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Editor's Note: Peter Rowbotham attended the 2001 meeting of the American Society of Hematology, held from Dec. 7-11 in Orlando, Florida, U.S.A. Rowbotham, whose wife has CML, has long dedicated himself to researching new treatment advances and passing that information along to others. Here, his series is presented verbatim.
By Peter Rowbotham
[Note from Peter: This report, and any following reports, are based on written notes which may be inaccurate or incomplete. Patients should check with medical professionals as necessary.]
Kantarjian is Chairman of the Dept. of Leukemia at MDACC, and one of the top experts on Gleevec, so when he is very optimistic in his assessment of Gleevec, we do right to be encouraged. But we would also be wise to listen to the more conservative voices. The argument put forward by the SCT specialists is essentially that, conservative, and it does have merit. Patients should be aware that there is no unanimity amongst the specialists, or as Druker put it, "there isn't a right answer." The SCT case has been weakened since the advent of Gleevec, but it is still an important option for a small minority of patients in specific situations.
Storb from the Hutch asked the question that apparently is beginning to irritate Kantarjian, "does STI cure?" In pushing this point, Storb made the strong argument that relapse is related to the number of transcripts (i.e. bcr-abl cells remaining) in both SCTs and IFN, and so this seemed likely to be the case for Gleevec patients as well. So the overall thrust of his argument (his "pitch" as he put it) is the risk of recurrence with Gleevec.
In a talk today on Gleevec administration, Druker indicated that his thinking is along similar lines. He said that cytogenetic response correlates with a better clinical outcome, and the goal of therapy should be a cytogenetic response. While there is still not adequate data on the durability of Gleevec responses or the survival of Gleevec patients, I think that there is a growing consensus that the better the molecular remission the better the chances of no relapse and long-term survival. Druker, if I understood him correctly, advocates a focus on PCR negativity, but he feels that Gleevec will need to be combined with other therapies if this goal is to be reached for most patients.
Goldman, a leading CML expert at Hammersmith hospital in London, also referred to the curability with SCTs and the uncertainty of other treatments. The problem as he put it, graphically, is that you kill the patient if you fail with an SCT. With Gleevec in mind, he referred to the extreme difficulty in deciding therapy for the younger patient eligible for an allogeneic transplant. He presented an algorithim (model) of treatment options, which I won't go into now, but as the chairman of a session yesterday wrote on a slide, treatment algorithms are "data light;" the data we need is still being collected. Nevertheless, Goldman felt it was necessary to have something to work with in the meantime.
A viewpoint that surprised me came from the Italian CML group, who still seemed to favour IFN over Gleevec, primarily it seemed because of the track record, where 80% of low-risk patients are alive after 10 years. However, the value of IFN seems closely related to these Sokal or Euro score risk factors, as well as to cytogenetic response. It is worth noting that when a significant number of the audience voted to continue IFN therapy in the case of a woman patient with a good IFN response rather than switching to Gleevec, in one of yesterday's case studies, Kantarjian was aghast!
I will try to report further tomorrow.
Regards,
[Correction: In the Orlando II report, I referred to Kantarjian's "surprise" at the decision in a case study. On reviewing my notes, I see that I erred in giving the wrong case study. That is a good warning to be wary of unintended errors in these reports. The actual case was a 50 year old male patient with an HLA matched 52 year old brother. When asked what therapy they would recommend the audience responded electronically as follows: Gleevec 48%; Allogeneic SCT 38%; IFN 13%; Hydrea 1%. What seemed to bother Kantarjian was the 13 % who would opt for IFN instead of Gleevec.]
Source: Peter Rowbotham, reprinted with permission
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