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Best options for an older patient with Ph+ B-cell ALL

December 30, 2021

Here's how readers responded to a You Make the Call question about best options for an older patient with Philadelphia chromosome (Ph)–positive B-cell acute lymphocytic leukemia (ALL).

Disclaimer: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is solely at your own risk.

Based on the data from the ECOG/MRC trial, five-year overall survival for Ph-positive B-cell ALL undergoing treatment after first complete remission (CR1) with MRD alloHCT versus MUD alloHCT versus chemotherapy alone is 44 percent versus 35 percent versus 19 percent, respectively. If the patient has a MUD or MRD available, reduced-intensity conditioning followed by alloHCT would be the ideal approach for long-term survival. She will need careful evaluation of her performance status, comorbidities, and social support.

Hamza Hashmi, MD
James Graham Brown Cancer Center
University of Louisville School of Medicine
Louisville, KY

Yes. The patient needs to be considered for alloHCT if she is in good clinical condition.

Giulio De Rossi, MD
Rome, Italy

If the patient is a fit 66-year-old woman with no major, or at least controlled, comorbidities (low HCT-comorbidity index), my recommendation is to move forward with alloHCT. A matched related donor (MRD) would be optimal, although matched unrelated donors (MUD) or other donors (haploidentical) can be suitable. Last, the use of post-remission alloHCT is controversial, and I would not consider using it if the patient continues to be MRD-negative after alloHCT. Optimization of post-remission alloHCT with tyrosine kinase inhibitors (TKI) in this population is challenging (Carpenter PA, Johnston L, Fernandez HF, et al. Blood. 2017:130:1170-2).

Jose D. Sandoval-Sus, MD
Moffitt Cancer Center
Pembroke Pines, FL

Change to ponatinib to prevent the evolution of T315I mutants. After dasatinib, you can find this mutation in more than 50 percent of patients. AlloHCT is associated with >20 percent acute mortality.

Erwin Wolber, MSc, PhD
Lübeck, Germany

Hyperdiploidy is a good prognostic feature. Older age increases morbidity/mortality for alloHCT, so I would not suggest it. I would have added imatinib up front.

James M. Granfortuna, MD
Cone Health System
Greensboro, NC

Yes, I would consider for alloHCT.

Anastasios Raptis, MD
Lemieux Center for Blood Cancers
Pittsburgh, PA

It depends. In Italy, we like to use the chemo-free regimen for induction (right now a protocol that combines dasatinib and blinatumomab is actively recruiting). This way, we obtain 100 percent complete hemotologic response and approximately 30 percent complete molecular response, and our patients are always in optimal condition. They don’t experience febrile neutropenia or the other side effects of standard chemotherapy.

We usually recommend transplant, especially if a sibling donor is available. I use transplant with pre-emptive TKI maintenance for five years. If the patient is too old, I usually continue with TKI indefinitely.

I think that if the patient is in good clinical condition (performance score = 0) and has no other comorbidities and a related donor is available, transplant should be considered. Otherwise, I would recommend dasatinib indefinitely with close monitoring of the BCR-ABL/ABL level.

Matteo Dragani, MD
Turin, Italy

Why would one not consider this patient for alloHCT? The data provided are insufficient to conclude that she is not a candidate for transplant. Four cycles of hyper-CVAD is not a picnic, and I use such tolerance history as evidence of good physiology. There is no mention of TKI therapy.

Of course, she should be considered for all available maintenance therapies, including alloHCT.

Robert K. Stuart, MD
Hollings Cancer Center
Charleston, SC

I would follow up every three to six months with PCR [for BCR-ABL]. As long as she remains in CMR, I would not send to transplant.

Ahmed Galal, MD
Durham, NC


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