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tion may have been affected by inconsistencies in chart interpretation, as well as clinical experience and practice style. There were a disproportionate number of relapsed/refractory patients compared to front-line patients.
It is vital to develop strategies to mitigate ibrutinib intol- erance so that efficacy can be further maximized. Examples include the creation of guidelines for the evalu- ation and management of problematic side effects such as atrial fibrillation, rash, and arthralgias. An educational forum focused on oncologists, physician educators, and nurses should be implemented. In addition, the design of future clinical trials should allow for cessation of therapy in order to minimize ibrutinib exposure, particularly in the
small subset of patients who achieve complete remission. This strategy has been successfully demonstrated in patients receiving venetoclax who were able to achieve minimal residual disease negativity.26 For example, the incorporation of BCL-2 inhibitors and/or anti-CD20 mon- oclonal antibody therapies in combination with ibrutinib may enable patients to experience minimal residual dis- ease-negative responses that may translate into shorter durations of treatment.27,28
Acknowledgments
The authors thank Joseph and Cindy Riggs for their ongoing support of this work. They also thank the Center for CLL, University of Pensylvania.
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