Friday, December 12, 2014

ASCO 2014: Dr. O'Brien Discusses Improved Trial Designs, CT Scans and the role of Chemo-immunotherapy In Frontline Therapy in CLL (chronic lymphocytic leukemia)

I am back from ASH 2014 with some informative video interviews from Drs. Hillmen, Byrd, Burger, Wiestner, Kipps. Sharman, Roberts, Pagel, and Kay. The congress was a huge success and I will be reporting on the important abstracts and news over the next few months first here and then on our new website for the CLL Society Inc.

I also am very excited with the video interviews from ESH in Greece including ones with Furman, Porter, Hallek, Stilgenbauer, Wu, and Brown.

But first I have to share this fourth and final thoughtful audio interview with Dr. Susan O'Brien despite all its hisses and pops.

We pick up on the issue of ethical trial design from the third part of her interview on the issue of equipoise. If you missed part 3 or part 1 or 2, please enjoy by clicking on the numbers.

In this segment, Dr. O'Brien and I discuss the place of CT scans in clinical trials and in the real world of CLL therapy. Her answer is not black or white but is balanced and well considered.

Next Dr. O' Brien gives as a nuanced response to the question of what might be the possible role for chemo-immunotherapy in and out of trials.

Spoiler alert: Consider FCR frontline if you are young, healthy, mutated, and trisomy 12. But only under those circumstances>

 Here is Dr. O'Brien

More soon from ASH and ESH.

And thanks to the well over 300 of you that have completed our survey. If you haven't done it yet, please, take a few minutes to add your voice to the others as to what are your particular unmet needs in living with CLL. We are building the nonprofit CLL Society Inc. in response to those needs.

We will be taking the survey offline in one week on December 19, so please don't delay.

Here's the link.

And a very special thanks to those of you who have generously given a tax deductible donation to help us with our website construction and developing our CLL specific support groups.

More details to follow soon after we have analyzed the survey results.

We still are welcoming any contribution, large or small. At the suggestion of several of you, we have added a donate button at the top of the blog and on our placeholder website for the CLL Society Inc.

Thanks for all your help.

We are all in this together.


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Anonymous Anonymous said...

Hi Brian. Thanks for another great post. Quick question and just want to confirm: You said, "Consider FCR frontline if you are young, healthy, mutated, and trisomy 12. But only under those circumstances." I'm all of those, except I'm 97% 13q (no trisomy 12), and at the point of deciding what front-line treatment to use. Have to admit FCR scares me, but don't want to throw it out without first carefully considering it might be the best front-line treatment for me. In your opinion, though, I should not do FCR because I am not trisomy 12, correct?

December 13, 2014 at 6:12 AM  
Blogger Brian Koffman said...

The best data is on the combo I described, but odds are good that you will get a long remission from FCR with your profile. I have a friend who is 14 years out and still MRD negative, but he has a second blood cancer. Worth considering: 6 months and done.

December 13, 2014 at 9:26 AM  
Anonymous Anonymous said...

Thanks, Brian. Andrew Schorr? This is why FCR scares me. Sure, a good chance at a nice long remission, and worth considering for sure, but at what cost? Might I be setting myself up for another blood cancer (maybe even MDS/AML)??? Guess I was hoping you'd say, "No, don't do it because you don't have the trisomy 12 deletion!" LOL! :)

December 13, 2014 at 10:07 AM  
Anonymous Anonymous said...

Highly informative as usual. My question is what prevents someone from starting with the newer agents first and if resistance or disease progression occurs go on to FCR rather than the other way around. FCR may change the cytogenetics and leave a more aggressive CLL and may predispose to a second malignancy. I have not seen this question addressed.

December 13, 2014 at 5:40 PM  
Blogger Unknown said...

Hi Brian,
With all due respect to one as learned as Dr. O'brien the perspective from one who is the patient and taking the risk that he/she is not going to be one of the 40% is fundamentally different. If the rationale for FCR is heavily weighted because of the "bright" expression of CD20 in 12 trisomy patients then why would a patient not be advised to gamble on one of the newest CD20 targeted mAbs like Obinutuzumab? Trisomy 12 is a marker that is fairly heterogeneous so I would want to know more about the volume quality of aberration before accepting FCR. This example to my thinking is begging for more data that might be obtained from NGS (Next Gen Sequencing).

How about a comparison of therapy paths for a Trisomy 12 patient in which an HSCT (Hematopoietic Stem Cell Transplant) is weighed against FCR. If the patient has a great matched donor the odds are roughly 60% cure vs 40% checking out of the "Hotel Life". Prospects of GVHD (Graft vs Host Disease) takes the clean edge off the percentages but if you are a gambler why not go for the brass ring?

Given the prospect of therapeutic advances, does the buy-yourself-time with less toxic therapies in the face of probable relapse look so bad? Ya pays yer nickel an ya takes yer chances my friend.


December 14, 2014 at 6:47 AM  
Anonymous Anonymous said...

First "Anonymous" here again — In my situation, I've been told to seriously consider FCR, BUT I was also offered the ACP-196 trial. So I'm also curious to know the answer to the second "Anonymous's" question — "What prevents someone from starting with the newer agents first and if resistance or disease progression occurs go on to FCR rather than the other way around?"

December 14, 2014 at 11:40 AM  
Anonymous Anonymous said...

Great post. Quick question on the survey: I've tried to take it several times, but keep getting stumped on the inability to answer questions differently than I have to do. For example: forced choice between doctor blogs and patient blogs. You are both, and one of my most important sources, but exactly BECAUSE you are both. How do I choose? Same with Andrew Schorr's blog and broadcasts. It's the combination of being a patient and/or journalist/doctor that makes the both of you so trustworthy. And ranking: is 1 considered most or least important? Surveys have a tendency to differ when asked to rank. Thanks for all your work!

December 14, 2014 at 1:38 PM  

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