Naveen Pammaraju, MD: Primary Care & JAK1 Inhibitors in Myelofibrosis

An oncologist needs to be ready and willing to use any and all tools at their disposal when treating a rare, threatening condition. That means understanding the benefit of both therapies and personnel.

In an interview with MD Magazine® while at the American Society of Clinical Oncology (ASCO) 2019 Annual Meeting in Chicago, IL, Naveen Pammaraju, MD, of the Department of Medicine, Division of Leukemia at MD Anderson Center, discussed the benefits of primary care physician input in treating patients with myelofibrosis.

Pammaraju also discussed the potential of ruxolitinib (Jakafi)—not only as a US Food and Drug Administration (FDA)-approved therapy for myelofibrosis, but as a promising breakthrough drug in numerous oncologic indications.

MD Mag: Do primary care physicians frequently play a role in the diagnosis or specialist referral for myelofibrosis?

Pammaraju: Myelofibrosis is often thought of fairly rare blood cancer, possibly something on the order of 4-6 patients out of every 100,000 diagnosed in the United States. However, as with any rare or less common blood cancer, there might be more patients walking around that just haven't been diagnosed.

In myelofibrosis and MPNs in general, the community practice provider plays a very important role in both the recognition diagnosis and management. Of course, I work at an academic center, and I always encourage any patient and any doctor to seek a second or even a third opinion, and to be referred to a major academic center.

But let's remember that in rare diseases, it's only rare to others—but when you have that disease, it's your disease and it's your body. So yes, I do encourage that the local community doctor has a very important role to recognize the disease diagnosed and we can co-manage together.

So that's the model that I favor: having multiple doctors involved, academic physicians, community physicians, working hand-in-hand for maximal patient care for patients with mild fibrosis.

Beyond its current marketed uses, what other indications could ruxolitinib benefit as a therapy?

This is a very emerging area of research. So, the initial indications for JAK inhibition included myelofibrosis and then polycythemia vera in the advanced setting. And now we're starting to see a number of different clinical trials pop up. You mentioned the recent FDA approval for acute graft versus host disease with the same molecule, the JAK inhibitor. So a number of different areas are in active investigation.

I think that the level of research in the JAK inhibitor has gone in 2 different ways, and they're very encouraging, and we need to see how they go. One is, as you mentioned, single agent for a number of different cancers—actually not even liquid or blood cancers but also solid tumors as well. That's important to follow.

But also we and others are starting to do combination therapies with JAK inhibitor and other molecules in other subsets of diseases. For example, patients with myelofibrosis with what's called a suboptimal response—not quite failing and coming off the drug, but remaining on the drug, and then adding a second agent to that. I think that's the next area of active research and you'll see on ClinicalTrials.gov and other websites: there are a number of trials like this popping up. So I'd like us to keep our eye on that field.