William Wierda, MD, PhD: Let’s move on into first-line therapy and treatment for patients with CLL [chronic lymphocytic leukemia]. Chemoimmunotherapy has been around for many years. I think it probably would be best to start out with a conversation about available chemoimmunotherapy and who we think today, we’ll talk a little bit about other countries, today in the United States who might be the candidate for chemoimmunotherapy? We’ll start with you Jacqueline.

Jacqueline Barrientos, MD: Yes. I still believe that there is a cohort of patients who may benefit from chemoimmunotherapeutic approaches. In particular, a young, fit patient who has mutated IGHV, without an 11q deletion, without a 17p deletion. For those patients we have long-term data, and not only from MD Anderson Cancer Center, also from Germany and Italy, that after 10 years, two-thirds of those patients will still be in remission, which is the closest I can think of as a cure for someone who has only received 6 months, fixed duration regimen.

So, it’s an option for patients. I do have patients in my practice who are young and fit and actually choose to pursue that route. For an elderly patient like we saw in the data from the Alliance trial presented by Jennifer Woyach, MD, last year, bendamustine and rituximab is still an option because many of those patients who did progress were able to be salvaged with ibrutinib.

It’s not an idea that would not be an option for the patient if they choose to pursue that. Granted it may cause some more myelosuppression and some more risk for infection. So, it’s important to have a one-to-one discussion with the patient. And similarly, the combination of obinutuzumab with chlorambucil, that might be an option, but now that we saw the data from obinutuzumab with venetoclax, I may just choose that instead of with chlorambucil. But I don’t know how accessible that is in other countries.

William Wierda, MD, PhD: In Australia, Stephen, fixed duration, chemoimmunotherapy-based treatment is still standard first-line therapy?

Stephen Opat, MBBS: There is definitely a subset of patients. I think practice is changing with the availability of testing for immunoglobulin gene mutation status in 17p. In younger patients who’ve got no adverse prognostic factors, I would add to that NOTCH1 and some...mutations, then I think there is a role. But you’d have to be aware that even in the best hands FCR [fludarabine, cyclophosphamide, rituximab] is associated with a 2% to 3% treatment related mortality. Often when that’s explained to patients, they’re very happy to consider a novel strategy, even though it may not necessarily be safer, but the perception is that it’s safer.

William Wierda, MD, PhD: And in Canada?

Carolyn Owen, MD: In Canada we’re, well at least, the provinces differ in terms of funding, but in Alberta where I work, we really do try to follow the evidence. And I think that a strategy of chronically suppressive therapy that is well tolerated is very appealing. But with the cost difference, time limited therapy that has the same overall survival I think is still the best choice for patients within a publicly funded healthcare system. I think it’s the most judicious use of our resources.

Transcript Edited for Clarity