A diagnosis of chronic lymphocytic leukemia (CLL) can be difficult to process. Each person responds differently, and patients may need to take some time to learn about the condition and consider the next steps with their healthcare team.
When treating CLL, doctors consider many factors. Not only the activity of the cancer, the presence of symptoms and the results of the pathology tests, but also previous treatments, a patient’s health, any medicines they are currently taking and the patient’s preferences. Multiple treatment options are available for CLL. Depending on the patient and the treatment plan, a therapy may be used alone or in combination with other therapies.
Understanding CLL
CLL is a cancer of white blood cells that grow and divide excessively in the blood, in the bone marrow, in lymphoid organs, such as lymph nodes and in the spleen. Often the disease develops very slowly. Even years may pass before a definitive diagnosis is established. Some patients are even diagnosed with CLL by chance when routine blood tests indicate an abnormality.
Symptoms are persistent fatigue, swollen lymph nodes, unexplained weight loss, night sweats, frequent infections, feeling of fullness in the abdomen due to an enlarged spleen, to name a few. Not all CLL patients experience these symptoms, and many patients with CLL have normal general health for years or even decades.
Blood tests, physical examinations and other diagnostic tests can be used to diagnose CLL and to monitor the disease over time. Information about the biological characteristics of the leukemia can be gained from certain tests such as chromosomal and/or molecular tests of the cancer cells.
When Treatment May Not Be Needed
Another important aspect of CLL management is that in many instances, treatment is not needed. If CLL is not producing symptoms or affecting critical organ function, a policy of watching and waiting (or active monitoring) can be appropriate. During this time, the CLL can be followed with repeated blood tests. When the disease begins to progress or causes problems, treatment can be initiated. The approach of watching and waiting does not mean that CLL is being ignored. Rather, it means that potential adverse effects of therapies can be avoided when they are not needed.
By monitoring changes in the disease, the healthcare provider can decide whether to start treatment. If there are no symptoms, impact on organs or impact on daily life then the disease may be monitored till symptoms show up. Watchful waiting or active monitoring is an approach used to spare the patient from exposure to side effects that might occur from using CLL treatments that are not required.
Understanding Chronic Lymphocytic Leukemia Treatments
When CLL does need treatment, many CLL treatment options are currently available, and research continues to develop even more CLL treatments. Chronic Lymphocytic Leukemia treatments include targeted therapies that work by specifically inhibiting certain proteins that leukemia cells cannot survive without.
Several treatments for chronic lymphocytic leukemia (CLL) are BTK inhibitors, which inhibit Bruton’s tyrosine kinase, involved in B-cell receptor signaling. There are several BTK inhibitors in use including ibrutinib, acalabrutinib and zanubrutinib. Pirtobrutinib is another BTK inhibitor with a different mechanism of action.
Also important are treatments that target specific proteins in the cancer cells. Here the BCL-2 inhibitor used to treat CLL and can be administered as per approved prescribing information. Different therapies are available for CLL, and there is no single cancer drug for all patients with CLL. Factors that have to be considered are the type of CLL, former treatments, coexistent diseases, potential drug interactions and the goal of treatment.
Why Genetic Testing Matters
CLL has many differences between individual patients. To develop a proper treatment plan for a patient, their CLL must be genetically and molecularly tested to determine the proper course of action.
Del(17p) or TP53 abnormality and CLL IGHV mutation status of the cancer cells can give insight into the behavior of the CLL and guide the treatment choice of the patient. The test results must be interpreted in the frame of the other parameters mentioned above. Blood tests and other clinical features that determine CLL behavior should be considered together with clinical features such as symptoms, blood count abnormalities, previous treatment, patient age and co-morbidities.
Managing CLL After Treatment
There are instances in which CLL may return or not respond to a previously administered treatment. Patients with relapsed or refractory CLL need further therapy and the prior treatments, and their degree of response can play a significant role in determining the appropriate course of action for the patient’s current situation.
For relapsed or refractory CLL, or when CLL has stopped responding to prior treatments, there are many different targeted therapies that can be used based on prior treatment, and clinical trials that are investigating newer and different combinations of therapies.
Pirtobrutinib is approved for some adults with CLL or SLL who have received prior covalent-inhibitor BTK therapy. Patients can evaluate their eligibility for participation in clinical trials of new therapies with the help of the healthcare team.
Managing Side Effects and Staying Safe
Every CLL treatment can cause side effects (actions or effects of a medication) of varying severity and type depending on the specific CLL treatment or combination used. The type and frequency of side effects can vary.
The healthcare team must be informed about new symptoms or changes in patient condition, and have a list of current prescription medicines, over-the-counter products, vitamins and supplements. Some CLL medicines can interact with other medicines. Decisions on stopping or changing the treatment must be made after consulting with the doctor about side effects.
Supporting Overall Health
Eating well, keeping active, getting enough sleep and looking after mental health and wellbeing are crucial to keeping overall health while undergoing CLL treatment. Vaccination and infection prevention must be discussed with the doctor, and it is also important to get emotional support from family, friends, support groups or counselors.
Staying Involved in CLL Treatment Decisions
Managing CLL is often a long-term process and can include many different aspects of treatment. Patients should ensure they have all their appointment dates, test results, medicines and symptoms recorded so that they can inform the healthcare team of the progress of the CLL and any other related health problems.
Patients can ask a variety of questions such as reasons for choosing a certain treatment, alternative treatment options, expected treatment duration, expected side effects, and when the side effects should be reported to the doctor. Patients may also discuss participation in clinical trials when appropriate.
Many cancers are serious diseases, but with research into new and existing treatments under way continually there are now many different ways to treat CLL, and with the proper management of the disease and with the support of family, friends and above all health care professionals of the patient’s choosing, CLL patients may be able to manage the disease.
Medical Disclaimer: The information provided in this article is intended for educational purposes only and should not be interpreted as medical advice, clinical guidelines, or a recommendation for any specific treatment.
