Communication, education key to optimal management of chronic myeloid leukemia
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In the last two decades, the approval of multiple tyrosine kinase inhibitors for chronic myeloid leukemia has vastly improved the treatment landscape for patients.
The approval of imatinib in 2001, followed by other TKIs, led to survival outcomes for patients with CML extending from about 5 years to a near-normal life expectancy. Because of the advancements in treatment and outcomes, patients sometimes hear they have a “good cancer” at diagnosis.
Although treatment with TKIs is often successful, some patients experience treatment failure because of TKI resistance or intolerance. Therefore, it remains critical to keep working toward improvements in care for patients, Gabriela Hobbs, MD, clinical director of the leukemia service at Massachusetts General Hospital, told Healio.
“There’s no cancer that’s a good cancer; the best cancer is the one you don’t have,” Hobbs said. “A significant portion of patients will still die of this disease. So, I think the label of a ‘good cancer’ is inappropriate and sends the wrong message to patients and to clinicians who are treating the disease. It’s imperative to treat this disease seriously, because CML that doesn’t respond to treatment can be absolutely devastating and very difficult to treat.”
Healio spoke to Hobbs about the current treatment landscape in CML, from initial treatment to monitoring, adverse effects and resistance, as well as the critical components of education and communication in the physician-patient relationship.
Healio: What factors need to be considered in initial treatment of CML?
Hobbs: We are fortunate in the world of CML that we have a variety of excellent treatments associated with really superb outcomes for the majority of patients. I’ll take a look at the patient, their comorbid conditions and medical history, blood work, kidney function, liver function, etc, and medications they are on to decide what would be the most appropriate initial treatment for their disease.
Healio: What should physicians be aware of in terms of identifying and managing adverse effects?
Hobbs: Each prescriber needs to be familiar with each specific side effect of each of these medications. It’s not one-size fits all.
Healio: How does monitoring these patients help in identifying these adverse effects?
Hobbs: When a patient is first diagnosed with CML, they will have abnormal blood counts. Some patients can have very minor abnormalities, with a white blood cell count that’s just slightly above normal, and some astute provider diagnosed CML just based on those abnormalities. And some patients have very, very abnormal blood counts and might require different monitoring.
In general, with initiation of treatment, which for CML is a TKI, four first-line drugs are approved: imatinib (Gleevec, Novartis), dasatinib (Sprycel, Bristol Myers Squibb), nilotinib (Tasigna, Novartis) and bosutinib (Bosulif, Pfizer). But it’s important to monitor patients fairly closely at the beginning of their diagnosis, perhaps weekly in the first month, for several reasons:
- to ensure that their blood counts are responding properly and determine if treatment needs to be held because of cytopenia;
- to make sure that their kidney and liver function do not show adverse signs in response to the medication; and
- so that providers and the provider team can form a good relationship with the patient, who may be going through a lot of emotional changes during that first month.
Many side effects from these medications can be much worse in the beginning and, fortunately, tend to improve over time. Supporting those patients in the first month of treatment is critical to ensure that a patient is able to stay on that medication during the treatment and, ultimately, have a good outcome with CML.
Healio: What factors lead to TKI resistance and how critical is patient monitoring to ensure early identification and recognition of disease resistance?
Hobbs: Not taking medications as prescribed can lead to TKI resistance, as can not having an initial good response to a TKI, such as not seeing that early molecular response in the first few months.
With CML we know at 3 months, the level of Philadelphia chromosome by PCR on the international scale needs to be less than 10%. At 6 months, it needs to be around 1%. At 12 months, less than 1%. If a patient doesn’t meet those landmarks, the disease may be resistant to the treatments, despite trick adherence to treatment.
Certain factors can predict who is going to be resistant, like the Sokal risk score or the EUTOS risk score. But patients who may have mutations in addition to the BCR-ABL could potentially have resistance, as well as patients who don’t have a rapid decline in their Philadelphia chromosome-positive level or don’t reach that initial landmark. These are patients that make us concerned that they won’t respond.
Healio: Adherence is also a common reason for treatment failure in CML. What is contributing to that?
Hobbs: One factor is financial. It’s important to be aware of and ask patients, ‘Are you able to afford your medication?’ Sometimes the co-pays can be absolutely prohibitive. I’ve made decisions about which treatments to start for patients depending on what their insurance will decide to cover. Patients will not be successful in long-term adherence to the medication if they have to pay thousands of dollars out of pocket every month.
The second is educating patients on what to expect and giving them tools to handle those side effects — explaining which may be transient or associated with initiating treatment, and then figuring out which may be longer term. Even if the patient’s CML is well-controlled by blood work, it is important to ensure they are still able to communicate frequently with the care team, including the nurse, nurse practitioner and physician, to allow them to successfully remain on treatment.
When you have a patient who is educated on the side effects, they may find it less terrifying because they know that it’s normal. And if you give them supporting medications to treat nausea, diarrhea or other things, they have tools to be able to deal with some of those side effects on their own.
Lastly, educating patients on the importance of adherence is critical. If a patient thinks this is a ‘good cancer’ and it’s no big deal, then maybe they won’t take their medication as prescribed. Education on all levels is critical in ensuring good outcomes.
Healio: Similar to the physician’s task in educating patients, keeping an open line of communication seems critical to improve survival outcomes, correct?
Hobbs: It is absolutely critical. As oncologists, we want to do right for our patients and help them have the best outcome. Going back to the initial question about a “good cancer” — that label is so damaging for both patients and physicians. The physician may have a waiting room full of people who look sick because they’re taking chemotherapy and have all sorts of acute medical conditions going on, and then see a patient with CML and think they look fine and that they have a “good cancer.” If the providers aren’t taking it as seriously and don’t give patients the time and say, “Well here’s your medication and I’ll see you in 3 months,” it’s a big mistake for a disease that’s so treatable.
For more information:
Gabriela Hobbs, MD, is clinical director of the leukemia service at Massachusetts General Hospital. She also is a HemOnc Today Next Gen Innovator. She can be reached at ghobbs@partners.org.
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