New Biological Insights and Recent Therapeutic Advances in the Management of Acute and Chronic Leukemias and Myelodysplastic SyndromesClinical management of ALL in the community compared to tertiary care settings
3:30 minutes.
TRANSCRIPTION:
DR STOCK: I think ALL is a complex series of diseases. It’s not one disease. And that’s, number 1, very important to recognize. We have Philadelphia chromosome-positive ALL. We have a very aggressive Burkitt-like ALL. And then we have precursor B and precursor T ALL. There’s a lot of activity in the world of clinical research in all of these areas, with improvements in survival. And I think the important things to know about are making the proper diagnosis and probably not treating patients with ALL in a community setting simply because it’s a very complicated disease to treat. And it makes it very difficult for community oncologists to treat this disease when it’s very complicated, very long treatment and requires great attention to detail. And so it’s a difficult disease for them to manage. It’s also treated by a variety of different physicians. I think maybe you’re alluding to the fact that it spans the age range of patients from childhood to older adults. And a large number of our patients are young adults with ALL, and they’re referred according to practice patterns. So another reason that it’s less well understood by treating physicians is because many different approaches have been used in the past and it’s been complicated for people to understand what the best approach is and for anybody to know, really, what the best approach is. But the major progress has come through participation in clinical trials recently, because it is a rare disease. And that’s the reason childhood ALL is now cured in the majority of children, because people have banded together to participate in trials that answer really important questions to improve outcomes. DR KANTARJIAN: So we talked about CML being a disease going into the community, although I’m much less emotional about CML. I think ALL is a completely different story. ALL is a rare disease. There is better outcome with cumulative expertise. There’s now a revolution in the treatment of ALL with the monoclonals and the CAR T-cells. Individualized therapy is applied at different particular subsets, Burkitt, T-cell, Philadelphia-positive, pre-B ALL, elderly ALL, adolescent/young adult. So I don’t think there’s any role for treating ALL in the community practice. I think their best outcomes are with referrals to tertiary centers. There are a lot of practical details in terms of the details of the chemotherapy, compliance with the treatment, measuring minimal residual disease, referring to allogeneic stem cell transplantation. And so what I’d like an oncologist to do is, as soon they diagnose ALL, high white cell count, blasts, you immediately transfer them to a tertiary center with leukemia expertise. You could give them a bolus of steroids, if the white cell count is high, with rasburicase, but there’s no need to do anything beyond moving them within hours to an expert referral center. |