44 replies to this topic

[Trey]

I can understand and support Joel's decision to stop TKI therapy after 4+ years PCR undetectable.  This is not for everyone.  I think there needs to be 2 factors involved to think about this option.  One is certainly a long term PCRU -- I would say the longer the better, and 2 years would be a minimum number.  The other necessary component would be fast response to TKI therapy.  Fast response shows high susceptibility of those higher level leukemic cells to TKI drugs.  If this approach is going to work, the high level leukemic cells must be killed off.  For it to work over the long term, all leukemic cells must be killed off.  The big question remains to be answered: after several years of TKI therapy and PCRU, are the leukemic stem cells all gone?  There is no answer to that.  Research tells us that they are probably not all gone.  But maybe they are.  I have suggested (maybe wishful thinking?) that after many years of pounding by TKI drugs, the last leukemic cells would give up because of unknown mechanisms at work.

There is also another less drastic option to reduce TKI dosage which I have previously discussed.  I have been PCRU for over 5 years.  I reached PCRU in well under a year.  I chose Gleevec dosage reduction down to 200mg per day, which I have been doing for 2 years now without loss of PCRU status.  I also have almost no side effects.

http://community.lls.../message/112202

Joel is doing this in a smart way, under increased monitoring.  Anyone who considers this should use the same approach.

[lasmith58]

Trey, I have been PCRU for 2 years solid now and am only taking 50 mg of Sprycel a day.  My issue isn't the Leukemia, it's the side effects.  Sprycel is much better on me than Gleevec was, but my quality of life is non existant.  I am working less than 20 hrs a week and can barely do that.  My Onc's only retort to any of this is let's change medicine.  I went off Sprycel for 2 months over this last year and am still PCRU.  I would certainly like to see what my alternatives are.

Thanks for letting me gripe,

Larry

[Taylor]

Good luck, Joel!  Please do keep us posted.  I think we're all looking forward to see how you do.

I hope to one day be able to reduce my dosage, but I would be wary of stopping--just a personal opinion.  I do know that before my 6-month FISH and PCR, my oncologist said he has reduced dosages for his other patients that are on Gleevec (I'm actually on Tasigna) and they maintain PCRU.

At six months, I went from 96.5% FISH and whatever my PCR was (I don't know my dx number) to negative fish and 0.003% PCR.  We did a BMB tuesday just to look deeper at everything.  I hope since I have responded quickly I will be a candidate in a couple of years to reduce dosage, if I can continue to improve and achieve PCRU.

I think a high initial dosage followed by long term, low-level maintenance may be the future for the majority of people, although some will be able to pull off cutting the medicine completely.  It would seem to me that with initial high amounts of leukemia cells, you need all the medicine you can to go around killing the cells; but if there are later only a few stem cells that wake up in a while, you would only need a minute amount in the blood stream to be taken up by the cells when they awaken.

Anyway, just my two cents.  I am excited whenever I see posts like this, not in the sense of a cure or getting out of taking TKIs, but just because we may be seeing a welcome change in how therapy is done.

[ChrisC]

This is an excellent discussion. Dealing with the side effects is the primary reason I want to stop my TKI. Five naps a day, hearing loss (I hope it is reversable: as Trey has pointed out elsewhere it might be due to edema), brain fog, etc.: gotta deal with these things to improve quality of life. At Stanford, the initial response to my ceasing Sprycel was that since it was working perfectly, why stop? Working perfectly except for the side effects, I responded. And so the discussion was on.

I asked whether reduced dosage might be an option, rather than stopping Sprycel, or in the event that I needed to restart it, might I do so with a lower dosage. Their policy has been and continues to be to only take the full dosage. Their reasoning was that a) most of the TKI is immediately excreted and very little is left in the body to do its work, and mutations, particularly the T315i, are the enemy and as there are no open T315i studies right now (he said), if after stopping Sprycel I developed that mutation, there would be no TKI to help me. I responded that I expected that since the Ponatinib trial was going so well, it would be approved by the time I needed it. (SO helpful to bring in what gets discussed here.)

I am hoping that at CML conferences this year there will be good reports on reducing dosage of TKIs after maintaining PCRU over time, to deal with side effects, as it appears that other doctors are working with that option. I'll have to try getting a consultation at USC if CML returns, rather than Stanford, if I want approval for a lower dosage. Each approach is a reasoned approach, yet they differ, and we need to see what results are found with each one.

[Taylor]

Hmm, that's interesting what you said, Chris, about their assertion that most of the TKI is excreted immediately.  I'd believe that if the drug was simply processed by the kidneys, but I thought that's why the liver is such a concern, because the liver processes the TKI, and I'd assume that would take a while.

[CallMeLucky]

I think the issue with reduced dosage is this idea that you could develop a resistance to the drug if there is only a small amount of the drug in you.  Kind of the theory with anti-biotics.  The disease could learn to adapt if there is not enough drug in the system to kill it all.  Now the question is if this is reality and I don't know if anyone knows.  I have heard some say yes and others say no.  I sure don't know.  So while I like the idea of lowering dosage to reduce side effects, it does concern me as well.  I'm inclined to try something like full dose for 2 years PCRu (if lucky enough), then reduce to 300 for 18 months and see if I maintain PCRu.  Then at that point evaluate if side effects are good enough or if further reduction would help.  If good enough, stay another 18 months and then consider cessation, or potentially go to 200 mg, see if PCRu is held for 18 months.  At that point it would be 5 years undetectable while at a reduced dosage.  If there is no sign of the disease (send a blood sample to another lab just to see if anything shows up)  Then at that point take a chance on stopping.  Although I'll tell you , if I am PCRu at reduced dosage with no side effects, and by that time Gleevec is generic, I might be inclined to just stay on it.

I'll add that during dosage reduction or cessation, I would look at supplementing with something like Curcumin of Fever Few.....

[threedprof]

seems like a plan.  Are you going to remain at your current testing schedule when you try the dosage reduction?  I am looking forward to seeing how reducing the dosage could be a possible solution, also, in case my numbers go into the positive after trying to stop therapy completely.

Oh, before the brain fog gets me, I want to endorse the Cascade Cancer Center in Kirkland, WA.  Dr. Michele Frank and her nurse Connie watched over me like a hawk with EXCELLENT bedside manner and care! They were so very patient and answered all of my questions when I was at my most frantic and downtrodden.  I called for my records since my current Onc. doesn't have the earlier PCR tests on hand and nurse Connie new me right away, five years later! That's remarkable! she was still the same sweet person I remember consoling me in the past.  So if any new comers are in that vacinity I HIGHLY recommend you give them a try.  They are extremely knowledgable and keep current with the latest information.

so was incorrect when I stated my PCR status.  Turns out it was pretty close to undetectable in October 31st at .001.  Since my old threads were whisked away in the forum update I will post my early PCR numbers:

2/14/06 (date of diag.): 19.5 (WBC 369K, PLT 1.2M)

8/30/06: 5.83

10/31/06: .001

2/01/07: undetectable

Trey, would you be so kind as to share your thoughts on my PCR progress?  I have a theory that if I managed to becoming undetectable within that period of time that my chances could be more positive.

[Susan61]

Hi:  I will pray that you do very well with stopping  your Gleevec.  I have been on Gleevec since 2000, and been PCRU for 8  years, and I am sure you see the notes from Michael telling me I am cured.  I really love him for all the encouragement he gives me.  I am still afraid to do anything like that.  My Oncologist did tell me that there will be a test in 5 years time that will show something with regard to staying PCRU, and being considered cured.  I am not sure exactly what she was talking about.

   Please keep us all informed of your progress.  Its people like you who are willing to take the chance to help others like me who are still leary.

God Bless You

Susan

[dpass]

OK folks, my first post after lurking around and benefitting from the info on these boards for seven years. I thought it time for me to offer my own experience, advise and well wishes to those who are attempting to get off of TKI's after being PCRU for an extended period.  I was dxd 7/25/2004 with 255,000 wbc.  While in the hospital I read-up on clinical trials that showed increasing response to dose of Gleevec so I requested and was allowed to start on 800 mg Gleevec/dy.  Within 5 mos. I was PCRU (Quest 0.000 pcr), reduced dose to 600 mg/dy after 9 mos, then 400 mg after 12 mos and stayed PCRU the whole time.  In the fall of 2008 (4 yrs after dxd) my liver enzymes (AST/ALT) started unexplicably increasing and continued to climb above 5x UNL in January 2009.  My onc put me on a Gleevec "vacation" with the goal for my liver enzymes to return to the normal range.  The onc measured my liver enzymes monthly, but left me on my quarterly schedule for BCR/ABL pcr analysis.  It took three mos. for my liver enzymes to return to normal range (non-drinker, but take 5 mg Crestor). When I did my next BCR/ABL pcr in the beginning of April 2009, the result was above 100% on international scale (Quest, 10.485 pcr).  I immediately did a repeat with mutation analysis; pcr was the same 100% range and showed the BP35I insert mutation (search Trey's postings).  I got a new onc and requested, and was put on, 100 mg/dy Sprycel, six weeks later (end of May 2009) I was re-tested and was PCRU again - that' right from 100%+  to PCRU in 6 weeks.  I have been PCRU ever since with quarterly pcrs.  I have had virtually no side affects on Sprycel (minor fatigue, minor skin rash).

In January 2011, I reduced Sprycel to 70 mg and after 6 mos and 2 quarterly PCRUs, reduced to 50 mg/dy Sprycel this pas June 2011, while adding 2400 mg/dy Zyflo (Zileuton, again search Trey's posts - I really have chronic bronchitis and am doing this with both my onc's and GP's knowledge and cooperation).  My goal is to find the minimum dose that will maintain my PCRU status.  My plan is to reduce dose each 6 mos I achieve 2 PCRUs.  Next January, I will reduce to 20 mg/dy, then in June 2012, if I am still PCRU, I will discontinue Sprycel and continue Zyflo.  I will then begin once per month pcrs for 3 mos, then bi-monthly for the next six mos, if I am still PCRU at that stage I will stop Zyflo, while continuing bi-monthly pcrs for another year.   If at any point I become pcr positive, I will revert to the previous dose. I don't advise this for anyone else.

The risk in discontinuing TKI's is that you may develop a mutation that may not be reverseable - Caveat Emptor applies - Buyer Beware!!!  If you are going to do this, do it under strict supervision with frequent pcr testing, it may take 6 mos or more for the ultimate result to manifest in pcr testing.

Best of luck to all, but unless you are willing to be a guinea pig, like me, I suggest you wait for more research results to support this option.

[Trey]

I don't buy the theroy that low dosage TKIs can cause resistance or mutations, just as most good Oncs have also rejected it.  Dr Druker has endorsed Gleevec dosage reduction below 400mg after excelent response.  Dr Cortes has Michael on steady state 20mg Sprycel.  NCCN guidelines discuss low dosage options.  The antibiotic analogy is not the same at all -- in fact it is just the opposite.  TKI drugs do not partially kill or stun a leukemic cell as low dosage antibiotics can.  Leukemic cells cannot come back "stronger" like bacteria can.  Leukemia does not spread to others after becoming "stronger"after being stunned.  TKIs at first are too low of a dosage to handle all the leukemic cells in the body, so is that called "low dosage" that could cause resistance?  No.  I have addressed these issues in the following thread:

http://community.lls...age/61058#61058

[Trey]

Joel,

You asked me to look at your PCRs and comment.  Your PCR story seems to suggest you have as good a chance of success as anyone could hope for since you achieved PCRU in one year.  Whether you will find success in this is another thing.  I prefer the low dosage route for myself.

[CallMeLucky]

To clarify, I am not a big subscriber to the resistance as a comparison to antibiotics, I only mentioned it because I have heard that argument thrown around.  The argument I find more credible was the one presented my Dr. Mauro when he spoke about the possibility of clonal evolution under reduced dosage.  He wasn't saying that would happen, I understood it to be a possible reason to be cautious.  His stand was pretty much until there are trials that show it is safe, he is recommending patients stay at the full dose.  Now that is also what he said to a room full of people at a conference, I don't know how that correlates to what he does with his patients in a one on one situation.

[CallMeLucky]

I would work with my onc and see what they recommend for testing schedule.  I would not accept anything less than 3 months and would probably want to go monthly for the first few monts.

[Trey]

Clonal evolution (disease progression) can certainly occur when a person has a high leukemic load and takes too little drug to fight the leukemia, generally due to side effects caused by the drug that do not allow the person to tolerate a full dosage.  That is an issue of inability to take an adequate dosage to fight the CML.

[ChrisC]

Josh, forgive all this discussion if it's not what you were looking for; I am adding what, to me, seems relevant, and am enjoying reading everyone's input.

I've requested that my onc/hem discuss frequency of testing with me (the Stanford specialist left this up to us); I will hear back next week. I have the lab work request for the first month, so I'm set to be tested mid-October (having again been found PCRU in Aug. All tests have always been by Quest's labs). My request to him is, given that reports from the studies all show that relapse happens in the first six month almost exclusively, to have monthly CBCs and PCRs for at least the first six months, then we'll see. Also, as reports are that at least in the beginning, as one's system has to reboot, to begin taking over the work the TKI was doing, in the beginning almost everyone's PCR shows some measure of CML, What is looked for, as we already know from our familiarity with PCRs, is a trend. Reportedly, 50%-70% of folks end up returning to their TKI during the first six months, but it was a continued increase of PCR results that triggered this, not a single, very low reading: often after such a low reading the next result was PCRU in those who have been able to continue w/o a TKI, even over two years later. I suggested to my onc that we'll talk resuming Sprycel if there are results that show more than a 1-log increase twice. Patience is called for, from what I read.

As I see the coming months, it is a matter of doing nothing and accomplishing everything. There will only be results to report here if they happen, or don't happen. I will be quietly recording a personal diary of my supplements, etc., but probably won't be discussing it yet. I will, as always, be following the discussion with relish. Thank you to everyone, and good health to all.

[scuba]

DPASS - In six weeks you went from 100% to PCRU - that's remarkable.  I wonder if the 100% was incorrect in the first place?  CML is a relatively slow disease to get started.  Once PCRU, it's hard to fathom that in just 3 months you would have such a spike in transcripts (or maybe not?) without a corresponding jump in WBC's?  and then crash back to zero in six weeks ... or maybe the cells had not had enough time to respond to the transcript signal?  I'm just very curious about this.

Your goal of dose modulation to maintain PCRU without extra drug is commendable.  I am going to do the same thing - but as Trey pointed out - in my case I am already at such a low "maintenance" dose of Sprycel already.   The big advantage of low dose is no side affects.  I asked Dr. Cortes if I can increase my dose and he said "no".  He has more concern about my  myelosuppression.  Since I had a 2 log PCR drop in two months after re-starting 20mg. Sprycel, he is very encouraged.  Notable is that my CBC after one month is little changed - but not going up to normal either.  I am just holding steady in a 'safe' zone below normal (ANC = 1.6; Plt = 105).  I am myelosuppressed, but only mildly so on 20mg. Sprycel.   He is concerned that if I increase my dose - I'll have major mylosuppression issues again.

I am intrigued with your Zileuton usage.   Dr. Li (U Mass) is doing research on Zileuton's affect on CML stem cells.  Coupled with a TKI it could produce a "cure" breakthrough.  I have personally come to the conclusion, however,  that a cure is not possible without T-cell involvment.  The recent work with CLL (Dr. June) is very promising in that regard.

[threedprof]

DPass - Thank you for passing that information along.  It's definitely interesting to hear from someone who's been in a similar boat as me.  The possibility that concerns me the most, as with everyone, is developing a mutation or cell evolution (however you want to label it).  I'm very curious to know what triggers mutation and if that's possibly one of the tests that was talked about by Susan61's Onc.  Not sure how we could help our bodies adjust so that IF there are any abhorent cells left we aren't leaving the door wide open for them to evolve during the washout period.  Which, I suppose, is why trials are trying a cocktail of drugs to retrain the body.  I suppose it'd be akin to a drug abuser who quits cold turkey and has the dangerous cleansing period because they've replaced their body's natural function with a foreign substance.

At the same time, i'd love to believe in the other idea that this isn't a bacteria or virus and would behave eradically when dosages are messed with.  We know soooo much about this illness but still quite a few large hurdles to overcome.  I'm a little shocked by DPass not trying to go back to Gleevec, but that must've been a personal decision rather than a Gleevec failed situation.  It is interesting that the disease load came back 100% in just three months.  Wonder what the WBC counts at that time.  That seems more analogous to disease progression at that rate but i'm fairly ignorant to the mechanics of progression.

Still all good information and thank you for sharing it.

ChrisC - I assume you meant Joel (not Josh).  This thread is open to anyone that wishes to share my journey and sort of live vicariously.  I know this is a risk and there are far more intelligent people here that will be following this so more information is better than too little.  share away

[ROM1212]

Thanks for sharing this information.

Can you advise what your WBC was at the time of diagnosis, or what stage you were in?  And did your Onc ever recommend first reducing the dosage before you decided to eliminate it entirely?

Thanks again.

[valiantchong]

Your response is very different from all others CMLers that I have read. Your response is extremely fast, from 100 to 0 then relapse to > 100 and then 0 again, within less than 3 moths. I was wondering what is your CBC during you stop Gleevec duration. Does your CBC show increase too. ? Since you experienced fast relapse, dont you think it is risky to reduce your dosage ?

[dpass]

My WBC was 5.8k in Jan. 2009 (just before stopping Gleevec), then 35.7k in early April ' 09 before re-start with Sprycel, then  3.8 k  at the end of May '09.  I have no reason to doubt pcr results as they were all done at Quest.  I re-started with Sprycel after consulting with Dr. Druker because of the BP35I insert mutation.  While his personal opinion was the BP35I is not kinase active (meaning it is not a location where ATP binds to allow phosphorylation and cell signaling for replication in the presence of kinases - I think I got that right), he thought it to be the more effective TKI in the event it was kinase active or if the BP35I represented the beginning of clonal evolution to a more unstable molecule.  Other research (Lee, et al. http://mct.aacrjourn.../7/12/3834.full) indicates the presence of the BP35I mutation may indicate imanitib resistance and clonal evolution.  I am not concerned with lowering the dose through time so long as I remain PCRU.  Evidently, Sprycel has wiped out the population of 9:22 cells truncated with the BP35I mutation, or at least, they exist below the pcr detection limit for now.