At last, a “Gleevec” of our own?
If you follow general interest medical news, or if you know anyone who was diagnosed with CML, you would have heard of “Gleevec” (imatinib). This kinase inhibitor has revolutionized the standard of care for chronic myeloid leukemia patients. Gleevec is a potent inhibitor of the activity of a tyrosine kinase called “bcr-abl” (as well as a few other tyrosine kinases). It has demonstrated significant activity in patients with CML in all phases of the disease, whether they have received prior therapy or not. Since Gleevec therapy became well established, the annual mortality for CML patients has been reduced significantly (less than 2%-3% per year).
I wish I had a dollar for every time I dreamed wistfully for a “Gleevec” of our own. For a change, it seems I was not day-dreaming. The era of kinase inhibitor drugs for CLL is dawning and it looks to be a bright day. Since nothing in life or cancer therapy is ever simple, I think it is important for you to learn about kinases, how they work, what makes them so important. I will make the science as simple as I can, I promise it won’t hurt even a teeny bit.
Kinases – master controllers
Kinases are extremely important enzymes that control much of how the cells in our body function. There are several hundred different kinases, controlling different functions. One type of kinases, called protein kinases, are the largest group. Protein kinases can transfer a phosphate group from ATP to a protein in a cell, thereby activating the protein.
If that bit of chemistry began glazing over your eyes, try this for size. Kinases function as an “on” or “off” switches. Without the help of a particular kinase turning the protein “on”, the protein in question is inactive and cannot do the job it is supposed to do. Thus, kinases control much of the machinery of the cell – its ability to proliferate (have babies), move about the body, ability to receive or send messages to its neighbors, whether it lives or dies.
To put in blunt terms, kinases are the central master switches of how each cell in our body works. As you can imagine, all hell breaks loose if one of the master switch goes awry, if it gets stuck in the “ON” position too long for example. Mutations, deletions or mangling of the structure of a regulatory kinase can play havoc with the particular protein and the cell function it is supposed to control. Most if not all human cancers are thought to be caused by one or more malfunctioning kinases.
Kinases make nice targets for new drug development
So, if a malfunctioning kinase is at the root of a particular cancer, how about blocking that kinase and thereby block its bad influence on the proteins it is supposed to control? Great idea, but not that easy to do in real terms. Many kinases share common features. So, a drug that is developed to block a particular kinase may also block a bunch of other perfectly normal kinases, and thereby disrupt some vital function of the body. Broad spectrum kinase inhibitors can be very toxic because they can block too many vital pathways – a case of the cure being worse than the disease.
Even Gleevec, the miracle kinase inhibitor drug for CML, has some toxicity concerns. A 2006 article linked Gleevec to heart failure in a small percentage of patients. “Ten CML patients treated with Gleevec at the M.D. Anderson Cancer Center in Houston developed congestive heart failure, although they had normal heart function when they began taking the drug. Studies in mice and in culture showed that the Abl tyrosine kinase protects cardiac cells from damage; when it is inhibited, heart cells die”. This was a bit of an “unanticipated side effect”, according to the researchers.
I am pointing this out not to take away anything from the game changing ability of Gleevec. It has truly been a miracle drug that paved the way for better and more targeted drugs in its wake. But all too many times I get letters from our members upset with the slow pace of clinical trials, unable to see the point of all these careful protocols and detailed research. Why can’t the FDA just approve CAL-101, and get done with it? After all, it is a biologic drug and not a nasty chemotherapy drug, it can’t possibly hurt – can it? The answer is YES, IT CAN. Biologic drugs can hurt, can even kill. This is one of the reasons why early stage studies generally recruit late stage patients, people who have been through several layers of therapy already, so called “salvage-cases” with few good choices left. “Do no harm” is a very important oath to remember, if you are a clinical researcher and you wish to avoid unnecessary tragedies.
Do we have similar kinase targets in CLL?
Turns out, we do. Not just one target, but four of them. And all four kinase targets are being examined, with suitable small molecule inhibitors that may be able to stop them cold.
Unlike CML, which has a particular messed-up protein (as you would expect, the protein controlled by Bcr-Abl kinase is called Bcr-ABL protein) that is responsible for the cancer, CLL does not have any one single such protein.
But in the last few years we have learned a great deal about what makes CLL tick. We know for example, that much of the survival advantage of CLL cells lies in their ability to resist suicide signals from the rest of the body. This ability to ‘live long and prosper’ is hugely enhanced when the CLL cells are surrounded by their closest friends and relatives, so called “nurse-like cells” in their immediate microenvironment, constantly giving them encouraging feedback.
We know by now that just about any therapy can bring down CLL counts in the blood. Shrinking swollen nodes and clearing infiltrated bone marrow – that is a lot harder. This is because out in the open blood circulation CLL cells are not all that hard to kill. But once they are nicely tucked away in the bone marrow, swollen lymph nodes, spleen, liver etc, they are much harder to kill. Think of this as a criminal out in the open streets with no friends and no place to hide, scared out of his wits and with no one to give him a pep talk. Compare this poor sucker with a hardened terrorist with a lot of local supporters willing to protect him and hide him, defend him with their very lives. The guy with no friends is more apt to be panic stricken, make mistakes that lead to his capture and execution. Not so the guy well hidden with lots of local moral support.
The four kinases listed above are known to be over abundant in CLL cells, cooperating with the microenvironment. They magnify the survival and proliferation and maturation signals the CLL cells receive from their neighboring nurse-like cells, through the B-cell receptors that each B-cell has on its surface. If we can take away this constant and soothing pep-talk magnified by overactive kinases listed above, it becomes a lot easier to kill the CLL cells.
This is a distinctly different approach to killing CLL cells than the usual chemotherapy drugs we have come to love and admire (Not!). We are not trying to poison the CLL cells, we are only trying to kick their damn legs out from under them. And when they are down and floundering around out in the open, if they are not already dead because of their scary isolation from their fan club, that is when we can kill them easily with appropriate therapy. Here is a link to a recent editorial in “Blood” by Dr. Varsha Gandhi that does a better job of explaining the science than my cartoon version.
For a change we have an embarrassment of riches, four different kinase targets to try and block. The BTK (Bruton Tyrosine Kinase) and PI3K kinase are in the lead. The small molecule drugs that we hope will block these two kinases respectively are PCI-32766 and CAL-101. I will focus on CAL-101 in this article, since I have read the most about it. Down the road it will be the turn of PCI-32766. Let us hope that one of these days they will come up with more sexy names for these potentially life saving drugs.
CAL-101
The kinase that is targeted by CAL-101 is called PI3K. Biological systems are always complex, and there are four different forms of PI3K kinase with slightly different functions. These four brothers are called Alpha, Beta, Gamma and Delta – respectively. Why is this important, why don’t we hit the whole dang family of PI3K kinases while we are about it? Well, that would be like shooting ourselves in the foot. Brother Alpha and Beta are expressed on a wide variety of cell types, they control a lot of rather crucial functions. Block these two guys and the daily business of the body comes to a screeching halt. At the very least the toxicity levels will be very high, at worst the patient may die. The youngest two brothers, Gamma and Delta, are only expressed on white blood cells. Gamma deals mostly with T-cells and neutrophils. Delta is our guy, the one we have to stop dead in his tracks. PI3K-Delta is specific for B-cell proliferation, survival and maturation. And PI3K-delta is heavily over-expressed in CLL cells. What makes CAL-101 unique from all the other PI3K inhibitors is that it specifically inhibits this particular member of the PI3K family, the Delta form of it.
CAL-101 Phase I Study
This study is being done to see if the drug is safe, if it actually works the way we want it to, and decide what would be a safe standard dosage. There were 54 CLL patients in this trial (along with a bunch of NHL, Mantle Cell and Multiple Myeloma patients). All were heavily pre-treated patients, not a chemo virgin in the lot. Every single one had been exposed to fludarabine. Most also had Rituxan and alkylating agents such as cyclophosphamide. 81% had bulky nodes, fully third of them had the dreaded 17p deletion. I would call this a tough crowd to treat, your classic “salvage” cases.
CAL-101 is an orally available drug, meaning you can just pop the pill. Dosages went all the way from 50mg twice a day to 350mg once a day. Therapy continued on a daily basis as long as patients got benefit from it.
There was some toxicity: 24% of patients had grade 3-4 pneumonia (grade 3-4 is heavy duty stuff, as you know by now) and there was also grade 3-4 neutropenia in 24% of patients. Was this due to CAL-101 or was it due to the fact that this crowd was so heavily pretreated already, with most chemotherapy drugs known to man? The researcher believe there were no clear pattern of CAL-101 related symptomatic adverse events.
Now for the interesting stuff. It seems CAL-101 is very good at cutting the apron strings that keep CLL cells close to home, nicely tucked away in lymph nodes and bone marrow. CAL-101 shrank swollen nodes in all CLL patients in the study, even those with high risk 17p deletion. As the CLL cells got flushed out of the nodes and into open blood circulation, there was a huge spike in the white blood counts – but this was temporary as these CLL cells were soon killed. As much as 80% of the patients had their lymph nodes reduce by 50%. That is pretty impressive, especially in this relapsed and refractory group of patients.
For patients who went into the clinical trial with low platelet counts, presumably due to the infiltrative late stage CLL we discussed in an earlier article, there was significant improvement in their platelet numbers as the therapy proceeded. My guess would be this parallels gradual clearing out of the bone marrow, allowing new platelet formation.
Based on the dose response at different levels the researchers concluded that future studies will use 150mg / twice daily as the standard dose.
Here is the best part of the whole shebang: control over CLL was pretty durable. More than 48 weeks of follow-up and we have more than 50% of the patients are still going strong, in progression free survival. Generally speaking, SLL folks with bulky nodes are harder to treat than CLL folks. That was not the case here, CAL-101 works great with bulky nodes. And the bit that impressed me most is that the shrinkage of swollen nodes happened quite nicely even in patients with the high risk 17p deletion.
Here is a link to the PowerPoint presentation that the researchers made at the ASH2010 conference. It has the latest information on the clinical trial. I expect the abstract below had been submitted earlier to ASH, some of the data is not quite as up to date.
ASH2010 Abstract
CAL-101, An Isoform-Selective Inhibitor of Phosphatidylinositol 3 Kinase P110δ, Demonstrates Clinical Activity and Pharmacodynamic Effects In Patients with Relapsed or Refractory Chronic Lymphocytic Leukemia
Oral Session: CLL – Therapy, excluding Transplantation: Novel Agents and New Approaches
Richard R. Furman, MD1, John C. Byrd, MD2, Jennifer R Brown, MD, PhD3, Steven E. Coutre, MD4, Don M Benson Jr., MD5, Nina D. Wagner-Johnston6, Ian W. Flinn, MD, PhD7, Brad S. Kahl, MD8, Stephen E. Spurgeon, MD9, Brian Lannutti, PhD10, Neil A. Giese, Ph.D.10*, Heather K Webb, Ph.D.11*, Roger G Ulrich, Ph.D.10, Sissy Peterman12*, Leanne M. Holes10* and Albert S Yu, MD10*
Introduction: The class I phosphatidylinositol 3-kinases (PI3Ks) regulate cellular functions relevant to oncogenesis. Expression of the PI3K p110δ isoform (PI3Kδ) is restricted to cells of hematopoietic origin where it plays a key role in B cell proliferation and survival. In chronic lymphocytic leukemia (CLL) the PI3K pathway is constitutively activated and dependent on PI3Kδ. CAL-101 is an isoform-selective inhibitor of PI3Kδ (EC50 of 62 nM in a whole-blood assay with >200-fold selectivity relative to other PI3K isoforms) that inhibits PI3K signaling and induces apoptosis of CLL cells in vitro.
Methods and Patients: This Phase 1 study evaluated the safety, pharmacokinetics, pharmacodynamics and clinical activity of CAL-101 in patients with relapsed or refractory hematologic malignancies. Sequential cohorts of patients were enrolled at progressively higher dose levels with cohort expansion based on toxicity profile and plasma exposure. CAL-101 was administered orally one or 2 times per day (QD or BID) continuously for 28-day cycles for up to 12 cycles (with the potential for more prolonged therapy on an extension protocol thereafter). Clinical response was evaluated according to standard criteria.
Results: At data cutoff, the study had enrolled 37 patients with CLL. Patients included: males/females n=31 (84%)/6 (16%) with median age of 65 [range 37 82] years, refractory/relapsed disease n=24 (65%)/13 (35%), bulky disease n= 29 (81%), and adverse cytogenetics of del(17p), del(11q) or both n=22 (63%). The median number of prior therapies was 5 [range 2-14]. The number (%) of patients with specific prior therapies included: rituximab n=37 (100%), purine analog n=37 (100%), alkylating agent n= 31 (84%), and alemtuzumab n=12 (32%). CAL-101 dose levels were 50 mg BID (n=1), 100 mg BID (n=4), 150 mg BID (n=11), 200 mg BID (n=10), 350 mg BID (n=7) and 300 mg QD (n=4). The median number of treatment cycles was 9 [range 1-13], with 21 (57%) patients continuing on treatment (11 on study and 10 on the extension protocol after 12 cycles). Symptomatic adverse events were infrequent, usually low-grade, and not clearly CAL 101 related. Grade ≥3 pneumonias occurred in 9 (24%) patients. Grade ≥3 hematological laboratory abnormalities included neutropenia n=9 (24%), thrombocytopenia n=4 (11%) and anemia n=3 (8%) that were not usually considered CAL 101-related. A pharmacokinetic analysis of dose-proportionality showed minimal increases in plasma Cmax and AUC at CAL 101 doses >150 mg BID; these data, taken together with the tumor regression results, have proved helpful in supporting Phase 2-3 dose selection. Flow cytometry of CLL cells from patients showed that CAL-101 reduced constitutive expression of phospho AKT to background levels when measured after 1 week of treatment (p<0.0001), demonstrating pharmacodynamic inhibition of activated PI3K signaling. Plasma concentrations of chemokines CCL3, CCL4, and CXCL13 were elevated at baseline and decreased significantly within 1 cycle of CAL-101 administration (p<0.001 for all comparisons). CAL 101 reduced lymphadenopathy in all 32 (100%) patients with at least 1 post-treatment tumor assessment; 29/32 (91%) achieved a lymph node response (≥50% reduction in target nodal lesions). An initial increase in peripheral absolute lymphocyte counts of >50% from baseline was observed in 21/35 (60%) patients; increases were maximal during the first 2 cycles and decreased thereafter; the pattern suggested drug-mediated lymphocyte redistribution. Considering nodal and peripheral blood changes together, partial responses were observed in 11/33 (33%) of patients. The median duration of response had not been reached; 7 patients had response durations of ≥6 months. Of 20 patients with CLL-related thrombocytopenia (baseline platelet counts <100,000/µL), 15 (75%) had either an improvement to >100,000/µL or a >50% increase from baseline.
Conclusions: CAL-101, an oral PI3Kδ isoform-selective inhibitor, shows acceptable toxicity, positive pharmacodynamic effects, and favorable clinical activity in heavily pretreated patients with CLL, including patients with refractory disease, bulky lymphadenopathy, and poor-prognosis cytogenetics. The high level of lymph node regression and prolonged duration of symptomatic tumor control strongly support evaluation of CAL 101 alone and in combination with other chemo/immunotherapy approaches to CLL management.
Disclosures: Byrd: Calistoga Pharmaceuticals: Consultancy, Equity Ownership. Brown: Calistoga: Consultancy. Kahl:Calistoga Pharmaceuticals: Consultancy, Research Funding. Lannutti: Calistoga Pharmaceutical Inc.: Employment. Giese:Calistoga Pharmaceuticals: Equity Ownership. Webb: Calistoga Pharmaceuticals: Employment. Ulrich: Calistoga Pharmaceuticals: Employment, Equity Ownership. Peterman: Calistoga Pharmaceuticals: Employment. Holes: Calistoga Pharmaceuticals: Employment. Yu: Calistoga Pharmaceuticals: Employment, Equity Ownership.
On-going Clinical Trials
The clinicaltrials.gov site lists four clinical trials for CAL-101 that are open and recruiting CLL/SLL patients. Each of the four trials listed below are live links, just click on them to see the full details.
- Dose Escalation Study of CAL-101 in Select Relapsed or Refractory Hematologic Malignancies
- An Extension Study for Patients Who Are Deriving Benefit With CAL-101 to Continue on Treatment at the End of the Current Study
- A Study of CAL-101 and Rituximab in Elderly Patients With Untreated CLL or SLL
- Study to Investigate CAL-101 in Combination With Bendamustine and CD20 mAb in Patients With Relapsed or Refractory Indolent B-cell Non-Hodgkin’s Lymphoma or Chronic Lymphocytic Leukemia
Trials 1 above is what we discussed above, the Phase -I trial for heavily pretreated patients. Trial 2 is continuation of that trial which allows patients to continue on the drug as long as they are getting benefit from it.
Trial 3 is for previously untreated but elderly patients. They plan to recruit 60 patients and one of the inclusion criteria is that volunteers have to be older than 65. I doubt most people consider 65 as “elderly” any more, but there you have it. The idea here is to see if in this “older” group of patients who still have their chemo naive status CAL-101 can deliver higher response rates along with low toxicity and remission durability – that is the Holy Grail combination. Remember, the Phase-I trial discussed above saw only 33% responses, and even those were only partial responses. I for one will be keeping my fingers crossed for the success of this trial with less refractory patients.
Someone asked me if the inclusion criteria are likely to be bent to let in patients who are close to 65, but not quite there yet. I doubt it. Clinical trial protocols are carefully developed with a lot of oversight by ethics committees etc. Playing fast and loose with inclusion criteria can get researchers into trouble and runs the risk of invalidating the hard won results. So, even if you got into every bar in town with fake IDs when you were not quite of legal drinking age, I doubt that would work to get you into this trial if you are not 65. Be patient. All of us get older each and every single day.
Trial 4 is once again for previously treated patients. But here the twist is that they will be combining CAL-101 with bendamustine and either Rituxan or ofatumumab. In other words, this is CAL-101 along with standard chemoimmunotherapy combination. I have no doubt that down the road someone will also want to do CAL-101 + FCR. The idea in these combination trials is to see if we can do better by bringing more fire-power to the game. What makes it interesting here is that we can hope CAL-101 drives out all the sneaky CLL cells luring in bone marrow and lymph nodes, while the big guns bendamustine and Rituxan wait out in the peripheral blood to kill the little buggers as they are flushed out. Good concept, it remains to be seen how the toxicity works out with this combination and whether it is more than paid for by stellar response statistics.
Is there any downside risk to CAL-101?
Aha. That is the million dollar question. As I pointed out in the earlier section of Gleevec, there can be “unanticipated adverse effects” with any drug, even kinase inhibitors. We can only hope to know what they are as we gain experience with this new drug through carefully conducted clinical trials. 24% grade 3-4 pneumonia and 24% grade 3-4 neutropenia seen in the Phase -I trial we discussed above gives me some cause for concern. The researchers felt this did not have anything to do with CAL-101, it was just a case of the patients recruited for the trial being really heavily pre-treated already and therefore prone to any little thing going around.
I did a little digging around. I found a few abstracts that raised questions for me. If I understood these articles correctly, drugs such as CAL-101 may interfere with the maturation and proper function of NK-cells and T-cells. Does this imply long term (maintenance protocols) use of CAL-101 may cause sufficient dysfunction in NK cells and T-cells – which in turn may increase aggressiveness of infections and secondary cancers? Did this have anything to do with the 24% of patients in the Phase-I trial getting grade 3-4 pneumonia?
I will be the first admit, I do not know exactly how important these studies are, especially since most of them are lab mouse studies. If CAL-101 is shown to have far fewer grade 3-4 infections when treating earlier stage CLL patients who are not quite this far-gone salvage cases, that would be reassuring. I touched base with Dr. Furman about my concerns. He felt it was not an issue. Nevertheless, I thought I would share it with you, just in case.
“Tis the Season to be Jolly..
I promised you a Holiday present, and this is it. Sorry it turned out to be so long, but I tried to do justice to a complicated subject. Before you start grumbling, just remember it took me a whole lot longer to research and write this article than it will take you to read it. If you don’t get all of it at one sitting, no problem, this website is not going anywhere, you can always read it again when you need to refresh your memory
With a little bit of luck, we may soon have new drugs available to us that work on a totally different basis, drugs that may prove to be effective, low toxicity and capable of giving long durations. There is a large amount of buzz surrounding these new generation kinase inhibitor drugs – which means we can hope to get credible results sooner rather than later. Keep your fingers crossed folks. We are about due for a bit of good luck and CAL-101 and the other kinase inhibitors coming down the turnpike may be what we have been waiting for.
Happy Holidays, from my family to yours. May the New Year bring you health, happiness and serenity.
Postscript:
CAL-101 is a hotly researched area and there are interesting developments, patient perspectives being reported. I strongly urge you to follow the discussion thread below if you want to keep up with the latest on this drug. Since our discussion sections are only open to registered members, you will have to login to read the comments of our members and my responses.
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60 comments on "CAL-101: Dawn of a new era"
Great article Chaya!
All the best to you
Sincerely
Jeff Douglas
I have seen articles on Cal-101 and have been patiently waiting for you critique as you have never steered us wrong. Thank you for your support and analysis on this treatment. I am 2 years in, on watch and wait with great anticipation of things to come in way of treatments.
Thanks, Chaya!
Thanks for all the work you do for us.
Chaya .
thank u so much for your article . It is indeed great news that CAL -101 looks so promising . I’ve been hoping all along for a Pill for CLL . Hopefully this will come sooner then later , I’m currently in remission for over 2 yrs w FCR + Lumi Clinical trial . Happy Holidays and always much thanks for your dedication to Us CLL ers .
Tony V
Age 56
NJ
We were giving our family an update of my husband’s CLL status (2.5 years “Canciversary”, still W&W, feeling good, barely Stage 1) and I mentioned with much optimism, this area of research. This morning there was your email in my inbox all about it! Thanks for your thoughtful presentation of this and so many other topics, Chaya. We love the learnin’!
Thank you Chaya for this article. I tuned in to a podcast via the Leukemia/Lymphoma society last week and this subject was brought up with much excitement by the presenter. I’m fortunate to be close to 4 yrs. from diagnosis with some poor prognostics (not 17p thankfully)and still in watch and wait; however will likely be starting my first tx. regimen soon. Kinase inhibitors just may be ready for me when I need them a few years down the road.
Kathy
Thank you. Keep up the good work please.
Merry Christmas and a happy new year.
I’ve been following CAL-101 for quite a while now. To my knowledge, I’ve never used the term, “Oh, my God” flippantly. I simply don’t like to hear it. But in this case, “Oh, my God, let it be so.”
Chaya…
I am in the second clinical trial category…on an extension continuing the CAL 101 I started in October 2009. After nearly seven years, being refractory and going through all kinds of treatments, FR, PRC, and Flavopiridol. I rode the BMT/SCT train up to being kicked off at the last moment with Kidney Cancer… I was on massive doses of steroids. In February 2009, I was weakened by the Steroid and necessitated my retirement from a job I loved and placed on disability… I basically went home to die.
I sought treatment from everyone from a strip mall oncologists in Sun City (initially before I became aware of CLL Topics.org) to Dartmouth Medical Center, Moffit Medical Center, and eventually (thankfully) Dr. Byrd and the OSU James Cancer Center Team. I read the forums daily, and most importantly early on, CLL Topics. CLL was my life.
Because of the CAL trial, on January 3rd, I return to work- I am 56, in the Automotive publishing business- a fun job with cool cars, so it really is a good place to be…The difference in my nodes and fatigue has been tremendous. My white counts have risen a bit, and I did have a bout of pneumonia last summer…but I am well today and hope to remain so…again with credit to CAL101.
Thank you Chaya for the knowledge based easy to read commentary you provide here.
Merry Christmas and Happy Holidays to all…there is hope.
Randy Shannon (Hotrodder)
Pam in Florida
Hi Chaya
Thank you for taking the time to write yet another article for us CLLer’s. Don’t know how we would make any sense out of the articles in medical journals even if we had access to all of them. So your translations into comprehensible english are invaluable.
It is wonderful to hear stories from people like Randy Shannon. I hope that miracles are just around the corner for all the other CLL patients who are having serious problems.
Thanks for the holiday present Chaya. Hope that 2011 will be a good year for you and your family.
Pam
This “ex hotrodder” loves Randy’s comeback story. I too ran the treatment gamut up to my STC in 2005. I have just finished my third SubQ Campath round since transplant failure. I’m feeling great, and believe I’ll get another good year as I did from the last two Campaths, then it’s on to CAL-101. I am blessed to have Dana Farber’s Jennifer Brown in my corner, so I am on her CAL-101 list when I need treatment next. I was actually scheduled for the original CAL-101 clinical trial, but my pressing need for treatment could not synchronize with the trial date.
I must say Chaya, it excited me to read this GREAT and thorough work from you. As I have said before, words fail me to adequately offer the praise you so richly deserve.
I extend heartfelt wishes to you and yours.
Bob Larkin
North Branford, CT
Chaya,
Oh, how exciting!! Thank you for sharing the news re:CAL 101. I really feel uplifted.
A Happy and Healthy New Year to you and your family and Many, Many Blessings.
Rita
Thanks, Chaya, for the great article and CAL-101 sounds full of promise.
How uplifting to learn about a new and possible breakthrough in treatment for CLL. Gleevec has demonstrated that such developments are realistic.
Happy Holidays
Chaya,
Thanks for the promising news. Have a wonderful holiday season.
It is pretty reassuring that we have cause for new optimism that less harsh treatments may be around the corner. Thank you for the update on this scientific progress.
Thank you for your hard work, Chaya. You do such a great job in translating the science for us. As a longtime science writer (and a CLL newbie), I’m not one to complain about the length. Lots of aspects to cover!
Happy holidays
Randall – thank you SO much for sharing your experience thus far. I will be anxious to hear your progress in the future.
HOPE is the very best Christmas present for which we could ask! If you don’t believe me, go find someone who has none.
Thank you Chaya for your continued efforts and commitment to all of us who have CLL in our lives. May it one day be gone and we call all just be facebook friends!
Thank you so very much for the wonderful Christmas letter of hope. This is the most cheerful gift I have received this year.
Betty
Wonderful and timely article .. one of the best gifts I’ll receive this year. Mahalo nui,
“Elderly” Lynn (Gotta laugh at that tag!)
PS — So pleased for Randy. What a story !!
Thanks Chaya for the article. As we start CAL 101 + Rituxan in early January, you have reminded me to be aware of possible side effects. We hope for good results, for us and for everyone after us.
Thank you, Chaya! Wishing you and your staff the very best for the New Year.
Monique
Chaya is the Richard Feynman of CLL. They each make Researcherese understandable.
What a timely article! I started the CAL-101 trial just yesterday with Richard Furman. I’m receiving CAL with Rituxan. The other arm of the study is getting it with bendamustine, and there will be a third arm in the future that will get it with both B and R.
I am hoping for good results, and I’m encouraged by success stories like Randy’s, though I’ve also had concerns about side effects. I’ve had one prior treatment, FR two years ago. After a good partial response, I started to progress within four months, so I’m officially refractory. I also picked up an 11q deletion and I’m unmutated. All the more reason to hope this works for me.
Chaya, could you clarify a point in the article about the response rate? It said, “Considering nodal and peripheral blood changes together, partial responses were observed in 11/33 (33%) of patients.” The article also said that 29/32 (91%) achieved a lymph node response of 50% or greater reduction in target nodes. I wonder what the definition of partial response was?
Thank you so much for keeping us informed about the latest in CLL treatment and research.
Claire
Chaya,
Thanks. CAL101 and others of its ilk look like they may be the next best thing, especially for those of us with 11q del and bulky nodes.
Another bonus is that there is much excitement among potential patients about them that should translate into less trouble filling trials and getting results.
As Dr. Keating talked about trials have become increasingly cumbersome and access to the drugs made more difficult.
I am seriously considering one of the new kinase inhibitors as a way of putting off a 2nd HSCT but I doubt I would qualify for any trial, so unless I can sweet talk someone into doing a trial of one, I may need to wait years for approval, years that I probably don’t have.
This is a serious flaw in how drugs get developed and the place of compassionate use.
Another issue is that so many trials can be set up to make the drug look good, a “beauty contest” trying to impress potential investors or attract a lucrative takeover rather than advance the science.
There is a lot of money to made in treating cancer.
Right now my hand is not being forced, so I will look for an opening that I can squeeze through and that make senses for my circumstances. Kipps is talking about a CAL 101 + ofatuzamab trial soon.
You do such good work here. I never feel a compulsion to get too involved in the medical details in my blog as you have done such a fine job of explaining things
Stay strong
Thanks again.
Brian
Chaya,
Because of the multiple kinase dysfunction in CLL, is it possible that CAL-101 might not be appropriate for some patients? Does this mean that in the future we will need not only CAL-101 but 102, 103 & 104? or is there need to target further upstream before dysfunctional kinases are created? Is there knowledge of how these kinases are made dysfunctional?
It would seem to me that early as possible high definition or high resolution scanning of patients at diagnosis to establish a bio-molecular baseline that could be compared to later disease progression would reveal critical intervention points and targets that would hopefully respond to least toxic therapy interventions. I know some of these sexier scanning technologies are being used in the research centers but I don’t get the sense that it is a co-ordinated effort. Any thoughts on this?
If we were destined to get a cancer we can be grateful that we got one where you are involved. Thanks for the Xmas present. I may be needing it this year.
WWW
Clairejoy:
You ask an important question. In order to do apples to apples comparisons, all researchers need to use the same criteria for defining the quality of remissions. In 2008 a high ranking group of CLL experts were charged with the task of defining all the guidelines. You can read (and save on your hard drive) the full text article in “Blood”
http://bloodjournal.hematologylibrary.org/cgi/content/full/111/12/5446#top
“Guidelines for the diagnosis and treatment of chronic lymphocytic leukemia: a report from the International Workshop on Chronic Lymphocytic Leukemia updating the National Cancer Institute–Working Group 1996 guidelines”
Table 4 of this very important article lists the conditions that must be satisfied for a patient to be declared to be in CR, PR, PD (progressive disease) etc.
The important thing to note is that all of the conditions need to be met before a patient can be said to be in CR, PR whatever. For example, “PR” requires that lymph nodes, spleen, liver, ALC must all be decreased by 50% or more. There must be 50% reduction in bone marrow infiltration. Platelets must be more than 100K, hemoglobin over 11g, ANC over 1.5K – or each of these items must be at least 50% better than they were at baseline when the patient went into therapy.
ALL of these conditions must be satisfied. A patient who passes all the criteria except one, say he flunks the platelet count requirement of 100K (or 50% better than baseline) requirement, he will not be classified as PR. Since it is entirely possible for patients to get good responses in most (but not all) of the criteria spelled out – such patients will not be classified as PR.
I strongly recommend you click on the link and look up the criteria in the original article. This paper is an important document for our community since it lays down the law – as it were.
Hope this helps answer your question.
Wayne:
No doubt there will be newer and more effective kinase inhibitors as time progresses. One step at a time.
Gleevec has been a miracle drug for CML. But nearly one-third of patients will still have an inferior response to it, either failing to respond to primary therapy or demonstrating progression after an initial response. The good news is that there are already other kinase inhibitor drugs tweaked just right to overcome Gleevec resistance.
Unlike viral infections such as smallpox, I don’t think the war against cancer will ever be won – in the full sense of that word. Cancer is part of how our bodies work, part of the aging mechanisms, part of random mutations that happen. What we should aim for is winning individual battles, gain ground and gain control over the battle field. I don’t expect to see CLL defeated, totally vanquished, as in no one ever dies of CLL anymore -at least not in my life time. What I want to see and hope to see is much better therapy options that give our patients long and trouble free remissions, even the high risk group guys. I want to see the penalty in life expectancy reduced across the board for all our guys. I want to see median survival for CLL to go from the 7-10 years it is now to say, 15-25 years. I want to see a huge majority of CLL patients dying with CLL, not because of CLL. One step at a time.
For all those who get frustrated by the slow process of drug development: this is how science works. Unless you have a terrific crystal ball, or you are willing to bet on the lives of human volunteers in poorly controlled clinical trials, we had better learn to be patient. And as for the profit motive of drug companies in developing new drugs, capitalism is a terrible system, except that it happens to be better than all the other systems out there. We need the creativity and competitiveness – while controlling some of the excesses with oversight, regulatory agencies etc.
Last but not least, a well informed consumer that votes with his feet (and his dollars) is our best protection, since money does drive the system. That is the part I try to address, the well informed consumer. You guys do not realize how much power you actually have, if only you chose to work together and use that power.
Nice Xmas present! a great intro to CAL-101 augmented with feedback from trial participants. Have a nice holiday, Chaya and Family.
Jim
I’ve been waiting almost fifteen years for some really optimistic news on development of beter treatment. This sure sounds like it. Thanks for all you do.
Njm
Thank you Chaya for a wonderful Christmas present. I listened to Dr Byrd’s webinar and was hopeful in hearing the information on Cal 101. I am going to the NIH study in January, after over a year wait, but I am looking forward to the experience. So far, I am 5 years past diagnoses and still in the watch and wait phase. Hearing about new advances gives me hope that by the time I need treatment these new drugs may be available. Thank you for your help in understanding the science involved. May you and yours have a wonderful holiday season and may 2011 bring you happiness.
Jf
Chaya,
Thanks for the great article. I appreciate your being in our corner. Happy Holidays to you and your family.
Chris R.
Great summary. Thanks very much. Have a wonderful Christmas.
Paul Z.
Chaya,
My wife has CLL and we have been W&W for 30 months. She is 53 and not eligible for the current trials of CAL 101. Her Hgb 300k, Plates are good, and some increase in node size. We are on our way to Phoenix for a trial using PCO with Dr. Leis.
Thank you for this site and the information you provide. The road is not smooth or flat, but you make it easier.
Steve
Thank you for your great news, Chaya!
Wondering if having AIHA would make you ineligible for these trials? Anybody?
Linda
Making Wayne’s words my own: “If we were destined to get a cancer we can be grateful that we got one where you are involved.”
I have been so down lately, this article gave me small boost I needed for now.
Thank you for reminding us of our power– you have said it repeatedly over the years, and we don’t seem to organize ourselves enough around specific issues. Perhaps because we are such a diverse group, our individual needs vary so much?
Thank you always,
Cristina
Contact persona Mona Stephanos at Ohio State (Byrd-land) says the CAL-101 dose escalation study is now closed nationally for CLL. Good news or bad news depending on your perspective.
Does she have it right?
I read this weekend that you can’t eat for one hour before taking the pill and for two hours afterwards. That doesn’t seem like much fun; how do you manage that every day during daylight hours?
Can someone tell me what an overall response is? Citations in this instance just adds to the chaos.
CAL 101 appears to be less broadly active than Bendamustine according to Calistoga’s very preliminary research data set. I understand the great advantage of a minimally evasive therapy, and would sign up today if the dose escalation study were still open, but since we’re in for hell anyway, why not go with the stronger Bendamustine if overall response is the name of the game?
Last thought: every doctor in the study appears to be an equity participant at Calistoga. Can’t say I blame them but how might that impact the study results? Can we wave away the frequent grade 3 and 4 events without further explanation?
Mark
Mark:
The reference I gave in my response to “clairejoy” describes in nice detail how CR and PR are defined. The number of CR + PR patients divided by the total number of patients evaluated is defined as the overall response.
No doubt bendamustine will have higher response rates than CAL101. I think this is a bit of a speedy hare versus slow but sure tortoise story. The remission rates from CAL101 will take a while to develop, but (and this is the devout hope of all the scientists involved as well as yours truly) it is expected that the remissions will come without the hugely expensive toxicity that follows all chemotherapy agents – bendamustine is no exception. The level of response reported for CAL101 in this heavily pre-treated group of patients is truly remarkable.
Just for the record, I do not own stock in Calistoga, I have not been paid a consultant’s fee, I have not been taken out to lunch by anybody remotely associated with the company.
If it is possible to whittle away at a patient’s CLL tumor load, a little each day, without a significant toxicity cost, with an orally available pill – I call that a huge improvement. It begins to make CLL a “chronic but manageable” disease, along the lines of high blood pressure or diabetes. Still dangerous, but manageable. One more important step along the way to full CURE.
Yes, I believe enrollments in the various trials is going full steam. Not surprised they already sold out on some of them.
Only larger trials and longer term follow-up will shed more light on the full scope of adverse effects. I am in the camp of “watch carefully, but optimistic right now”. As for the inconvenience of taking the pill on an empty stomach – I wish all problems were that small!
I have completed 12 cycles of CAL-101 and have started the extension trial. I have 17p deletion and was transfusion dependent for both red blood cells and platelets before starting the trial. I was running out of options before I started CAL-101. I am feeling very well now, and I have not needed a transfusion since last March (hemoglobin is now 11.9, platelets 74). My lymphocyte count started at 106. In August it was 9.5. It has started going up a little (13.6 in October, 19.5 in December). Hopefully this upward trend won’t continue.
Originally, our instructions were that you must wait two hours after eating before taking CAL-101 and could not eat for one hour after taking it. Now they say you must wait one hour after eating to take it and still say do not eat for one hour afterward. As mentioned, this is a small inconvenience for a very large benefit.
Kellerdon,
Did you have a BMB before starting the trial? I’m very interested in the effect CAL-101 has on the marrow.
Thanks
Lynn
Lynn,
I did have one the day before I started the trial. My marrow was mostly packed with CLL (96% if I recall correctly). However, I have not had another BMB since then. The indirect evidence (improvement in hemoglobin and platelets) is that there is improvement in the marrow, but no follow up BMB to quantify it.
Don
kellerdon:
Like LynnS I too am interested in knowing the effectiveness of CAL-101 on the bone marrow. I wonder why they have not done a post-therapy bone marrow biopsy. Inferring by circumstantial evidence (improved Hg and platelet counts) is all very well, but this is a clinical trial, looking for clinical evidence that will become important when the drug has to be approved by the FDA. I am bothered by this.
Kellerdon,
What impact did CAL-101 have on your hemoglobin counts? Also, do you know of any forums that have a lively exchange of CAL-101 experiences?
Mark
Thank you Chaya for explaining about CAL-101.
Terry is beginning FCR-Lite on 1/10/11, Monday.
He got an excellent response on intial Rituxan for 4 weeks in September 2010. By that I mean his ALC dropped from 40’s k to 2k. Platelets increased to near 150, Red counts rose and neutrophil count is fine. His enlarged liver, spleen and abdominal and pelvic nodes shrunk by 30%. He had gotten ill in August with Shingles then pneumonia. The infections, falling platelets and red cell counts plus organ and lymph node enlargement was why he was advised to begin treatment at 8 years after dx.
Terry is 63, healthy and strong aside from well-controlled Type II diabetes and feeling well since Rituxan. He has mostly favorable genetics with the exception of 12 trisomy. Since that genetic indicator showed the most response to FCR Lite in the initial trail we and his oncologist look forward to a strong remission that lasts long. It is great that there is now the CAL-101
CAL-101 and Bone Marrow Clearance
Nothing is ever simple and easy in the land of CLL. Since writing this article I have been doing some more digging into the details of how CAL-101 works in the bone marrow. Not so well, it seems.
Here is a scenario that worries me. Patient goes in to CAL-101 therapy with some amount of CLL in his blood, some swollen nodes and moderately infiltrated bone marrow. CAL-101 does a terrific job shrinking his nodes, flushing out all the CLL cells into the blood. Sure, the blood counts rise in the early days, but eventually all those CLL cells swimming naked in the peripheral blood with no “nurse-like-cells” to protect them get killed as well. WBC looks great, nodes are gone, spleen is shrunk back to size and therefore no longer sequestering perfectly good red blood cells and platelets. Everything begins to look just great on CBC blood tests and CT scans!
All of this takes time. No one said CAL-101 therapy is an over-night miracle, it takes many moons for the nodes, spleen, blood and CBC to get back to normal. The million dollar question: What is happening to the bone marrow while all this other good stuff is gradually taking place? Any chance the bone marrow is quietly getting more and more infiltrated, so that when and if the other shoe drops, the patient is in heavily infiltrated late stage (Stage 4, Stage C, depending on whether you are using Rai or Binet staging system) CLL, in need of urgent therapy to get his bone marrow sufficiently cleared and working again?
What do the experts say about CAL-101 and the bone marrow? Here is a comment from Dr. Furman, the researcher who has done some of the early phase studies in CAL-101 in CLL:
Advances in LLM
Edited by Dr. Susan O’Brien
New Agents in Early Clinical Trials for CLL Therapy
By Dr. Richard R. Furman
http://www.clinicaladvances.com/article_pdfs/ho-article-201007-llm.pdf
“CAL-101 is a new agent for which I am particularly excited… CAL-101 has demonstrated very dramatic reductions in lymphadenopathy in very refractory patients in its phase I study. More than 90% of the patients in this very refractory group of patients had greater than 50% reductions in their lymphadenopathy. CAL-101 seems to have far less efficacy on bone marrow disease, which has taught us a great deal about the molecular pathways involved in lymphocyte trafficking, including CXCR4 and CXCL12.”
As I said in an earlier comment, this worries me. If this pattern is confirmed, namely poor efficacy of CAL-101 in the bone marrow compared to lymph nodes, we will have to wait until we see intelligent pairings of this new drug with others that are capable of delivering killing power in the bone marrow – hopefully without adding to the toxicity side of the equation. Otherwise, as in the scary scenario I imagined above, patients may be walking to the edge of gradually increasing infiltration of the bone marrow without even being aware of it, lulled into a sense of security based on CBC and CT scans but no bone marrow biopsies. I would very much like to see before and after bone marrow biopsy results of patients going through CAL-101 trials today! Is the percentage of marrow infiltration decreasing, or heaven forbid, increasing as patients go through CAL-101 therapy?
Bone marrow biopsies are not fun, no one would do them unless it is necessary to evaluate the health of the marrow. I do not see how it will be possible for CAL-101 to get FDA drug approval until and unless this question is settled in a direct manner – not inferred by improving CBC counts.
There have been past references to blood tests that can determine the condition of the bone marrow without BMBs. Does anyone know what they are?
Btw, I think CAL-101 is an important discovery and I’d be grateful for further discussion here of its merits and limitations.
mschaeffer33:
You must be referring to four color flow cytometry. This blood test is more sensitive than the ordinary flow cytometry test and therefore able to look for CLL cells at a higher level of sensitivity. It is used for testing for MRD negative status which would otherwise require a bone marrow biopsy.
But we are not talking about MRD negative status here. We are far from MRD negative remissions in this case. All of these patients still have sufficient CLL cells that can be seen by ordinary methods, large majority of them are not even CR. The question is whether CAL-101 is doing a decent job of clearing the bone marrow. Is the percentage of infiltration going down, even though there is still some amount of infiltration? IF the bone marrow is also getting cleaned at a slow but steady rate, along with shrinking lymph nodes and clearing blood counts, then indeed we can hope CAL-101 becomes the long term maintenance drug we are hoping for.
Among the available agents, chemo and non-chemo, are any of them clearly superior in reducing bone marrow infiltration? And are there blood tests that would establish improvement in infiltration?
Mark
Chaya,
I wanted to first apologize for mispelling your name. My second word to you is that I agree with you on the way a pill has to be taken in order to get a benefit in comparison to the effects of Chemo drugs. Absolutely no comparison and I wanted to let you know that my husband John is having a BMB immediately before the CAL-101 trial and 8 weeks there after to compare with baseline. It appears according to Robert Boccia M.D. at the Center for Cancer and Blood Disorders in Maryland BMB’s are done and will be able to provide an information base for those wanting to know what the infiltrated BM progress is. I will personally do my best to see that we contribute to that cause. You will hear from us again**
Paula
Paula:
I really am looking forward to your updates n how your husband fares on the CAL-101 trial. Patients who volunteer for clinical trials are the real heroes in my estimation. The risks they take with early stage drugs paves the way to safer and more effective drugs for the next generation of patients. Without these volunteers we have no way of getting better therapy options.
So, please do keep us in mind, please do post periodic updates. I hope he gets a nice long remission, worry free. And not to worry about mis-spelling my name. Foreign names are tough on anyone.
My husband completed 3 rounds of CAL-101 from 2/10 – 5/10. He enrolled in the clinical trial hoping that the CAL-101 would reduce his mesentery nodes such that they would be small enough for him to go forward with a MUD SCT. This was accomplished after the first month of treatment. The SLL/CLL in his bone marrow, which was extensive when he was first diagnosed, had been significantly reduced by his prior FCR and HDMP + R treatments. The plan was for my husband to stay on the CAL-101 until his transplant which was scheduled for late 7/10. My husband did not appear to have any side effects on the CAL-101 (quite a difference from the FCR and HDMP treatments) until at some point during 5/10 his liver enzymes became quite elevated. His doctor at Dana Farber had warned him that this was a possible side effect and, as a consequence, he would need to be closely monitored. When the enzymes became elevated, he was taken off the med and his liver enzymes returned to normal over a period of weeks. My husband then proceeded to transplant according to schedule. A bone marrow biopsy was done just before the transplant and I don’t recall anything remarkable about the results.
Around the time my husband started on CAL-101 he developed neuropathy in his feet. We’ve been told that this does not appear to be a side effect of CAL-101. It could be related to his prior treatments or something completely different. If anyone has had any luck treating neuropathy, I’d appreciate their input.
Agail,
A very significant set of numbers for some of us would be more detail on the bone marrow characteristics going into the CAL-101 (thus after his chemo) and the numbers coming out of CAL-101 before the transplant. Those are the sorts of numbers we haven’t seen yet — i.e. the effect of CAL-101 on marrow.
Thanks and best wishes for your husband’s transpant.
LynnS,
My husband did have a bone marrow biopsy in 2/10 and one in 7/10 at Dana Farber. I can’t find the entire report for 2/10 so I’m afraid I can’t answer your question but will try to get it. At the time of the reports, we were concerned less with whether the bone marrow infiltration had decreased/increased and more with whether the bone marrow infiltration was less than the cap that is used for transplants.
I am heading to Stanford on Tuesday to learn more from Dr. Coutre about the Phase II CAL-101 + R for Elderly Untreated patients (NCT01203930) and the Phase IB PCI-32765 for Elderly Untreated Patients (NCT01105247).
As both of these drugs seem to jack up the WBC in the beginning, is there anyone out there who had WBC > 200 who is in either the CAL-101 or the PCI-32765 study? Or, anyone who is an untreated patient in either study .. I’d love to hear how you are doing.
I have heard that in the case of a few patients who were undergoing the CAL-101 clinical trial, when they completed the planned number of doses and stopped getting daily dose of CAL-101, unfortunately their CLL returned quickly and the remission was unexpectedly short.
This is anecdotal data, I have not been able to find any real details and therefore these concerns need to be taken with a big pinch of salt. However, once again this raises the concern for me that if CAL-101 is unable to clear the bone marrow, the CLL cells safely tucked away there can form a reservoir of cancer cells that can quickly re-seed the rest of the body once the drug is stopped.
Of course, this does not mean CAL-101 has failed. It may just mean that the drug needs to be paired with a second drug that is more effective in bone marrow clearance department. Unfortunately, single agent Rituxan is not particularly good either at bone marrow clearance either. But perhaps when paired with CAL-101 it can do the job. As we have seen in the case of prior drug cocktails, it may be a case of 2 + 2 equaling more than 4. We can hope.
LynnS,
I did get the biopsy report for 2/10 and it does appear that the bone marrow infiltration of CLL/SLL did increase between 2/10 and 7/10 even though mesenteric nodes decreased. I’m reluctant to give too much specific information because I have a hard time interpreting together the pathology report from the biopsy, the lab test from the bone marrow aspirate and the flow cytometry test, and I don’t want to mislead you. Let me know, though, if you’d like any other information.
Thanks so much Agail. Not to worry .. to read those BMB reports one definitely needs a translator. Hope all is going well with your husbands transplant.
Lynn
Chaya-
Thank you for all you do– my spouse was diagnosed in 1999 and has been through most chemos (except Campath) since 2008. Now looking at competing opinions from doctors between stem cell transplant (if we can get him stable) or possible BTK (PCI-32765)at MD Anderson. We’ll be very interested to hear what you and others think of that drug.
Margaret:
Bruton Kinase inhibitor (BTK) is still relatively new and not much is known about it. Clinical trials (such as the one at M. D. Anderson) will help us understand more about it in the future. But for right now, it is still bit of a mystery molecule.
Like CAL-101, this kinase inhibitor too is thought to do its best work in reducing lymph nodes. Since the task at hand is stabilizing your husband and getting him into low tumor load position prior to a transplant, this may be a very good choice for him. Do keep in touch and let us know how things work for him on this clinical trial. We are all better off when we share information, especially important clinical trial information such as this one.
As I have commented several times above, my concern is whether CAL-101’s inability to do a full bore clearance of CLL cells – especially in the bone marrow – means that when patients are taken off of the drug their disease may come roaring back. I have heard from a few of our members who have been in the CAL-101 trials where this was the case.
Below is a quote from Dr. Rick Furman in one of the other websites, commenting upon CLL staging a quick return after patients came off of the CAL-101:
“For both CAL-101 and PCI-32765 we have seen the disease
flare when treatment is discontinued. It is hard to know
how to interpret this as the patients who have discontinued
treatment have only been those who really did not respond.
We do not know what that would mean for someone who has
responded, as there is no reason to stop therapy.”
Folks, the early news suggests that while CAL-101 is probably going to be an important addition to our available therapy options, chances are it is not going to be a miracle cure of CLL. The waiting goes on.
In particular, I would like patients with infiltrative late stage CLL (see our recent review on stage 4 infiltrative CLL) not to waste too much time exploring this particular drug option. By now most experts are agreed CAL-101 does not do much for clearing the bone marrow.
This informaton from Chaya is very interesting and valuable. It has been awhile since I have seen new data on CAL-101 or PCI-32765, and I am anxious to see results from more extended trials. It looks like the multi-agent studies with PCI-32765 already mentioned on this site will be very important. From what I do hear, the ongoing single-agent PCI-32765 trials are apparently going well.
In my own case, I have completed 9 28-day cycles of PCI-32765. My HgB, ANC and platelets are all pretty good. I have no detectable lymph node enlargement – after major involvement there at the beginning of treatment. My WBC spiked at 60K in cycle 4 and is now down to 11K. I feel great, with no infections this past winter, and am looking forward to continued treatment. It should be noted that I have been getting IVIG since January. This result is a godsend for me, being IGVH unmutated. I had achieved only a two-year, partial remission from FR, and we couldn’t see any other really promising alternatives last summer – save rolling the dice with a transplant. I am very content to be approaching an apparently stable, relatively safe situation for now – and maybe the future.
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