Chronic Lymphocytic Leukemia (CLL) can be a very scary diagnosis for patients and families. Patients may have lots of questions about the disease and available treatments. It is very important that patients have a complete understanding of CLL and treatment options, and how to effectively manage the disease.
Many of the current CLL treatments have different goals. While there are some overlapping side effect profiles, there are significant differences that dictate which is appropriate for a specific patient. CLL treatments also need to be considered in the context of a patient’s prior therapies, disease status, overall health and age, as well as goals for treatment.
When Does CLL Need Treatment?
The general impression many people have of CLL is that treatment would be started immediately. However, since most people with CLL are asymptomatic and not at risk of serious illness for many years and even decades, the healthcare team initially monitors the patient. This approach to management of CLL is called “watchful waiting” or “active monitoring” of CLL and it is applicable in vast majority of cases of CLL at the time of diagnosis.
Monitoring, or watchful waiting, of chronic lymphocytic leukemia during the inactive phase can become important and, in some instances, will be the mainstay of care. On occasion, symptoms, an increase in size of lymph nodes, spleen, low blood counts or other active CLL features may develop. When they do, an appropriate treatment can be initiated.
Watching and waiting does not mean ignoring treatment. Rather, in the absence of symptoms or significant organ impairment, it allows a delay in starting the treatment and its potentially toxic effects when it is not necessary to ameliorate pressing symptoms or organ dysfunction.
Understanding CLL Disease Treatment Options
When a patient requires CLL disease treatment, they now have access to the same targeted therapy used to treat other cancers. In the case of CLL, these treatments target specific pathways by which cancer cells survive and reproduce.
Research has led to the development of several different forms of targeted therapies for CLL. These medicines work by targeting specific processes by which cancer cells survive and reproduce. Examples of targeted therapies for CLL are the BTK (Bruton’s tyrosine kinase) inhibitors including ibrutinib, acalabrutinib and zanubrutinib. Pirtobrutinib is another form of a BTK inhibitor, but it is given in a slightly different manner and used in specific situations.
Venetoclax blocks the BCL-2 protein which is important for the survival of certain cancer cells. Venetoclax is approved to be used either on its own, or in combination with other therapies including a monoclonal antibody. Targeted therapy for CLL is becoming more individualized and based on the characteristics of cancer and the previous use of other cancer therapies.
The Role of Genetic and Other Test Results
Before choosing a treatment for CLL, tests may be performed to reveal more about the cancer cells. Such tests can identify chromosomal abnormalities and/or genetic mutations. Some examples are the deletion of chromosome 17 (17p deletion), abnormalities in the TP53 tumor suppressor gene, and IGHV mutation status.
They don’t dictate a single course of treatment but are part of a more complete clinical assessment which also considers the symptoms presented, the therapies to which the patient has already been subject, the patient’s overall state of health and the desired goals of the treatment.
What Happens If CLL Comes Back?
CLL may return after a period of treatment, or it may stop responding to a previously effective therapy. When this occurs, healthcare professionals consider factors such as the patient’s prior treatments and duration of benefit when evaluating subsequent treatment options.
A different targeted therapy may be appropriate depending on prior treatment(s) and disease characteristics. For patients with relapsed CLL/SLL, treatment options may include BTK inhibitors, venetoclax-based regimens, other therapies, or participation in a clinical trial, as appropriate.
Pirtobrutinib is a non-covalent BTK inhibitor indicated for the treatment of previously treated CLL/SLL patients, including those with prior covalent BTK inhibitor therapy. Pirtobrutinib is among newer therapies that have been evaluated as treatment options for certain CLL patients.
Side Effects and Patient Considerations
It is very important to note that there are side effects of the treatment, and they can be quite different for every single drug used in treatment of CLL as well as different for every single patient. Some common side effects of treatment with BTK inhibitors are increased risk of infections, decrease in blood counts, bleeding, gastrointestinal symptoms and others.
It is important for patients to inform their healthcare professional about all medications, supplements, and medical conditions they have or have had, including any previous cancers. Some treatments used for CLL may interact with prescription medications, over-the-counter products, or dietary supplements.
Patients need to inform their treatment team of any other medications they are taking and any contraindications, such as existing health conditions and the possibility of interactions with other prescribed treatments. If a patient experiences new or worsening symptoms while on CLL treatment, it is important to report them to the healthcare team rather than discontinuing the prescribed treatment without medical supervision.
Living With CLL and Planning Treatment
People with CLL who are not currently on treatment need to be under the care of a doctor and have regular blood tests and checkups. Even if treatment is not currently required, it is possible that at some point the disease may get worse and require treatment.
Treatment for CLL is increasingly individualized, and decisions about therapy for CLL take into consideration a number of different factors including the patient’s age, the patient’s overall health, genetic features of the leukemia, previous treatment, symptoms that the patient is experiencing and for which the patient needs therapy, potential drug interactions, and the patient’s preferences. Clinical trials may provide access to investigational therapies. They may be considered after discussion with a hematologist/oncologist.
As the understanding of CLL and its management continues to evolve, a range of treatment options may be considered. Patients are encouraged to discuss these options with their healthcare team to determine the appropriate treatment approach.
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.
