Chronic Lymphocytic Leukemia (CLL)

Treatment considerations for TN and R/R CLL, including high-risk CLL

Among CLL patients^1,2

Graph of patients on active treatment and those in “watch and wait” category — Graph showing an approximate proportion of patients with CLL who need treatment right away (≈1/3), those who will not need treatment right away but will need it at some point (≈1/3), and patients with CLL that may never need treatment (≈1/3). Overall, ≈2/3 of patients are placed in the “watch and wait” category.

When do patients with CLL need treatment?

iwCLL indications for treatment^3,a

Lymph nodes

Massive (ie, ≥10 cm), progressive, or symptomatic

Liver and/or spleen size Massive

(ie, ≥6 cm below the left costal margin), progressive, or symptomatic

Constitutional symptom

Disease-related symptoms^b

Circulating lymphocyte count

Progressive ≥50% over a 2-month period, or lymphocyte doubling time <6 months^c

Platelet count

Worsening thrombocytopenia <100 x 10⁹/L due to progressive marrow failure^d

Hemoglobin

Worsening anemia <10 g/dL due to progressive marrow failure^d

Bone marrow

Progressive marrow failure as per above

Extranodal

Symptomatic or functional extranodal involvement (eg, skin, kidney, lung, spine)

^aAutoimmune complications (including autoimmune cytopenias) poorly responsive to corticosteroids or current treatment may represent an additional indication for change in treatment.

^bUnintentional weight loss ≥10% within the previous 6 months; significant fatigue (ECOG performance scale ≥2), fevers (38°C) for ≥2 weeks without evidence of infection; night sweats for ≥1 month without evidence of infection.

^cNon-CLL factors that may contribute to lymphocytosis (eg, infections and corticosteroids) should be excluded.

^dHemoglobin and platelet count cutoffs require consideration of the rate of decline. In certain patients, counts slightly below these levels may remain stable for an extended period and not require treatment initiation.

Decision making criteria in the treatment of B-cell malignancies^4-11

Criteria in the treatment of CLL — Selection of treatment in CLL depends on malignancy type, stage of disease, rate of disease progression, patient characteristics, evidence-based clinical practice guidelines, prognostic biomarkers, prior therapies, patient preference/access to care

Developing a treatment plan for patients with CLL involves shared decision-making between patients and providers after considering stage of disease, risk of progression, overall prognosis, and potential side effects^12,14
For patients with CLL in which treatment is indicated, the presence or absence of del(17p) and TP53 mutations are most often used to direct treatment selection¹³

Shared decision making between HCPs and patients

Leverage SHARE principles for shared decision making^14,16

Shared patient decision making occurs when HCP and patient work together to make a healthcare decision that is in the best interest of the patient

To gain a medical oncologist’s perspective on how shared decision making impacts treatment selection in CLL, you will find Dr Thompson’s and Dr Roeker’s video and an infographic on CLL therapies in the related resources at the bottom of the page.

BCL-2=B-cell lymphoma 2; BTK=Bruton’s tyrosine kinase; CLL=chronic lymphocytic leukemia; ECOG=Eastern Cooperative Oncology Group; HCP=health care provider; iwCLL=2018 International Workshop for Chronic Lymphocytic Leukemia; PI3K=phosphatidylinositol 3-kinase; R/R=relapsed/refractory; TN=treatment naïve.

References

Shadman M. JAMA. 2023;329(11):918-932.
HealthTree Foundation for Chronic Lymphocytic Leukemia. What is watch and wait for CLL? Accessed August 12, 2024. https://healthtree.org/cll/community/articles/what-is-watch-and-wait-for-cll
Hampel PJ, Parikh SA. [published correction appears in Blood Cancer J. 2022;12(12):172]. Blood Cancer J. 2022;12(11):161.
Jamil A, Mukkamalla SKR. Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560826/
Cheson BD, et al. J Clin Oncol. 2014;32(27):3059-3068.
Lumish M, et al. J Hematol Oncol. 2021;14(1):5.
Terret C, et al. Expert Rev Hematol. 2015;8(3):329-341.
. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. In brief: What are clinical practice guidelines? [Updated 2016 Sep 8]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK390308/
Sun R, et al. Mod Pathol. 2016;29(10):1118-1142.
Ngu H, et al. Am Soc Clin Oncol Educ Book. 2022;42:1-14.
Loh KP, et al. Blood Adv. 2020;4(21):5492-5500.
Lymphoma Action. CLL and SLL. Accessed August 12, 2024. https://lymphoma-action.org.uk/types-lymphoma/chronic-lymphocytic-leukaemia-cll-and-small-lymphocytic-lymphoma-sll#what-is
Campo E, et al. Haematologica. 2018;103(12):1956-1968
Katz SJ, et al. J Oncol Pract. 2014;10(3):206-208.
LUNGevity Transforming Lung Cancer. Shared decision-making. Accessed May 12, 2024. https://www.lungevity.org/research/patient-focused-research-center-patient-force/shared-decision-making
Agency for Healthcare Research and Quality. The SHARE approach: a model for shared decision making. Accessed May 12, 2024.https://www.ahrq.gov/sites/default/files/publications/files/share-approach_factsheet.pdf

VV-MED-163244

When do patients with CLL need treatment?

iwCLL indications for treatment^3,a

Leverage SHARE principles for shared decision making^14,16

How do you approach shared decision making in CLL?

What factors do you consider when treating patients 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:

When do patients with CLL need treatment?

iwCLL indications for treatment3,a

Leverage SHARE principles for shared decision making14,16

Related Resources

Downloadable PDFs

How do you approach shared decision making in CLL?

What factors do you consider when treating patients 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:

iwCLL indications for treatment^3,a

Leverage SHARE principles for shared decision making^14,16