Minimal Residual Disease (MRD): What Does it Mean for You?

Minimal Residual Disease (MRD): What Does it Mean for You? from Patient Empowerment Network on Vimeo.

Dr. Matthew Davids defines the term minimal residual disease (MRD) and explains its role in managing chronic lymphocytic leukemia (CLL).

Dr. Matthew Davids is the Associate Director of the CLL Center at Dana-Farber Cancer Institute. More about this expert.

See More From The Path to CLL Empowerment

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Transcript:

Dr. Matthew Davids

So, one term that patients often come across when they’re looking online that they might not know exactly what it means is so-called MRD. This stands for minimal residual disease.

And MRD is increasingly becoming an important endpoint in our trials, meaning that it’s a test that we rely on to try to make decisions about treatment in the trials. And we’re hoping that this will be a strategy that we can eventually use in regular clinical practice.

So, what is MRD? Basically, MRD is a way to look, at a very, very molecular level, at tiny, tiny amounts of the disease. And this a feature of the fact that we have very effective treatments for CLL, and so we can give various treatments, whether it’s chemoimmunotherapy or drugs like venetoclax, for example. And then we can look under the microscope in, for example, the bone marrow tissue, and we might not see any CLL cells. So, we might call that a complete remission.

But often, there’s still evidence of molecular disease left behind that we can’t see under the microscope, but we can use very sophisticated biological techniques to actually detect what we call MRD. And we find that, if there is MRD present, that patients don’t tend to have as durable of a remission compared to when MRD is so-called undetectable.

So, it’s a very important term to understand. When patients get to an undetectable MRD state, that’s a very good thing. It means that they’re likely to have a very long response to whatever therapy they had. But you also have to remember that MRD itself has its limits of what it can detect. And so, just being undetectable for MRD does not mean that you’re necessarily cured of the CLL.

And there are patients who have undetectable MRD who later do have a recurrence of the CLL. But it does help us guide the treatment in terms of knowing that patients are in a good remission, that they may be able to stop the treatment that they’re on and enjoy a long response without the need for ongoing treatment.

But eventually, for most CLL patients, the disease will come back. And we can detect that sometimes with this MRD test as well. And that’s an interesting research question ongoing as to whether we should intervene at that point to restart therapy when we first see the MRD test become positive again. And hopefully, that’s something that we’ll continue to learn about as we further explore that question in clinical trials.

Diagnosed with CLL? An Expert Outlines Key Steps

Diagnosed with CLL? An Expert Outlines Key Steps from Patient Empowerment Network on Vimeo.

You’ve been diagnosed with chronic lymphocytic leukemia (CLL), now what? Dr. Matthew Davids explains key steps to take following a diagnosis.

Dr. Matthew Davids is the Associate Director of the CLL Center at Dana-Farber Cancer Institute. More about this expert.

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Transcript:

Dr. Matthew Davids

So, if I were diagnosed with CLL today, we’ve discussed some of the resources that are available in terms of educating one’s self about the disease: CLL Society website, other videos on VJHemOnc, things like this. There are other websites that give more basic information about the disease, for example, Lymphoma Research Foundation, American Cancer Society, American Society of Clinical Oncology.

So, personally, I would want to know a lot about the disease. And I would probably first turn to these particular resources, which I think can be very helpful.

I would certainly partner with a local oncologist hematologist who can help guide the management. But one thing that you should remember is that most general practitioners for oncology may only see a few CLL patients a year, and the field has changed quite a bit over the last few years. And it can be hard to stay completely up to date on all of these developments.

So, one thing that I would think would be very helpful for anyone diagnosed with CLL is that, if you do have access to a major center that has someone who specializes in CLL or at least in lymphomas, that can be a great resource. And so, I do recommend, if patients can do it, to try to seek out a second opinion from a CLL specialist. And this can be very helpful even if the recommendation is still just observation, that they can help educate about the disease, identify other resources for educational purposes, and just become a part of your team, to have them available down the line.

And I see many patients like this who come for a second opinion at diagnosis. And I kind of tell them, “Go back to your local doctor. Stay on observation. It’s likely you’ll do well for many years on this watch and wait strategy. But at the time when they’re recommending that you need treatment, come back and see me then. It’s easier to get in once I know you.”

And at that point, I can help reassess, 1.) Do I agree that treatment is really needed at that point? Sometimes, it’s actually possible to wait even a bit longer; and then, 2.) What would I recommend for the best treatment option at that time? Could be a clinical trial that might only be available at that center. And I think unless you have a CLL specialist on your team, it’s gonna be hard to know about those available resources.

So, it’s not that you necessarily need to follow exclusively with a CLL specialist. But it’s more to just have them involved, have them know about you. And that way, if you need them down the line, they’ll be available to help support you.

I think in terms of education and self-advocacy, this is a very personal issue. And so, for many of my patients, it’s very important that they are educated about the disease and kind of know the ins and outs of the different clinical trials and so forth.

But it’s also important to remember that that’s not gonna be true for every patient. A lot of my CLL patients are also older patients, and they may not want to know all the details of what’s going on. I think it is important to have someone who’s involved with your care know about these details. Ideally, if it’s not you, it might be a spouse or a partner or a child, for example. A lot of my older patients don’t wanna know all the details about the molecular biology and the clinical trials. But often, it’s their son or daughter who is there with them who wants to know this.

And so, I think it’s helpful often to bring a family member with you to the visits. Because as you can see even from today, there’s a lot of information to learn, and it can be hard to remember everything.

So, having someone else, another set of ears and eyes, someone else can maybe take some notes at the visit and review them with you later, I think can be very, very helpful in terms of your own self-awareness about the disease.

So, in general, I love when patients ask me questions. Sometimes, they are very savvy questions. They are familiar with the literature, and they can kind of really push me to explain my opinions and beliefs about certain treatments. And sometimes, they’re just very basic questions that may be seem silly to the patient but are really not silly questions.

Really, this is a brand-new area for most patients. They have no experience with this when they first start out. So, they should never feel like they’re bothering their oncologist with these questions. I think it’s really important for them to understand the basics of what’s going on. That should really be a minimum for every patient.

And then for patients who wanna know more about some of the details from the research and the clinical trials, I think their doctor should also be able to help explain that to them as well. So, they should never feel like they’re bothering their oncologist with their questions.

Could a Clinical Trial Be Your Best Treatment Option?

Could a Clinical Trial Be Your Best Treatment Option? from Patient Empowerment Network on Vimeo.

Is participating in a clinical trial a last resort or could it be your best treatment option? Dr. Matthew Davids explains the clinical trial process and what’s involved in patient participation.

Dr. Matthew Davids is the Associate Director of the CLL Center at Dana-Farber Cancer Institute. More about this expert.

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Transcript:

Dr. Matthew Davids

My patients often ask me about clinical trials and whether I think that would be a good fit for them. I think there is, in some cases, a bit of a misconception that clinical trials are a last resort for our patients. And we do have some clinical trials that are exploring brand new mechanisms of a drug that have never been used before.

And in that scenario, I would only recommend a trial like that for a patient who has already exhausted all of the standard options.

But I think that, in my opinion, clinical trials should really be the first best choice for most patients. Because we have many trials in CLL that are using the drugs that are already approved, so we know that they’re gonna be effective. And now, we’re putting them together for the first time in new combinations and in new creative ways that will help to advance the field. And most of the trials we have in CLL are not randomized, placebo-controlled. So, patients know what they’re getting. They’re gonna be getting an effective therapy.

And this is a way that they can really get access to cutting-edge care. I would say when you’re a part of a clinical trial, you have a lot of other eyes watching you. In addition to your oncologist and the infusion nurses, for example, you also have research coordinators, research study nurses. Some centers have additional scheduling staff that helps with the clinical trials. So, it’s really a way to get excellent quality clinical care, often getting access to cutting edge treatments.

And so, here at Dana Farber, for example, we try to have a clinical trial option available for patients at every stage of the disease, so that we have trial options for patients who have never had treatment for their CLL, trial options for patients who have maybe only had one or two prior treatments, and then some of those other more experimental clinical trials for patients maybe who have exhausted some of the other options that are available by the FDA-approved therapies.

So, I’m really a huge advocate for clinical trials. I think that’s how we’ll continue to improve the treatment options for our patients with CLL.

CLL Treatment Advances: What Do You Need to Know?

CLL Treatment Advances: What Do You Need to Know? from Patient Empowerment Network on Vimeo

Dr. Matthew Davids reviews promising chronic lymphocytic leukemia (CLL) research and shares online resources for patients to stay informed as treatments develop.

Dr. Matthew Davids is the Associate Director of the CLL Center at Dana-Farber Cancer Institute. More about this expert.

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Transcript:

Dr. Matthew Davids

So, this remains a very exciting time for CLL research. The last several years have witnessed the development of a number of these novel agent-based approaches, these oral drugs that target the different pathways inside the CLL cell that the cell survives with.

And so, we’ve really kind of reached the end of the beginning, as I call it, because the first goal, of course, was developing each one of these novel agent drugs on its own. We had to show first that they were safe and figure out what the dose was for patients, and then figure out that they’re effective on their own. And we’ve kind of checked those boxes at this point and reached a point where we have now several different novel agents that are FDA approved already for CLL patients.

And so, I think the big research challenge now going forward is kind of twofold. One is identifying the best combinations of these drugs to put together. And No. 2, identifying which patients will benefit most from which specific combinations.

And so, there’s a number of different clinical trials going on right now looking at these questions.

And just kind of highlighting some of them, one of them is the study of venetoclax with obinutuzumab that I mentioned before. We just had a pretty early readout from this study. But I think it’s gonna be very important to see how patients do over time after they finish the one year of therapy, and both for this study as well as another study called MURANO, which looked at the patients who had already had prior chemotherapy-based regimens and then received venetoclax, in this case with rituximab.

In both cases, when there’s time-limited therapy, I think a key research question is gonna be, when those patients do have progression of the CLL – hopefully years later – do they respond again to that same treatment? Can you use venetoclax again? And do the patients respond nicely? And if they do, then that could be a very nice intermittent treatment strategy to allow patients to be off therapy for a period of time, and then only to receive additional treatment when they need it.

I think another important and exciting area is the combination approaches. And I’ve talked about both ibrutinib and venetoclax as probably two of our most promising new drugs. And so, there are now a number of different studies exploring the combination of ibrutinib plus venetoclax given at the same time. And some of the initial data that’s been published looks very promising. This is a very well tolerated and highly effective combination in the initial studies. It’s all oral, which is nice. So, it’s just pills without the need for any infusions. And again, it’s designed to, hopefully, be a time-limited regimen, and patients hopefully will have a nice durable response after an initial treatment with these two drugs.

There are certainly a number of other drugs that are very promising as well. There’s a whole class that we haven’t talked about yet called PI3 kinase inhibitor drugs. We have two such drugs currently approved now for CLL patients, idelalisib and duvelisib. These drugs also are very effective for treating CLL but tend to have more side effects when they’re given as the first therapy. So, most patients will start with a different therapy. But then the PI3 kinase drugs can be a great option for patients who are in the relapse setting after they’ve had prior treatments.

And there’s another one in development called umbralisib, which also looks very promising and seems to perhaps be even the safest of these PI3 kinase inhibitor drugs. And that’s not yet FDA approved. But we anticipate it’s likely gonna get an approval relatively soon.

And so, combining these new PI3 kinase drugs also with venetoclax is an area of research interest, and a number of other combinations. As you can imagine, the longer the list grows of drugs, the more different combinations we can explore. And we’re trying to use the science from the laboratory to try to determine ahead of time what we think are the most promising strategies because we can’t do clinical trials of every single combination. But those are some of the sort of novel agent studies that I’m excited about right now.

I think the other area that could prove to be very helpful for our CLL patients is CAR T-cell therapy, which stands for chimeric antigen receptor T-cells. CAR T-cell therapy is a way to harness the body’s own immune system to fight cancer.

So, to do this, we would take cells out from a patient. And these are T lymphocyte cells. So, not the CLL cells, but a normal immune cell called a T lymphocyte. And then the cells get educated outside the body to recognize CLL cells more effectively. And they’re grown up and expanded and then reinfused into a patient, where they can go around and kill CLL cells. This can be a very effective treatment and can lead to complete remissions with durability.

And this approach is now in clinical trials. There are some risks to CAR T-cell based therapy. Something called cytokine release syndrome, where patients can get very sick, almost like they have a severe infection, but they don’t have an infection. There’s some neurologic risks to this as well that can be quite scary if they happen but in almost all cases are reversible. So, I think that this is an interesting area of research right now. It’s certainly not yet approved by the FDA for CLL. But we hope that, over time, as the CAR T-cell therapy becomes more effective and has fewer side effects, that eventually it will become a therapy option for patients who have had prior treatments for their CLL.

So, I think despite the fact that we’ve made a lot of advances in the last few years, we still have a lot of work to do in the research area to try to improve our treatments even further for our CLL patients.

So, in terms of how patients can stay informed about all these developments, it frankly is quite challenging, even for us in the field, to keep up with all of this. But there are some resources that can help. The first thing I would say is that the research tends to come along in fits and spurts, and one of the fits is generally the big research meetings where we all gather together to present our new data.

And probably the biggest highlight of the year is the ASH meeting, American Society of Hematology, which is usually in early December. That’s a good time to start looking on the internet for news about CLL, latest treatments, those sorts of things. Often, it’s kind of early December where we first hear about these breaking stories.

Another meeting that’s become big over the last few years is the European Hematology Association, which usually takes place in mid-June. And that’s, again, another time when we often see new data coming about. And one area where I would say this could be very helpful – or one website that I think is helpful – is the CLL Society website. This is led by Brian Koffman, who himself is a CLL patient.

And he kind of collates a lot of the information from these meetings and puts them in one place on his website. He’ll often interview CLL specialists to get their opinion about some of the newest developments. And so, I think Brian’s webpage, CLLSociety.org, can really be a great resource for getting up to date on the latest data.

There certainly are other websites out there now as well which are helpful. For example, another one that I’m working with closely is called VJHemOnc. And VJHemOnc comes to these big meetings, again, interviews a lot of the experts on their takes on the new data.

And I find that this platform in particular, the video-based platform, can be very engaging. It really forces us, as the investigators, to kind of hone down on what the most important key points are and give little snippets about that. And I would think that would be easier for our patients, in many cases, to digest, compared to some of the original papers themselves, which can be quite dense.

So, those would be my major resources that I’d recommend for CLL patients who are looking for additional information on the latest research.

CLL Treatment Decisions: What Path is Best for YOU?

CLL Treatment Decisions: What Path is Best for YOU? from Patient Empowerment Network on Vimeo.

Dr. Matthew Davids discusses factors that can impact a chronic lymphocytic leukemia (CLL) patient’s treatment course, including genetic testing results, age and co-existing conditions.

Dr. Matthew Davids is the Associate Director of the CLL Center at Dana-Farber Cancer Institute. More about this expert.

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Transcript:

Dr. Matthew Davids

So, there are a number of different factors that go into the decision of which of these regimens to choose for the initial therapy of CLL. One of them is certainly the age and fitness level of the patient and what other medical issues they have. So, as patients get above the age 65, they typically may have other medical issues and may not tolerate more aggressive chemoimmunotherapy-based regimens like FCR. But they could certainly tolerate the novel agent regimens like ibrutinib or venetoclax plus obinutuzumab.

Another consideration that comes into play is the biology of the CLL cells themselves. Some patients with CLL have a higher risk form of the disease. We call this either deletion 17p or TP53 mutation. And those patients typically do not benefit as much from chemoimmunotherapy.

So, even younger patients there, we think about a novel agent-based approach. And we have, again, the longest-term data on ibrutinib for that population, although venetoclax plus obinutuzumab is also a consideration.

And then as we think about debating between these different options, we also think about the specific other medical issues that a patient may have. So, ibrutinib does have some risks in terms of atrial fibrillation, which is an abnormal heart rhythm. It can cause patients to be a bit more prone to bleeding or bruising. And so, for patients who have these existing risks, if they have heart disease already, or if they’ve had issues with bleeding recently, ibrutinib may not be the best option, and venetoclax plus obinutuzumab would be appealing for a patient like that.

Now, with venetoclax and obinutuzumab, it can be such a potent regimen that it can break the tumor cells open too quickly. This is something we call tumor lysis syndrome. It’s not something we’ve seen commonly with this regimen. But we do watch patients very closely when they’re first dosing.And so, for example, patients who have poor kidney function might be at a higher risk for this side effect. And those might be patients, again, where we think about ibrutinib as a very good option, since it’s very well tolerated even by patients who have issues with their kidneys.

So, those are some of the factors that go into it. Certainly, patient preference makes a big difference. Some patients don’t mind the idea of going on a pill, and they like the idea that it’ll control their disease in the long term. And so there, a therapy like ibrutinib may make a lot of sense. Other patients may find that they prefer what we call a time-limited strategy. And using the venetoclax plus obinutuzumab makes a lot of sense there because it’s a one-year regimen, and they can stop. But we don’t know yet the durability of those effects. So, those are some of the factors that go into making this important decision as to what to receive for a first therapy.

I think patients have an increasingly large role in making treatment decisions about what they would like to receive, especially for their first therapy for CLL. It used to be that we had very limited treatment options for CLL, and really the only choice was chemotherapy. And so, that was a pretty easy choice if you had no other options.

So now, as I’ve highlighted, we have multiple different choices. We have chemotherapy-based approaches. We have novel agent approaches, both continuous and time limited. And so, I think it’s helpful for patients to educate themselves about the pros and cons of these different options, to get input from a CLL specialist, if possible, and certainly from their oncologist as well as family members and friends, particularly if they have had friends who’ve gone through this. Getting their advice can be helpful.

And reaching out to online supports as well can be a useful thing in terms of educating oneself. And at the end of the day, the patient has to make the decision as to what they think is best for them.

And it might be a different decision for each individual patient. But the good news for patients, even though it can be challenging to make this decision, all of these options are good ones. And so, there isn’t really a wrong decision here. But there may be some that are better suited for individual patients based on their own preferences.

CLL Treatment Options: What’s Available NOW?

CLL Treatment Options: What’s Available NOW? from Patient Empowerment Network on Vimeo.

Dr. Matthew Davids reviews current chronic lymphocytic leukemia (CLL) treatment approaches and discusses the role of watch and wait.

Dr. Matthew Davids is the Associate Director of the CLL Center at Dana-Farber Cancer Institute. More about this expert.

See More From The Path to CLL Empowerment

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Transcript:

Dr. Matthew Davids:   So, we’re very fortunate in CLL that we have a number of very effective treatment options. But I would like to start by highlighting the fact that, for the majority of CLL patients when they’re first diagnosed, a watch and wait or observation strategy is generally preferred.

And this goes back to many years of research showing that there’s no survival advantage to starting early with chemotherapy-based approaches.

And we have some recent data with the newer drugs that, even with these better agents in terms of the tolerability, that early intervention strategies still probably don’t make a difference for our patients and are associated still with side effects and risks. So, the first important thing is to understand that it’s okay to be observed and go on to this watch and wait strategy, and that many patients can stay on this type of approach for many years.

However, once treatment is indicated, we do have a number of therapy options for CLL patients. And these go back to chemotherapy-based approaches, which have been around for quite a while now and now include some newer drugs that we call novel agents that are really transforming how we manage the disease. So, for younger, fitter patients, we can still think about chemoimmunotherapy, and in particular a regimen called FCR, which includes two chemotherapy drugs, fludarabine and cyclophosphamide, and a third drug which is an antibody called rituximab.

And this combination works very well, in particular for patients who are very fit and can tolerate it and remains a viable option. An advantage of this approach is that it’s time limited. It’s a six-month course. But there are some significant side effects from chemotherapy and some longer-term risks. And so, it’s something that we think carefully about before we recommend.

We really think about the novel agents now as being a good option for most of our patients with CLL. And these novel agents are typically pills that, in general, tend to be well tolerated, although each one has its unique risks and potential side effects. We’ve been using the drug ibrutinib now for a few years for the initial treatment of CLL. And this drug targets one of the pathways in the CLL that the cell relies on for its survival. And it’s a drug that patients take once per day. And once they start on it, they usually continue on it for a long period of time. We’ve had patients on this drug up to seven or eight years now who continue to do well.

Ibrutinib doesn’t tend to completely eradicate the CLL. But it often gets patients into very good remissions. And if they tolerate the drug well, then they can stay on it long term and control the disease. But typically, the drug is given as a continuous therapy. So, we don’t have as much experience with stopping it at this point. And so, that’s typically how we recommend giving it, is as a continuous drug.

Now, another new option for the initial therapy of CLL patients is called venetoclax, which is another pill that we have had a lot of experience with over the last few years in clinical trials. It was approved for patients who had previously had treatment for CLL for the last three years or so. And then just recently, the FDA gave approval to venetoclax as a first therapy for CLL patients. And we typically give this in combination with a different antibody drug called obinutuzumab, which is given intravenously.

So, this regimen, which we call venetoclax plus obinutuzumab, is typically given for a six-month combination course, followed by about six additional months of venetoclax pills. And then patients stop therapy at that point.

So, one of the advantages of this approach is that, like the chemotherapy, it’s a time-limited approach for one year. And we can often see very deep remissions that allow patients to remain off therapy for a period of time afterwards.

One of the issues so far is just that we don’t have as long-term follow up as we do with ibrutinib. So, we don’t know what’s gonna happen to these patients seven or eight years after they’ve started venetoclax plus obinutuzumab. We certainly hope that this one year of therapy provides a durable response for patients, and it certainly looks promising in that regard so far. But we currently have more long-term experience with ibrutinib as an initial treatment.

So, these are kind of the main options that we think about for patients who need their first therapy for CLL. We always think about observation first. But when patients do need treatment, we move toward either a chemoimmunotherapy-based approach with a regimen like FCR, or ibrutinib, or venetoclax plus obinutuzumab. And so, it’s great to have all these very valuable and effective options for our patients.

The Pro-Active CLL Patient Toolkit Resource Guide

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CLL Toolkit Resource Guide

Download this Guide

Chronic Lymphocytic Leukemia (CLL) Defined

Chronic Lymphocytic Leukemia (CLL) Defined from Patient Empowerment Network on Vimeo.

What is CLL? Dr. Brian Hill defines chronic lymphocytic leukemia (CLL) and explains how it differs from small lymphocytic lymphoma (SLL).

Dr. Brian Hill is the Director of the Lymphoid Malignancies Program at Cleveland Clinic. More about this expert.

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Transcript:

Dr. Brian Hill:

So, chronic lymphocytic leukemia is a term that refers to a cancerous condition in which the abnormal or cancerous white blood cells are a type of B-cells with certain characteristics that are present above a certain threshold in the blood. Those same cancer cells can also grow and divide and set up shop in other organs besides the blood and bone marrow.

And that can be a lymph node, spleen and sometimes we find the exact same type of cell in a lymph node or other parts of the body. And we don’t find it in large quantities enough in the blood. And when that happens, we call it small lymphocytic lymphoma or SLL. So, people get very confused by the terminology, “Do I have leukemia, or do I have lymphoma.” And so, a lot of times there’s a reference to a condition called CLL-SLL. CLL-SLL really is one disease.

And the term leukemia or lymphoma really just refers to where is the predominant location for the abnormal cancer B-cells. Are they in the blood or are they in the tissue?

If it’s in the blood, mostly above 5,000 cells per microliter, that’s the cut off. If it’s in the blood predominantly, it’s CLL. But if those same cells are in the lymph nodes or the spleen but not above that threshold of 5,000 in the blood, then the term is small lymphocytic lymphoma. And often times that diagnosis made from a tissue biopsy or a lymph node biopsy rather through a blood test or a bone marrow biopsy. Really, these are the same disease. And even physicians who don’t practice in this area get confused about it.

And it’s important to know that they can be treated exactly the same and are interchangeable. Rarely I’ve seen a mistake be made that someone who has a diagnosis of SLL or small lymphocytic lymphoma is treated with the types of chemotherapy drugs that we would typically use for indolent forms of lymphoma.

And some of those therapies overlap. So, there are biologic similarities and clinical similarities between B-cell lymphomas and CLL-SLL for sure. But there is a lot of nuance in B-cell lymphomas, and not every single treatment that works really well for B-cell lymphoma should be used in CLL or SLL.

You’re Not a Guinea Pig: Understanding Clinical Trial Participation

You’re Not a Guinea Pig: Understanding Clinical Trial Participation from Patient Empowerment Network on Vimeo.

“Will I be a guinea pig if I participate in a clinical trial?” CLL expert Dr. Brian Hill explains the clinical trial process and addresses common patient fears and misconceptions.

Dr. Brian Hill is the Director of the Lymphoid Malignancies Program at Cleveland Clinic. More about this expert.

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Transcript:

Dr. Brian Hill:

So, one of the first questions many people ask about being a clinical trial participant is, “Am I a guinea pig?” And what I would say is we’re always practicing medicine. Anything we do, we’re practicing.

But we are always trying to get better whether it’s formally on a trial or not. In terms of side effects of treatment, no matter what – if we have the treatment available, any medication can potentially cause side effects. And it’s very difficult to predict. So, even if you are not on a clinical trial, you could be treated with a standard therapy and potentially have problems or difficulty with it. In terms of clinical trials, it depends where in the sort of journey you are in. If you have never been treated before and now you need to be treated, there are trials that are appropriate for people who are at their first line of treatment.

And this is not typically where we are experimenting with new drugs. So, this is typically where we have established treatments or just sort of trying to compare which one is better. Sometimes these are randomized.

So, there’s a flip of a coin, and you can be assigned to one or another. And I understand why many patients may not want to have their treatment determined by chance. But I would keep in mind that usually if this is being done, it’s been vetted through not just the institution where they are being treated, but often times through review boards throughout the country who basically say, “We think it’s okay to have a flip of a coin decision here because if we have a great treatment which is A and a great treatment which is B and we really don’t know if A or B is better, it’s okay to sort of have a randomization where you may get A or B.”

Sometimes A is the standard and B is likely to be better, but we don’t really know that B is better. And the only way to get the second option would be to be on the clinical trial. So, in that case if you are enrolled, the “worst” option would be the standard.

But it may give you the option of being even better than the standard. And again, if we knew that the second option was better then it wouldn’t be a clinical trial, it would be our standard.  This is sort of how we make progress. And it requires a buy in from the medical community and physicians, but also, it’s important that patients feel comfortable with it. So, that’s kind of for front line treatment. In terms of subsequent therapies, again there are a lot of very good standard treatments available.

And sometimes there are new drugs that are being developed. If the new drug has never been given before to a human, that’s called a Phase One trial. And typically, those are given or offered to people who have had many other lines of therapy and may not have other good options. But sometimes we know that the new drug has been given to people, it’s safe.

The side effect profile is already known even if it hasn’t been given to large numbers of people. And in those cases that would be something around something often called a Phase Two trial where we know it’s safe, but we’d love to see how well it works. And that’s an option for patients as well.

Right. So, outside of talking with your hematologist/oncologist or CLL specialist, there are many other resources for getting information about CLL. The Lymphoma Research Foundation, The Leukemia Lymphoma Society and the CLL Society are all great organizations that have useful websites.

They have 1-800 numbers you can call into. Many of these groups have – I know the CLL Society has a support group in many cities that’s held on a regular basis. And often times there are patient meetings organized through LLS or LRF, the two groups that I mentioned, that allow patients to come and learn from each other and also ask questions of specialists who may be speaking at those events.

An Overview of New CLL Treatments

An Overview of New CLL Treatments from Patient Empowerment Network on Vimeo.

Are there new CLL treatment approaches that patients should know about? Dr. Brian Hill reviews the “explosion of new treatments” in the past few years.

Dr. Brian Hill is the Director of the Lymphoid Malignancies Program at Cleveland Clinic. More about this expert.

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Fact or Fiction? CLL Treatment & Side Effects

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Transcript:

Dr. Brian Hill:

So, there’s been an explosion of new treatments for CLL just in the past five years. As of before 2014, most of the treatment we had involved both traditional chemotherapy drugs with antibodies.

Those antibodies include Rituximab and more recently other antibodies such as obinutuzumab. The explosion that I’m referring to is really in the development of very effective and generally well tolerated targeted agents. The most well known in the first one of these was Ibrutinib which inhibits a protein that tells the CLL cells to grow and divide called BTK. There are other blockers or inhibitors of BTK that are now approved include Acalabrutinib. The side effect of these are slightly different, and there are reasons why you might choose one or the other.

There’s also a very potent medication called Venetoclax which is now used – which has a different mechanism of action than BTK blockers.

Many of these work better when you combine them with the antibodies I mentioned. And so right now a lot of the research that’s ongoing is examining the utility of combining these agents or how to best sequence them. So, much of the decision about how we can best treat patients is derived from really well done, well designed clinical trials. And sometimes clinical trials can give patients an option that’s not yet a standard but is likely to become a standard.

Or it can give you access to a drug that is promising and not yet widely available. So, there are definitely times to seek – at least ask the question whether a clinical trial is a good option or the best option.

And there may be times where it is not appropriate, and the standard treatments are very reasonable and may require fewer visits to a referral center to be treated. So, I think it’s worth having that conversation both with the primary hematologist/oncologist as well as the CLL specialist.

Not to Worry! Your Guide to Watch and Wait

Not to Worry! Your Guide to Watch and Wait from Patient Empowerment Network on Vimeo.

 Watch and wait, or active surveillance, often feels like watch and worry to CLL patients. Dr. Brian Hill provides a comprehensive guide to the period of time before CLL treatment begins and shares approaches for managing anxiety.

Dr. Brian Hill is the Director of the Lymphoid Malignancies Program at Cleveland Clinic. More about this expert.

Related Resources

Overwhelmed By a CLL Diagnosis? Key Steps to Take

How to Learn More About Your CLL

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Transcript:

Dr. Brian Hill:

So, watch and wait is the term that’s referred to for not actively treating a patient with CLL after the diagnosis. As many people probably out there watching know, the diagnosis of CLL is often made incidentally or accidentally through routine laboratory tests that are done for some other reason.

Maybe they are going to have surgery. Or maybe they are going to have just a primary care checkup. And blood count shows too many white blood cells. And everything else is fine. The patient feels normal. There’s no symptom. But it leads to a referral usually to a hematologist who then does more testing and makes a diagnosis of chronic lymphocytic leukemia. The word leukemia is very scary because it often conjures up images of acute leukemia which is a disease that can make people very sick very quickly.

We’re taught in much of medicine and in much of cancer that early diagnosis and early treatment is very important. And it is very important for many conditions – breast cancer or we’re taught let’s get our mammograms.

And have an early detection and immediate treatment to cure the breast cancer. Similarly, colon cancer – get your colonoscopy, get your diagnosis sooner rather than later. And have surgery so you can have a higher likelihood of a cure. In the case of chronic lymphocytic leukemia, it’s never been shown despite multiple attempts over many decades, that treating someone with CLL is – earlier, is going to impact the outcomes and the big picture. But we do know that treating CLL earlier can lead to more side effects earlier.

So, in other words, if you feel fine and your blood counts are just a little abnormal, and there’s not compelling indication to treat, we can safely observe patients until an indication for treatment exists. And what I tell patients is that if we treat today, the treatment will work.

If we treat tomorrow, the treatment will work. And if we treat in five years, the treatment will work. So, there’s – we have very good evidence that delaying treatment until you need it does not compromise the likelihood of the treatment working. So, it’s a little bit of a different mindset from other types of cancer where we are taught to treat early and immediately. So, a lot of times people will call it watch and worry instead of watch and wait, and there’s a lot of anxiety about that.

Again, their diagnosis has the word leukemia in it. It can be a very scary time. And it takes a little bit of trust to be convinced that you don’t need to be treated just because you have it. And that’s often times when we do get second opinions if the first hematologist/oncologist says it’s okay to watch it and wait. We don’t need to treat. A lot of the time people then seek another opinion to confirm that’s accurate. And in most cases – I would say 90% of the time when I’ve had a second opinion for a patient who’s been recommended to watch and wait, I typically concur with that recommendation.

So, during watchful waiting or – I like to call it active surveillance because it’s not that we aren’t doing anything, we are surveilling or monitoring. And the two things that we monitor are symptoms and blood counts. So, it sort of begs the question that many people ask which is, “If you are not going to treat me now, when will you treat me? When will I need to be treated?” And the first indication – the first thing we look at is symptoms. So, if you have symptoms of significant fatigue to the point where you are really having a difficult time functioning.

Or if you have drenching night sweats that wake you up from night and make you change your nightclothes. Those type of symptoms would push us to treat. So, those are the things that are being asked of patients at their regular follow up which is usually every two or three months initially.

And sometimes can be spaced out to every four to six months if things are stable. But usually during the first year you want to be checking on folks every two to three months. Weight loss would be another symptom to look out for – sort of unintentional weight loss. The other thing we monitor is the blood counts. So, with a simple CBC or complete blood count, we can see what is happening with the white blood cell count which may and often goes up.

And a lot of folks focus on the white blood cell count and its trajectory and how that is rising. Some people’s white blood cell count can fluctuate. Others can stay relatively flat. And some people do have a continued rise on the white blood cell count. The white blood cell count in and of itself is not the final reason to recommend treatment.

But with time, as the white blood cell count goes up, we sometimes see the other numbers going down. And actually, the other numbers going down are the ones that are more important. Those numbers are – the red blood cell count measurement which is usually measured by hemoglobin concentration or hematocrit. And then the other is the platelet number. So, if either the hemoglobin or the platelet number gets below threshold, those are typically indications for treatment.

So, during this period of observation or active surveillance – watchful waiting, whatever term you choose. This can go on for years.

And it can be associated with anxiety. So, trying to do things to cope with managing anxiety is important. Other things that many people are interested in are – is diet. So, do we know of a particular food or food group that we should focus on? Or is there something we should avoid? And the short answer to that is that many – it’s a difficult topic to study. As you might imagine, diet can be so varied around people. And in a typical week the average person eats so many different types of foods that it’s difficult to focus in on one particular thing.

What we can say is that in general for health, clearly fresh fruits and vegetables are the best source of nutrition. And also, are best for your health.

Avoiding processed foods and processed meats and other foods that are high in saturated fats is probably important in general for your health. Although we can’t say specifically that it’s definitely going to make an impact in the white blood cell count or the trajectory of the CLL. In terms of supplements and natural products, many people are interested in this topic. And again, it is a difficult one to study. Some of the natural products out there are purified forms of things from plants and other ingestible herbs and so forth.

But the problem is, is that if you take any component – even if it’s natural occurring, take it in large quantities it can lead to other problems. There was a well-known study from – that studied the impact of green tea extract on the white blood cell count.

And if you took large quantities of green tea extract, it seemed as if it did sort of lower the white blood cell count a little bit. But some people also had abnormalities of their liver function as a result. So, I don’t recommend green tea extract. And I instead say, “If you like tea and you want to drink green tea, I think that’s probably fine.” But I wouldn’t do it in excess. And just maybe try to incorporate it into a balance diet otherwise.

Why You Need a CLL Specialist

Why You Need a CLL Specialist from Patient Empowerment Network on Vimeo.

Why should you seek care with a CLL specialist? Dr. Brian Hill outlines the benefits of seeing a CLL expert and advice for approaching a second opinion.

Dr. Brian Hill is the Director of the Lymphoid Malignancies Program at Cleveland Clinic. More about this expert

See More From The Pro-Active CLL Patient Toolkit


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Transcript:

Dr. Brian Hill:

Patients should consider seeing a CLL specialist because oncology is a very complicated field. There are many different types of cancers that oncologists treat. And particularly in smaller hospitals, maybe with general oncologists who see lung cancer, colon cancer, breast cancer and CLL as well as many other types of – patients with many other types of problems. It’s very difficult to stay 100% up to date on all those fields. All of oncology is very rapidly evolving.

And the progress that’s being made in all the diseases I mentioned is very fast paced. And so, things change. And there’s new data emerging all the time. And CLL specialists or lymphoma specialists are able to stay more up to date on these topics. And usually that can result in maybe better options for patients.

So, we often get second opinions or third opinions for patients with CLL.

And one of things patients are understandably concerned about sometimes is the impact this will have on their primary oncologist. Maybe they are from a smaller town or have a smaller hospital. They have an oncologist, hematologist, gynecologist who they like, and they trust, and they don’t want to hurt their feelings or damage the relationship because they may need their primary or local hematologist, oncologist to help them if they are sick or something goes wrong.

So, I think that most oncologists recognize that – again, the field is very complicated. And it’s common for people to seek opinions from referral centers. So, I would say the best thing is to be up front about it. And explain to their primary that it’s not that they don’t like them or don’t trust them.

But it’s important – it’s their health. And they really want to make sure they have another set of eyes. And I even sometimes encourage my own patients that if they have questions about what I’m talking to them, to welcome another opinion. And if there’s good communication about it, I don’t think that you should be concerned about the sort of hurt feelings aspect of it.

CLL Genetic Testing Explained

CLL Genetic Testing Explained from Patient Empowerment Network on Vimeo.

  Genetic testing results can impact a chronic lymphocytic leukemia (CLL) patient’s treatment options and prognosis, but these tests are different from the “hereditary” tests you hear about.  Learn about the types of testing available, how the information is used to guide treatment decisions and clear steps to empower you to work with your healthcare team to access personalized care.

See More From Your CLL Navigator

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Transcript:

CLL Genetic Testing Explained

Chronic lymphocytic leukemia, also known as CLL, is a type of blood cancer that occurs when the bone marrow makes too many abnormal or cancerous lymphocytes. It is the most prevalent type of leukemia in adults. Some forms of CLL are slow growing and may not require treatment immediately, if at all. Patients with CLL are monitored closely to determine when, or if, they will need treatment.

How Can You Learn More About Your CLL?

Genetic tests can provide more detail about your specific disease. By using laboratory approaches to identify changes in chromosomes, genes or proteins occurring in your CLL cells, the results can assist your healthcare team in providing better overall care. These tests do not look for genetic changes you inherit or that you pass on to family members. A gene mutation is an abnormal change in a gene’s DNA sequence.

Identifying mutations and changes in chromosomes can help determine:

  • Whether a patient needs closer follow up.
  • A patient’s prognosis and outcome.
  • And the best treatment for that individual person.

The types of genetic tests that physicians use for patients with CLL include:

  • Fluorescence in situ Hybridization, or a FISH Test, which is used to identify specific genes or chromosome changes. This type of test is essential before beginning a treatment regimen.
  • Molecular testing identifies specific gene variations or mutations. Types of Molecular tests include:
  • Polymerase chain reaction, PCR for short
  • DNA Sequencing
  • and Next-Generation Sequencing

Your healthcare team can determine which type of tests are appropriate for you.

Mutations associated with CLL include:

  • Notch1 mutation
  • TP53 mutation
  • and SF3B1 mutation

Your healthcare team will look for the following changes in chromosomes using the FISH test:

  • Deletion 13q
  • Trisomy 12
  • Deletion 11q
  • and Deletion 17p

Patients with Deletion 17p do not respond well to chemotherapy. These patients have a better response to oral targeted agents and should strongly consider a clinical trial for treatment. Prior to treatment, your healthcare team should check for the IGHV mutation. This mutation in CLL patients is a favorable finding, and indicates that the patient may have a slower growing cancer that is easier to treat. Watch and wait, also known as active surveillance, is the period of time before treatment begins in which a patient is monitored closely. When the disease progresses or symptoms occur, your healthcare team will begin treatment.

When it’s time to treat, there a number of approved CLL treatment options Including:

  • Oral targeted therapy
  • Clinical trials
  • Monoclonal antibody therapy
  • Chemotherapy in combination with a monoclonal antibody
  • And stem cell transplant

How Can You Take Action?

  • Make sure you see a CLL specialist.
  • Discuss which tests you should undergo with your doctor.
  • Review the results with your doctor.
  • Do your own research on the findings.
  • Work with your healthcare team to determine a personalized treatment plan for Your CLL.
  • Ask your doctor when you should be re-tested.

Fact or Fiction? CLL Causes & Symptoms Resource Guide

Download this Guide

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Download this Guide

How to Learn More About Your CLL

How to Learn More About Your CLL from Patient Empowerment Network on Vimeo.

How can you learn more about CLL? CLL Expert Dr. Javier Pinilla-Ibarz shares credible resources and valuable tips to help you become an educated and empowered patient.

Dr. Javier Pinilla-Ibarz is the Lymphoma Section Head and Director of Immunotherapy in the malignant hematology department at Moffitt Cancer Center. More about this expert here.

See More From The Fact or Fiction? CLL Series


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Transcript:

Patricia Murphy:        

Okay, well we’ve talked about a lot of treatment and side effects and myths. As an informed patient, I may want to go out on the internet and find out all I can about CLL. What should I be looking for? What should I be careful about when it comes to online awareness and health literacy?

Dr. Javier Pinilla-Ibarz:        

Very, very important topic that I love to really discuss with my patients. I always say that some patients kind of intoxicate themselves with multiple websites and with different backgrounds.

I think we – I do recommend them to really go to the websites, to the websites who really provide a very fair and really clean and important information. I would definitely – we were discussing about the Leukemia Lymphoma Society, CLL Society, Patient Power, to really – National Cancer Institute’s website, places that they have very well filtered information that we can really give to the patient. There is no doubt there’s many others not in this list, but I think we always have to be aware that there’s other websites that may not really provide really, really a good information or may really confuse our patients. So, I like to always really go to the sources that I really trust the most.

Patricia Murphy:

Yeah, so reputable sources and always checking with your doctor, obviously, about things that you’re considering.

Dr. Javier Pinilla-Ibarz:        

Absolutely. Absolutely. I always tell to my patients, “You go there, you look at that, you read, but then after that you have a question. Come because sometimes you may have misconceptions.”