapies, the patient community is better informed about their rare disorder than the community healthcare professional who must handle the full spectrum of illness his or her chosen specialty demands.

For more on this subject see this article in BMJ  provocatively titled: What happens when patients know more than their doctors? Experiences of health interactions after diabetes patient education: a qualitative patient-led study

Case in point: Dosing of ibrutinib.

The only approved dose for ibrutinib is four tablets a day for mantle cell lymphoma (MCL), which by the way is usually a nastier disease than CLL. The Imbruvica dosing is right on the package insert.

So the community oncologist dutifully looks up what the dose to use for CLL, and finding no FDA sanctioned guidance, recommends using the MCL dose. After all,  the somewhat arbitrary dose of rituximab is the same across a wide spectrum of illness.  Arbitrary because, according to legend, the original dosing was based upon how much rituximab was available, divided by how many trial patients needed it. That worked out to be 375/M² and the rest is history.

The circumstances are less arbitrary with ibrutinib. We know that ibrutinib works by irreversibly blocking BTK through covalent binding to cysteine-481. We know that the sweet spot for getting that site fully saturated is somewhere between two and three 140 mg. capsules a day.

Moreover we know that mutation of cysteine-481binding site is an important cause of late resistance. Ibrutinib no longer fits, and the BTK pathway, and thus BCR signaling continues unabated. Not a good thing.

One sure way to increase the odds of that sinister development is to start with a low dose of ibrutinib that only partially blocks the site, but allows a significant population of lymphocytes to continue to express BTK. That is the last thing we want in cancer therapy. What we want is a SHOCK AND AWE approach to cancer. We don't want the cancer cells retreating, regrouping, and later coming back to get us by probing our weak points.

Worse yet, the up and coming second generation BTK inhibitors also seem to bind at the exact same site, so if we become resistant to oneBTK inhibitor, we may be resistant to them all. A strong incentive to get the full dosing the right from the start.

So when a doctor suggests slowly going from one to two to three or more capsules a day, it is OK for a patient to say: Can we please get a second opinion from someone with more experience with the particular drug? (Of course, there is always the possibility of the individual's extenuating circumstances that we just don't know).

Some drugs for good reasons such as allopurinol in gout needs very slow upward titration to prevent increased painful flares, but ibrutinib and most of the other TKIs should almost never be dosed that way.

Bottom line: The standard dose for CLL is three 140 mg. capsules once a day, for MCL four 140 mg. capsules once a day. Sometimes those doses can be adjusted due to adverse events or hepatic disease or concomitant medications that effect its clearance (more on that topic, specifically on the CYP3A4 pathway in another post). Short of end stage renal disease or dialysis where there is no data to go by, no dose adjustments are needed as less than 1% of the drug is excreted unchanged by the kidneys.

The right dose is more than important, it is mission critical.