Adam S. Kittai, MD: Advancing CLL Care and Training the Next Generation

For Adam S. Kittai, MD, the best care for chronic lymphocytic leukemia (CLL) starts with listening. As director of the CLL Program at Perlmutter Cancer Center; director of the Lymphoma Program at Perlmutter Cancer Center–Long Island; and associate professor at NYU Grossman School of Medicine, he notes that CLL usually offers “a long runway” before treatment. He uses that time to learn what matters to each patient so that therapy fits the life it will become part of.

The stakes are higher in Richter transformation, where clinicians must treat 2 cancers at once. Even so, Kittai sees reason for cautious optimism: survival is improving, and trials pairing pirtobrutinib with a bispecific antibody may push outcomes further. In this interview with The American Jouranl of Managed Care^® (AJMC®), Kittai discusses what he has learned about treating Richter transformation, how patient priorities guide choices among effective options, and what mentoring the next generation of hematologists has taught him.

This transcript has been lightly edited.

AJMC: What have you learned about treating Richter transformation, and where do you see the greatest opportunities to improve outcomes?

Kittai: Richter transformation is when CLL transforms into an aggressive lymphoma. In any cancer, when a transformation occurs, usually it’s associated with a poor prognosis. It’s no surprise that Richter transformation is the same. Additionally, you’re now dealing with 2 different cancers as opposed to just 1 because we have to treat both the CLL and the diffuse large B-cell lymphoma [DLBCL], which makes things difficult. Happily, we now have more new therapies for CLL, which have now been translated to treatment for Richter transformation. We’ve made some improvement where patients with Richter transformation do appear to be living longer in the era of our modern therapies, but there’s still work to do.

I’m really excited about some various trials that are ongoing. One is combining pirtobrutinib with a bispecific antibody for Richter transformation. That study is being done in Europe. The reason why I’m excited for those particular studies is because bispecific antibodies and chimeric antigen receptor T-cell therapy appear to be effective in patients who classically have a poor prognosis. Hopefully, these outcomes in chemorefractory DLBCL translate to better outcomes for patients with Richter transformation.

And so while Richter transformation is somewhat a rare disease—so we don’t have many trials that are designated and dedicated for Richter transformation—although that appears to get better, we are able to extrapolate a lot from the studies that are being performed in CLL and DLBCL to come up with novel combinations of therapy to use in patients with Richter transformation that we’re hopeful will make strong impacts for survival of this terrible disease.

AJMC: What impact does your philosophy of prioritizing clear, compassionate communication have on your approach to treatment decisions when there are multiple effective options?

Kittai: In general, how that gets translated is, I spend a lot of time with my patients. Usually, the conversation doesn’t just skip to treatment. Luckily, in the world of CLL, we usually have a long runway before we have to start treatment, so I get to kind of know them and know what their priorities are. Sometimes we do have to make a treatment decision the first time I’m meeting a patient, and usually I still try to get to know them, get to know what brings them joy out of their life, what they like to do on a daily basis—because we can somewhat target our therapy based on what patients want, because we know that at least in CLL, a lot of our therapies are going to work great no matter what the prognostic features are and are also associated with very tolerable toxicity.

In other cancers, we don’t have as much luxury. There’s not as many options in the frontline space for DLBCL or other aggressive lymphomas. But in CLL, we do have this luxury, and so I usually spend a lot of time with my patients finding out what they are doing in their life, what treatment might best fit into their life based on what’s going on, especially if we don’t have any comorbidities or other prognostic features to consider. I [also] explain the toxicities of the drugs to my patients, and also I explain how often patients are going to have to come in to get those drugs and best pick the therapy that me and the patient both decide together is the best that will serve the patient’s needs.

AJMC: What have you learned from mentoring the next generation of hematologists, and what do you hope to instill in physicians entering the field?

Kittai: I believe that in order for us to continue to develop clinicians who are strong and compassionate and empathetic, we need to make sure that they are supported and that they’re getting the training that they need to make good decisions with their patients. I do have a very strong passion for this because I believe that the young doctors are our future, especially as we need more and more doctors as our society ages over time and are living longer lives. What I’ve learned from my mentees is that they are much more adept at using new technologies such as artificial intelligence. I think that they are stronger in their personalities and informing us of what they need in terms of how they perceive the best education for them to be, and we can marry that well with what they need and what has worked classically to make sure that they get the best training that they can get.

Ultimately, I think what I get most excited about working with trainees is their energy. It’s always nice to see people get excited about all of the things that we’re seeing and the treatments that we’re doing. Because even though malignancies in cancer and oncology and hematology are really exciting fields, and we’ve done so well in developing new medications that are making patients live longer with less toxicity, having to explain this to new trainees and then to see their eyes widen and get excited about new possibilities and what we can do for the future is always refreshing and wonderful to see.