Precision medicine allows for treatment plans to line up with a specific genetic profile. Find out from Dr. Michael Keating what is used to target CLL patients with a 17p deletion and when treatment should generally start. Dr. Keating also shares other genetic mutations to be aware of, and which tests are used to locate them.
What we’re talking about in medicine—precision medicine. What’s your specific situation, and do we have treatments that line up with it, and how to we monitor you so that you get what’s right?
So, Dr. Keating, just for you: we’ve talked about it on Patient Power a lot, the 17P mutation, and I’ve always heard that that would be a more aggressive kind, and years ago some of those people were headed for transplant, which is a big—you know, big gun, with a mortality that could go with it as well. With some of these medicines now, are you identifying people who have or are developing 17P who now won’t need a transplant, and some of these inhibitors will work?
Certainly, when you give—and the greatest experience early on has been with ibrutinib (Imbruvica) —getting around about 5 years of experience now. But the 17Ps can be controlled for a fairly long period of time, but the patients that have 17P loss on FISH, they’re the ones that tend to progress and lose control because you get a mutation, oftentimes, in the target of ibrutinib.
So that it no longer fixes on the target and the patients are more likely to progress. So 17P on FISH is a very good way to test. I think that one of the reasons I do the IgVH on every patient when they come in, pretty much, is that it doesn’t change. It remains fixed right through the life of the patient. So it gives you a good idea as to whether they’re likely to evolve, or not. And you watch the patients that are unmutated closer than you watch the IgVH. So I think we have to realize that there’s an era now that we’re using things like ibrutinib, or combinations upfront, and the longest follow-up that we have is 5 years.
So in some circumstance, if you come from Saudi Arabia, that’s 5 years at $140,000.00 a year. You’ve got to be really sure that they need treatment. We combined with the Mayo Clinic at one point, and found that patients that had very early-stage disease and 17P deletion, many of them didn’t need any treatment at all for years and years, and that’s because they lost one 17P—so, part of chromosome 17 on one chromosome—and the other chromosome is still working.
That is, that they haven’t got a mutation in the P52 in the other one. And there’s emerging evidence that particular mutations in P53 are harmless. So I think we still have to go back and have a period of observation to see what the clinical behavior of the disease happens to be, before we just jump on.
I think a lot of people are being treated early with 17P or a P53 mutation, who probably don’t need treatment right now.
Okay, so this is why you need to consult with a CLL specialist, such as these folks, because this is a moving target.
Published By :
Nov 21, 2017
Original Title :
CLL With a 17p Deletion: What Is the Treatment Plan?