Jan A. Burger, MD, PhD:If we see a patient who’s over 70 and has good performance status, a fit elderly patient in that age group, it would be a question, first, if there are certain risk factors that could guide us toward the best treatment if the patient has high-risk features. I would say if the patient has 11q or 17p deletion, or if he has or she has unmutatedIgVHgenes, then this patient would be probably best suited for targeted agents, idelalisib or ibrutinib, because we see the most durable responses with these new agents. An alternativeif the patient doesn’t want to be on a continuous long-term treatment, if there are concerns about financial burdens of these treatments—could be antibody treatment. But, in general, I think it is accepted that those antibody-based treatments are less durable, but they can be repeated. If it’s a patient who has low-risk disease features, then we could also consider dose-adapted chemoimmunotherapy. But, in practice, we haven’t really done that much lately. Usually in a patient who is over 70, we would probably rather do an antibody-based or kinase inhibitor-based treatment. So, the chemoimmunotherapy approach is largely now these days, I think, reserved for younger patients.
Our experience with ibrutinib in elderly patients in the frontline setting is not very broad. It hasn’t been used too much in this indication yet because most of the studies were done in relapsed/refractory patients. There is some clinical trial experience, and now the first patients are moving on to this type of approach. But the drug was just approved earlier this month in March 2016, so, there’s not a vast experience. But we know from the relapsed setting that the drug is well tolerated. Patients go into remission, especially if they have large bulky disease. They notice quick changes, improvement. In terms of their blood counts, they need to be prepared for this redistribution phenomenon, which I think most people are aware of. And patients have to be made aware that initially their leukemia cell counts are likely to increase rather than decrease, just due to the nature of mechanism of action of this drug.
Case 1:A Fit Elderly Patient with Newly-Diagnosed Chronic Lymphocytic Leukemia.