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The End of Watch and Wait: What Factors Indicate It’s Time to Treat?

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Published on July 11, 2018

Watch and wait, also known as active surveillance without treatment, is closely monitoring for an indication that the disease is progressing. Chronic lymphocytic leukemia (CLL) patients who were put on watch and wait may wonder what the signs to initiate therapy are. A panel of CLL experts, including Dr. Alessandra Ferrajoli, Dr. Nicole Lamanna and Dr. Jackie Broadway-Duren, explain what factors may suggest that treatment is necessary, how patients can contribute to treatment decision-making and how a patient’s lifestyle can influence treatment strategy. The panel also discusses how having a specialist on the healthcare team can make a difference in a person’s cancer care. Watch now to learn more. 

Provided by CLL Global Research Foundation, which received support from AbbVie Inc., Gilead Sciences, Inc., Pharmacyclics LLC and TG Therapeutics. It is produced by Patient Power in collaboration with The University of Texas MD Anderson Cancer Center.

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Transcript | The End of Watch and Wait: What Factors Indicate It’s Time to Treat?

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Jeff Folloder:

Dr. Ferrajoli, we’ve been talking about the toolbox that we have, for treating various forms of CLL. We’ve talked about this inventory of how the patient is doing during watch and wait. How do we know it’s time to treat? Where’s that tripwire?

Dr. Ferrajoli:               

So, there is not a specific level, or a specific finding, or a specific factor that will make the decision. It is kind of where I call medicine being something between an art and a science. It’s where you put together the facts that you have in front of you. That are given by all the lab tests you have done, by what you see in the bone marrow.

Some patients, it will be physical exams, some others will even have results from the CAT scans. And, you put it together with how the person is feeling, and you factor in really a number of elements that I can’t even list, but some of them will be the age, if there is any other condition that is going on, how well can they function? And then, one other component may be what the patient’s goals are, what do they see their future being, commitments? You really sit down, and you do it in a way where you input your impressions and your advice, and then the patient will also respond with their impression, and their advice, and you develop what I call truly a treatment strategy, a plan. It’s never like a switch that you say, okay, this thing tomorrow. This doesn’t happen in CLL.

And, when I talk to my patients, I say this is an advantage, because usually, CLL gives us enough warning signs and enough findings that you may say, okay, I think we are getting there, Let’s make the visits more frequent, let’s start talking, and then you get to a point where it’s usually pretty obvious that it’s good to initiate therapy. Of course, there are some criteria, that are also written in the guidelines, that we’ll follow, but it’s not what, I dunno, a more technical job will be. It’s really a combination between your impression, the patient’s impression, and the options that you have. 

Dr. Lamanna:              

I think this is unique to, I mean, prostate cancer, right? But, think of this as unique to this cancer. Most other cancers, you find a solid tumor, malignancy, and pros—I guess prostate, again, separate prostate. But, colon cancer, and pancreatic, and breast, and lung.

You know, you’re either gonna get surgery, or chemotherapy, or radiation right away. I mean, this is different. And so, this is very unique to your circumstance, and as Alessandra said, it is rare that we say to somebody, you need treatment tomorrow. It’s extremely rare. So, it’s a planning that takes place between you and your doctor. And, I think that’s really quite unique, and why people need to be in specialized hands. Because I’m sure all of us have seen patients on this panel, where they’ve been recommended to have therapy, and didn’t need therapy. And, could have gone on being watched for years. So, I think it’s really important to—we take all the information about you, and really individualize the care for CLL for each patient.

 And, that’s why some of you may have gotten ofatumumab (Arzerra), but some of you may be on ibrutinib (Imbruvica), and some of you might have had fludarabine (Fludara), and so, you see it’s very different until—unless we find something that’s one-size-fits-all, and it cures everybody, it’s a very individualized approach, depending on your other medical problems, your age, other symptoms, side effects, maybe do you have bulky disease, maybe you have this factor, or that factor, and so, we have to take that all into account, when we plan your treatment. 

Dr. Broadway-Duren:

I think one of the most difficult things for patients to accept is that the treatment is not based on a level of your white blood cell count. As soon as they walk in the door, a new patient, well, how high does it need to get before I need treatment? And so, then, as Dr. Ferrajoli stated, you have to sit down with the patient, and try to help them understand, that there are many factors involved in determining that. But, we don’t treat people based on the white blood count. By the same token, we’ve had people with well over 200,000 cells, that didn’t get any treatment. And, so they didn’t need it, you know? And so, that’s a difficult thing for patients to accept.

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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