What Goes into Determining When to Treat CLL?
- Most patients who are diagnosed with CLL do not require treatment right away.
- Doctors will conduct a series of tests to determine the prognosis and stage of the disease.
- If a patient doesn’t require immediate treatment, their doctor will actively monitor their disease for months, or even years.
- For patients who do require immediate treatment, there have been many exciting developments in the field of CLL treatment over the past decade.
“The tempo of their disease is very, very important,” Dr. Lamanna said “Initially when somebody gets diagnosed, if they don’t need treatment, I tend to follow people quarterly, more or less the first year. The longer somebody has had this leukemia, and declaring that they don’t need treatment, we don’t see them as often. We start spreading out those visits, because their blood counts have been stable for years, and some of those folks are seeing me every six months. Some of them are seeing me annually.”
Read MoreWeighing Treatment vs. Active Surveillance
“In terms of the path that patients go on when they’re first diagnosed with CLL, it can vary quite a bit. Many patients are actually asymptomatic at the time of diagnosis, and it’s just a routine blood count that leads to the discovery of the disease,” Dr. Matthew Davids, associate director of the center for CLL at Dana-Farber Cancer Institute, told SurvivorNet. “This is often just an elevated lymphocyte count that’s not associated with any symptoms.”Tests that go into diagnosing and planning treatment for CLL include:
- Flow cytometry of blood or immunohistochemistry of lymph tissue or bone marrow
- FISH
- DNA sequencing
- CpG-stimulate karyotype
- Physical exams
- Blood tests: CBC with differential and a comprehensive metabolic panel
“Once the diagnosis is established, there’s a variety of different molecular tests that can be sent from the blood that can help inform the prognosis for patients,” Dr. Davids explained.
“When we have the full profile of these prognostic markers, it can be very helpful in terms of determining when a patient may need treatment … For example, patients with the chromosome 17 deletion or TP53 mutation often need treatment within a few months or a year or so of diagnosis. Whereas patients who have lower risk disease like chromosome 13 abnormalities or mutated IGHV may actually go for several years, if not decades, before requiring therapy.”
Dr. Matthew Davids explains how IGHV mutations play a role in CLL prognosis.
Staging the cancer will also help doctors determine if treatment is necessary right away, and if so, what type of treatment to go with. In the U.S., the Rai staging system is commonly used for CLL. This staging system is based on how many lymphocytes are affecting the body and it’s broken up into five stages, zero, I, II, III and IV.
Staging CLL
“Early stage disease typically is manifested by an elevated lymphocyte count in the blood without any other manifestations, and we actually call this Rai stage zero CLL,” Dr. Davids explains. “When we can feel enlarged lymph nodes on the physical exam, that’s considered to be Rai stage I disease, and when we can feel an enlarged spleen or liver, we consider that Rai stage II disease. All three of these stages, zero, one, and two, are typically considered to be early stages of CLL.
“When the disease infiltrates the bone marrow and starts to result in low red blood cell count, which we call anemia, or low platelets, which we call thrombocytopenia, these are the advanced stages, three and four, of CLL, and typically those do require treatment,” Dr. Davids added.
The five stages can also be condensed into three risk groups:
- Stage 0 is low-risk of getting worse
- Stage I and II are intermediate risk
- Stage III and IV have a high risk of progressing
For patients with disease that does require treatment, chemotherapy was once the standard approach. However, in recent years there have been incredible developments when it comes to treating CLL. Chemotherapies can now also be used with other drugs like antibody treatments to help treat the disease.
One of those therapies, the most common antibody treatment for CLL, targets the CD20 antigen, a protein found on B cells (which, in the case of CLL, are cancerous) in the body and summons a patient’s immune system to attack the cancer cell.
Dr. Julia Vose explains how obinutuzumab can be used to treat CLL.
The drug obinutuzumab, a CD20 antibody, is now being combined with other agents in certain treatment plans to potentially increase its effectiveness. This monoclonal antibody is usually most effective when used in combination with CLL targeted-therapy drugs, according to Dr. Julie Vose, chief of hematology and oncology at the University of Nebraska Medical Center's Buffett Cancer Center.
Those drugs can include:
- A BTK inhibitor, which is an oral drug that targets a protein on the B cells called Bruton tyrosine kinase (BTK)
- A BCL2 inhibitor such as venetoclax, also taken orally, that targets the protein BCL2
Dr. Vose explained to SurvivorNet that when obinutuzumab is combined with these other drugs, it can be more effective at targeting and killing cancer cells.
Learn more about SurvivorNet's rigorous medical review process.
