Bruce D. Cheson, MD; Gilles Salles, MD, PhD


June 13, 2013

In This Article

Expect Targeted and Overpriced Drug Combos

Dr. Salles: It is a fascinating world, because we are learning more and more about the lymphoma cells and the different pathways. These 2 drugs are not identical. They target different pathways. They might have similar or comparable efficacy, but because they use different pathways, in the future we will try to combine them -- because neither of these pathways is a key oncologic event that explains the disease. We are just acting to maintain the disease, so by combining them we may have superior efficacy in the future.

Dr. Cheson: At ASH, someone came up to me after an ibrutinib presentation and asked whether it was going to be like imatinib. I said, "No, because with chronic myelogenous leukemia (CML) you have 1 target, you have 1 problem. Here, you have got a myriad of anything from JAK2 to Akt to mTOR, et cetera." Combining these would be the way to go. The problem is that the companies who make them don't play with each other very well at the present time.

Do you think we are going to need chemotherapy in at least follicular and other indolent lymphomas?

Dr. Salles: It is a little early to say. We have to see more results with these agents. In some of the lymphoid malignancies, such as chronic lymphocytic leukemia, for instance, it is likely that these drugs will push chemotherapy from the frontline to second-line. In some indolent lymphomas, I am convinced that they will replace chemotherapy in frontline therapy in the future, but this has to be evaluated.

We will still need chemotherapy in some patients who have a large tumor burden or who have a presentation for which we need something more efficient. In addition, the preliminary results of these agents indicate that we don't reach many complete remissions with these drugs when used as a single agent. So we will probably need to combine them for a period of time, and maybe use a prolonged treatment. I am not enthusiastic about seeing patients take pills for their whole lives.

Dr. Cheson: The drug maker would love it, obviously, but that is one of the problems because apparently, you have to keep taking these drugs. The question is, is that because you need a better induction regimen? That may be several of these, but several of these are going to cost a whole lot of euros.

Dr. Salles: Yes, or a whole lot of dollars.

Dr. Cheson: That is going to become an issue as it has with the CML drugs, which have now priced themselves off of the scale. When these come out, they are going to be fairly expensive.

Dr. Salles: That is why we need to evaluate them carefully alone and in combination with chemotherapy in clinical trials.


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