Chronic Lymphocytic Leukemia (CLL)

Aspects of Supportive Care

CLL management and supportive care involve shared decision making between the patient and the medical team to ensure the following:

Deciding on a treatment plan that matches patient needs and goals^1,2

Patient staying up to date with vaccinations³

Proactive infection prevention through mask wearing and frequent handwashing⁴

Regular primary care provider visits, dermatologic screening, and other cancer screening^5-8

Support system for patients with CLL^9-11

CLL is a lifelong diagnosis, and patients benefit from strong social support

Medical care team

Orchestrate care
Provide educational resources

Mental health
Treat emotional toll of disease

Social worker
Help identify support

Patient support groups

Solidarity through similar experiences
Patient education

Caregiver

Attend patient visits
Partner with patient at home

To gain a medical oncologist’s perspective on supportive care and education for patients with CLL, you will find Dr Thompson’s and Dr Roeker’s video in the related resources at the bottom of the page.

Adverse Event Management

Common adverse events associated with CLL treatments

Each CLL therapy has a unique adverse event profile; however, certain adverse events are common to many treatment types and require timely clinical management and/or prophylaxis

Infection

(13%-81%)^12-22,a

Dyspnea

(9%-28%)^{18,20,21,23,b}

Anemia

(5%-67%)^{12,14-16,19-27,a}

Diarrhea

(14%-51%)^12-25,27,a

Thrombocytopenia

(6%-24%)^{12,16,19-28,a}

Fatigue

(5%-36%)^{13-15,18-28,a}

Arthralgia

(6%-26%)^{13-16,23,28,c}

Headache

(2%-38%)^{13,15,18,22,23,25,28,a}

^aRange based on data from patients with advanced CLL treated with chemoimmunotherapy, CAR T-cell therapy, and targeted therapy (BCL-2 inhibitors ± anti-CD20 antibody, BTK inhibitors, and PI3K inhibitors ± anti-CD20 antibody)

^bRange based on data from patients with advanced CLL treated with chemoimmunotherapy and targeted therapy (BCL-2 inhibitors ± anti-CD20 antibody, BTK inhibitors, and PI3K inhibitors ± anti-CD20 antibody)

^cRange based on data from patients with advanced CLL treated with chemoimmunotherapy and targeted therapy (BCL-2 inhibitors ± anti-CD20 antibody and BTK inhibitors)

Infection prevention in patients with CLL

The 5-year risk for severe infections in CLL is 26%²⁹

Recommended vaccinations for patients with CLL^30,a

Recombinant hepatitis B
COVID-19 vaccine
Pneumococcal vaccine
Seasonal influenza vaccine
Recombinant zoster vaccine

^aAs indicated by clinical practice guidelines. Patients with CLL should only receive inactivated (non-live) vaccines³

Strategies for infection prevention in patients with CLL

The 5-year risk for severe infections in CLL is 26%²⁹

Bacterial infections³⁰

No routine antibiotic prophylaxis
Ig replacement therapy for severe hypogammaglobulinemia and/or recurrent or severe infection
Monitor ANC

Fungal infections³⁰

Consider prophylaxis
- In frail older patients with R/R CLL and/or prolonged neutropenia
- Those with previous fungal infections
- Patients receiving chronic, concomitant steroids

Viral infections³⁰

Monitor for infection/pretreatment of HBV, HCB, HIV, HSV 1/2, VZV, and CMV prior to starting CLL therapy
If HBV reactivation detected, preemptive therapy with antivirals

Secondary primary malignancies in patients with CLL

The 5-year risk for severe infections in CLL is 26%²⁹

Standardized incidence ratios^a for second primary cancers after CLL³¹

Incidence ratios of secondary primary malignancies in patients with CLL — The graph illustrates incidence ratios of secondary primary malignancies in patients with CLL of 1.63 for all cancer types, 1.67 for solid tumors, 1.42 for hematologic malignancies, 2.74 for melanoma of the skin, and 4.82 for squamous cell carcinoma of the skin.

^aStandard incidence ratio is a ratio of the number of cancers observed in a given population compared with the number expected.

Strategies to reduce the incidence of secondary primary malignancies in patients with CLL

An increased risk of secondary primary malignancies in patients with CLL necessitates timely cancer screening^5,31

Annual dermatologic skin screening is recommended for skin cancer prevention⁵

Cancer screening guidelines should be followed closely for breast, cervical, colon, prostate cancers, and lung cancer for smokers⁶

To gain a medical oncologist’s perspective on managing risk of infection and secondary malignancies in patients with CLL, you will find Dr Thompson’s and Dr Roeker’s video and an infographic on supportive care in the related resources at the bottom of the page.

Multidisciplinary Teams to Manage CLL

Composition of the multidisciplinary team in the care of patients with CLL

Composition of the multidisciplinary team in care of patients with CLL

Multidisciplinary care involves cooperation between different specialties in order to improve patient care, and has become a major focus of contemporary cancer management^32,33

A multidisciplinary care team in oncology can include³⁴

Core team: participates in tumor board meetings and primary decision-making and usually consists of medical oncologist/hematologist, radiation oncology, benign hematologist, pathologist, nurses, and cardiologist
Extended team: participates in management of patient care and social services. It can include genetic counselor, pharmacist, nurse navigator, APPs, palliative care, primary care, and financial counselors

Potential benefits of multidisciplinary care

Multidisciplinary teams involve a variety of staff that work together to educate and support the patient to be engaged and empowered in their health care³⁵

Support from multidisciplinary teams increases the use of shared decision making among hematology/oncology advanced practice professionals³⁶

Multidisciplinary teams encourage proactive patient communication about side effects and symptoms, help support patient adherence to oral therapy, and offer resources to help patients living with CLL deal with difficulties associated with chronic disease, such as financial toxicity and psychosocial distress³⁷

For more information on shared decision making in hematologic malignancies, please see shared decision making slide deck and infographic in the related resources at the bottom of the page.

ANC=absolute neutrophil count; APP=advanced practice provider; BCL-2=B-cell lymphoma 2; BTK= Bruton’s tyrosine kinase; CAR=chimeric antigen receptor; CD20=cluster of differentiation 20; CLL=chronic lymphocytic leukemia; CMV=cytomegalovirus; HBV=hepatitis B virus; HCP=health care provider; HCV=hepatitis C virus; HIV=human immunodeficiency virus; HSV=herpes simplex virus; Ig=immunoglobulin; KOL=key opinion leader; PI3K=phosphatidylinositol 3 kinase; R/R=relapsed/refractory; SCC=squamous cell carcinoma; VZV=varicella zoster virus.

References

Katz SJ, et al. J Oncol Pract. 2014;10(3):206-208.
Brown R, et al. J Clin Oncol. 2012;30(8):857-862.
CLL Society. Accessed August 12, 2024. https://cllsociety.org/2022/03/vaccinations-for-patients-with-cll-sll
LLS. Infections. Accessed August 12, 2024. https://www.lls.org/treatment/managing-side-effects/infections
Mansfield AS, et al. J Oncol Pract. 2014;10(1):e1-e4.
Welch A. Recognizing secondary malignancies in CLL. Accessed May 8, 2024. https://www.onclive.com/view/recognizing-secondary-malignancies-in-cll
Schneider MA. When a cure isn’t an option. Accessed August 12, 2024. https://ashpublications.org/ashclinicalnews/news/7672/When-a-Cure-Isn-t-an-Option
HealthTree Foundation for CLL. Infection prevention for CLL patients with Dr. Meghan Thompson. Accessed August 12, 2024. https://healthtree.org/cll/community/articles/cll-infection-prevention-dr-meghan-thompson
Bell R. J Adv Pract Oncol. 2017;8(5):462-473.
Frankly Speaking About Cancer. Accessed August 12, 2024. https://www.cancersupportcommunity.org/sites/default/files/fsac/CLL_Improving_Communication_with_Your_Patients.pdf
Academy of Oncology Nurse & Patient Navigators. Navigating chronic lymphocytic leukemia: the critical importance of the first 90 Days. Accessed August 12,2024. https://aonnonline.org/navigation-tools/4879:navigating-chronic-lymphocytic-leukemia-the-critical-importance-of-the-first-90-days
Eichhorst B, et al. N Engl J Med. 2023;388:1739-1754.
Sharman JP, et al. Leukemia. 2022;36:1171-1175.
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Tam CS, et al. Lancet Oncol. 2022;23:1031-1043.
Brown JR, et al. N Engl J Med. 2023;388:319-332.
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Byrd JC, et al. J Clin Oncol. 2021;39:3441-3452.
Flinn IW, et al. Blood. 2018;132:2446-2455.
Gopal AK, et al. N Engl J Med. 2014;370:1008-1018.
Fischer K, et al. N Engl J Med. 2019;380(23):2225-2236.
Seymour JF, et al. N Engl J Med. 2018;378:1107-1120.
Patel H, et al. Expert Rev Pharmacoecon Outcomes Res. 2023;23:651-658.
Grywalska E, et al. Cells. 2020;9(11):2398.
Rivera D, Ferrajoli A. Curr Oncol Rep. 2022;24(8):1003-1014.
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Goede V, Stauder R. J Geriatr Oncol. 2019;10:497-503.
Taberna M, et al. Front Oncol. 2020;10:85.
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Selby P, et al. Am Soc Clin Oncol Educ Book. 2019;39:332-340.
Tariman J. ASH Clinical News. 2016. Welcome to the era of shared decision-making. Accessed August 12, 2024. https://ashpublications.org/ashclinicalnews/news/2559/Welcome-to-the-Era-of-Shared-Decision-Making
Association of Community Cancer Centers. Multidisciplinary chronic lymphocytic leukemia care. Accessed August 12, 2024. https://www.accc-cancer.org/docs/projects/chronic-lymphocytic-leukemia-(cll)/cll-models-of-effective-care-delivery.pdf?sfvrsn=3ebbf592_2

VV-MED-163244

Aspects of Supportive Care

Support system for patients with CLL^9-11

Adverse Event Management

Common adverse events associated with CLL treatments

Infection prevention in patients with CLL

Strategies for infection prevention in patients with CLL

Composition of the multidisciplinary team in the care of patients with CLL

What is your approach to supportive care and preventive measures for patients with CLL?

How do you support patients diagnosed with CLL?

References

Please rate your satisfaction with the content on the following statements:

Please rate your satisfaction with the content on the following statements:

Aspects of Supportive Care

Support system for patients with CLL9-11

Adverse Event Management

Common adverse events associated with CLL treatments

Infection prevention in patients with CLL

Strategies for infection prevention in patients with CLL

Composition of the multidisciplinary team in the care of patients with CLL

Related Resources

Downloadable PDFs

What is your approach to supportive care and preventive measures for patients with CLL?

How do you support patients diagnosed with CLL?

References

Please rate your satisfaction with the content on the following statements:

Please rate your satisfaction with the content on the following statements:

Support system for patients with CLL^9-11