Chemotherapy-free strategies in treating leukaemia

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Published: 20 Jun 2019
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Prof Robin Foa - University of Rome, Rome, Italy

Prof Robin Foa speaks to ecancer at the 2019 European Hematology Association (EHA) Annual Meeting about treatment alternatives to chemotherapy for leukaemia.

He explains that today there are many targeted treatments that are succesful, particularly with the help of minimal residual disease monitoring.

Prof Foa also highlights CAR-T as an area of excitement and a real step forward but that the treatment's high cost and restricted availability are current setbacks.

ecancer's filming has been kindly supported by Amgen through the ecancer Global Foundation. ecancer is editorially independent and there is no influence over content.

Again, we’re witnessing a very exciting area in haematology because we’re talking about, as I would say, one is a targeted treatment with the TKI, tyrosine kinase inhibitor, whether it’s imatinib, dasatinib, ponatinib, erlotinib, but this targeted treatment. The lesson came from CML and expanded into Philadelphia. Then we took blinatumomab, proof of evidence that immunotherapy can work, that’s immunotherapy. Putting together the two we managed to control many patients without chemotherapy. So the area of all this more targeted treatment is increasing but there are many other examples in haematology. Just to remind our audience, the first lesson came from acute promyelocytic leukaemia in history and that was the first targeted treatment in oncology in fact, in a leukaemia where there was a genetic marker identified many years ago and many patients can be cured without chemotherapy. So we have an example of that. Then CML came on the scene and the tyrosine kinase inhibitors and then Philadelphia positive ALL. So there are many examples and more we could discuss now.

So we’re tying together targeted treatment, minimal residual disease monitoring which in ALL is available for all patients but in many other diseases – CLL, myeloma – can be monitored, lymphoma too, some milder leukaemia. So immunology is incorporated and targeted treatment, MRD all work together. We have to get rid of the disease.

CAR T is another step forward. There’s a lot of hype on CAR T, many sessions here, many obviously because there has been a lot of excitement, maybe even too much because of the costs of these and the non-wide availability of these procedures. But it is a major step forward, there’s no doubt about it, another form of immunotherapy through genetically modified T-cells of the patient that then are given back to the patient and recognise residual neoplastic cells. This is still at the early days of this because it developed very rapidly but it is another step forward in the same direction.

I would finish by reminding ourselves that after all the last Nobel Prize for Medicine was given for immunology in general and immunotherapy, checkpoint inhibitors. So that is the field. So it’s not just expectation, now we are actually going into it. So putting together very more refined definition of patients, genetic markers, genetic targeted treatment, minimal residual disease, immunotherapy, for many conditions the situation is very positively changing. So we have to be optimistic.

Final point, if you’re using targeted treatment this can be given to patients of all ages. We couldn’t give heavy chemo to an 80 year old, this is impossible, even 70 maybe. Now with more targeted treatment this changes so we can treat elderly patients. Since we are an ageing population in the world, life expectancy is increasing always more, this is a key point.

If I have to make one final thought obviously my concern and worry is that the world is very vast. We are talking of a lucky few – expensive, difficult, availability, accessibility – whilst the world does not access all of this. So this is a worry that we all have but we can’t go ahead…  with an academic hat we go forward but we have to keep an eye on what real life is and try to help at different levels.