Does Chemotherapy Still Have a Role in Frontline CLL Treatment?

Only in select patients with low risks

• Fludarabine-cyclophosphamide-rituximab (FCR) used to be the standard frontline therapy for CLL
• Today it has been replaced by newer combinations such as venetoclax (brand name: Venclexta) plus obinutuzumab (brand name: Gazyva)
• According to Dr. James Gerson, only young patients with low-risk cytogenetic features may still be candidates for FCR

In the past, the standard first-line therapy for chronic lymphocytic leukemia (CLL) was fludarabine-cyclophosphamide-rituximab (FCR). Because this regimen is both immunosuppressive and myelosuppressive, there has been a move away from FCR to novel combinations, such as venetoclax (brand name: Venclexta) plus obinutuzumab (brand name: Gazyva). Is there still a role for chemotherapy in the frontline treatment of CLL?

“The only patient who I will consider giving something like FCR to is a young patient who’s motivated for extremely limited duration of therapy and who has the best risk cytogenetics,” Dr. James Gerson, hematologist-oncologist at Penn Medicine, tells SurvivorNet Connect.

He doesn’t recommend FCR for patients with high-risk features such as 17P, 11Q, or TP53. “Though FCR can be a very effective therapy…the risk of prolonged cytopenia, the risk of secondary MDS and AML, the risk of infection is remarkably high.”

Dr. Gerson says he would consider this therapy for a patient who doesn’t want to do venetoclax-obinutuzumab and doesn’t want to be on a BTK inhibitor long-term, provided they fit all the criteria. “But it’s incredibly rare in today’s age, at least in my clinic,” he says. Although some of his colleagues still offer FCR, “I’ve moved pretty firmly away from it.”