Alessandra Ferrajoli, MD, discusses importance of shared decision-making when considering the use of BTK inhibitors in hematologic malignancies.

Dr Ferrajoli on Shared Decision-Making During BTK Inhibitor Selection in Hematologic Malignancies

Alessandra Ferrajoli, MD, hematologist/oncologist, associate professor of medicine, Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, discusses the importance of involving patients in shared treatment decision-making when considering the use of acalabrutinib (Calquence) or other BTK inhibitors to manage hematologic malignancies.

Ferrajoli begins by stating that it is critical to engage in comprehensive discussions with patients about potential toxicities, monitoring requirements, and individual patient factors that may influence their outcomes with acalabrutinib or other BTK inhibitors. During consultations, Ferrajoli emphasizes the importance of understanding possible adverse effects and the necessary steps for appropriate monitoring. Patients are encouraged to actively participate by monitoring their blood pressure at home by maintaining a blood pressure log regularly, adjusting the frequency based on individual needs, Ferrajoli states. This allows their clinician to obtain a more accurate picture of their day-to-day measurements, considering factors like traffic and clinic-related anxiety that can impact in-office readings, she explains.

In cases of uncontrolled hypertension, daily monitoring should commence alongside active involvement of the patient's primary care physician or cardiologist, Ferrajoli continues. This is particularly important if there are multiple risk factors involved, she notes. For complex cardiovascular considerations related to cancer treatment, close engagement with cardio-oncologists, who specialize in managing patients on targeted therapies, should be prioritized, she adds. This collaborative approach ensures that patients receive comprehensive cardiovascular assessments and appropriate guidance for treatment decisions, including clearance for specific therapies or advice on managing treatment-related cardiovascular issues, Ferrajoli says. The goal is to optimize treatment outcomes and patient well-being through a holistic and well-informed approach that integrates both oncological and cardiovascular perspectives, she states.

By involving patients in shared decision-making and collaborating with multidisciplinary teams, healthcare providers ensure that treatment decisions prioritize patient preferences, safety, and overall well-being. This approach fosters a supportive and informed partnership between patients and healthcare providers, enhancing treatment adherence and optimizing outcomes in patients receiving BTK inhibitors for hematologic malignancies, Ferrajoli concludes.

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Alessandra Ferrajoli, MD, discusses the importance of shared decision-making when considering the use of BTK inhibitors in hematologic malignancies.

Dr Ferrajoli on the Incidence of Hypertension in Patients With CLL Receiving Acalabrutinib

Alessandra Ferrajoli, MD, associate medical director, professor, Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, discusses the rationale for, and findings from, a cumulative review of hypertension in patients with chronic lymphocytic leukemia (CLL) and other hematologic malignancies who received acalabrutinib (Calquence).

As the clinical use of BTK inhibitors increases, oncologists are learning more about their activity and unique toxicity profiles, Ferrajoli says. Information on the toxicities associated with these agents can help oncologists choose the optimal BTK inhibitors for individual patients, Ferrajoli explains.

CLL is associated with a high rate of comorbidities, such as cardiovascular disease, of which hypertension is the most common. Previous studies have demonstrated that hypertension can develop or worsen in patients with CLL who receive the BTK inhibitors ibrutinib (Imbruvica) and zanubrutinib (Brukinsa). However, the phase 3 ELEVATE-RR trial (NCT02477696) indicated that the selective, second-generation BTK inhibitor acalabrutinib induced a lower rate of hypertension vs ibrutinib at a median follow-up of 40.9 months in patients with previously treated CLL.

Ferrajoli and coinvestigators determined the incidence of new or worsening hypertension in patients from the acalabrutinib global development program and compared this rate with the prevalence of hypertension in a real-world population of patients with CLL who had yet to initiate treatment. Investigators obtained safety reports of new or worsening hypertension from 11 clinical trials evaluating the efficacy and safety of acalabrutinib monotherapy, including ELEVATE-RR and the phase 3 ELEVATE-TN (NCT02475681) and ASCEND (NCT02970318) trials. Furthermore, ibrutinib hypertension data were obtained from ELEVATE-RR, and hypertension data with other comparator agents were obtained from ELEVATE-TN and ASCEND.

This study confirmed that the prevalence of hypertension in patients with CLL who received acalabrutinib monotherapy across all 11 clinical trials was similar to that in patients with CLL who had not yet received treatment, Ferrajoli concludes. 

Alessandra Ferrajoli, MD, discusses the rationale for, and findings from, a cumulative review of hypertension in patients with chronic lymphocytic leukemia and other hematologic malignancies who received acalabrutinib. 

Alessandra Ferrajoli, MD, a professor of Medicine in the Department of Leukemia at The University of Texas MD Anderson Cancer Center, discusses the challenges that still remain in patients with chronic lymphocytic leukemia (CLL). Ferrajoli shared this insight in an interview during the 2016 

 State of the Science Summit on Hematologic Malignancies.

Patients with CLL have an increased likelihood of developing secondary cancers and other diseases, often based on their age and gender, Ferrajoli explains. She advises the importance of all patients with CLL visiting with a dermatologist on an annual basis. Additionally, patients should report on if they have any type of skin lesion removed and what the diagnosis was. Patients should also be proactive, she adds, and keep a schedule for their health maintenance and requirement—beyond colonoscopy, prostate checks, and mammograms.

Additional steps that patients can take is to receive their annual flu immunization and pneumonia immunization. They should also contact their oncologists if they travel abroad to certain countries to review appropriate health precautions, she explains.

Alessandra Ferrajoli, MD, discusses the benefits and limitations of utilizing fixed-duration therapy with monoclonal antibodies in the frontline setting for patients with chronic lymphocytic leukemia.

Dr. Ferrajoli on the Benefits and Limitations of Frontline Fixed-Duration Therapy in CLL

Alessandra Ferrajoli, MD, a professor of Medicine in the Department of Leukemia at The University of Texas MD Anderson Cancer Center, discusses the challenges that still remain in patients with chronic lymphocytic leukemia.

Dr. Ferrajoli on Remaining Challenges in Treatment of CLL

Alessandra Ferrajoli, MD, associate professor, Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, discusses treatment options for elderly patients with chronic lymphocytic leukemia (CLL).

For elderly patients, as well as those without 17p deletion, a treatment option is the combination of chemoimmunotherapy with either fludarabine/cyclophosphamide/rituximab or bendamustine plus rituxumab. These combinations are most appropriate in patients who are more physically active, Ferrajoli adds. They also demonstrate overall remission rates of approximately 90% in these patients.

For patients with comorbidities, the combination of CD20 monoclonal antibodies with alkylating agents have been established as a beneficial treatment option. The combinations of obinutuzumab plus chlorambucil and ofatumumab plus chlorambucil have demonstrated response rates of 60% to 70%, and can achieve complete remissions. Both combinations are well-tolerated with no known impact on quality of life, Ferrajoli says.

Alessandra Ferrajoli, MD, associate professor, Department of Leukemia, Division of Cancer Medicine, the University of Texas MD Anderson Cancer Center, discusses treatment options for elderly patients with chronic lymphocytic leukemia. 


Dr. Ferrajoli on Treatment of Elderly Patients With CLL

Alessandra Ferrajoli, MD, associate professor, Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, discusses managing chronic lymphocytic leukemia (CLL) in elderly patients.

Clinical trials that have shown that the management of elderly patients with CLL needs to be different from the fit and young population. Though there is no standard of care for elderly patients with CLL, physicians are beginning to move away from chemoimmunotherapy and towards monoclonal antibody-based treatment. Physicians are also starting to accept that new agents may work best in this population, as they are well-tolerated and easy to take.  lk 

In addition to considering the fitness and type of disease of elderly patients, physicians must consider transportation difficulties, limited financial budgets and ease of treatment.

Alessandra Ferrajoli, MD, from The University of Texas MD Anderson Cancer Center, discusses managing chronic lymphocytic leukemia (CLL) in elderly patients.

Dr. Ferrajoli on Managing CLL in Elderly Patients

Alessandra Ferrajoli, MD, associate professor, Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, discusses individualizing the treatment of chronic lymphocytic leukemia (CLL).

Ferrajoli says that her dream is to use prognostic factors and new molecular markers to identify the best treatment for an individual patient. Currently, a physician will treat a patient with what they feel is the best option. Following a clinical trial, researchers will analyze data to determine what treatments perform best. This strategy helps in the management of all CLL patients as a whole, but not in the management of each individul patient that is treated.

Ideally, a physician could run a panel of tests, including classic prognostic factors and novel findings (such as the expression of miR-155), and determine the best course of action upfront.

Dr. Ferrajoli on Individualized Treatment of CLL

Alessandra Ferrajoli, MD, associate professor, Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, discusses the recent approval of ibrutinib for patients with chronic lymphocytic leukemia (CLL) who have received at least one previous therapy.

Ferrajoli says physicians at MD Anderson Cancer Center have worked with ibrutinib extensively. This agent demonstrates good activity, especially in the lymph nodes, and has a favorable toxicity profile. Ferrajoli says the side effect of infection is difficult to sort out between the natural predisposition of the patients or a factor related to the agent. Patients respond well to ibrutinib with rapid improvements in hemoglobin and platelet levels. Their quality of life also improves while on the agent, Ferrajoli says.

Now that the drug is approved, physicians are able to offer the agent to patients who did not qualify to take part in clinical trials. Ferrajoli says she is looking forward to using the agent in combination and is looking forward to future clinical trials exploring the combination of ibrutinib with other agents. 

Alessandra Ferrajoli, MD, discusses the recent approval of ibrutinib for patients with chronic lymphocytic leukemia (CLL) who have received at least one previous therapy.

Alessandra Ferrajoli, MD

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