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When Would My CLL Need Aggressive Treatment?

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Published on September 14, 2020

How Do You Know When It's Time To Try A New CLL Treatment?

How can chronic lymphocytic leukemia (CLL) experts predict when treatment will start to fail? When should patients look at switching to a different, and potentially more aggressive CLL treatment option? Host and CLL patient Andrew Schorr spoke with the University of Rochester Wilmot Cancer Center's Dr. Paul Barr to get these answers.

This is Part 1 of a three-part series. Watch Parts 2 and 3:
Part 2: Aggressive Treatment Options: When Are They Right for CLL Patients?
Part 3: What Advances Have Been Made In CLL Treatment?

This program is sponsored by AbbVie, Inc. and Genentech, Inc. These organizations have no editorial control. It is produced by Patient Power. Patient Power is solely responsible for program content.


Transcript | When Would My CLL Need Aggressive Treatment?

How can we predict when our current medicine is starting to fail, and should we switch to a new medication?

Dr. Barr:
That's a good question. So there's no doubt that the BTK inhibitors as you mentioned in the Bcl-2 inhibitor venetoclax (Venclexta) have completely transformed how we treat CLL patients. Unfortunately, the responses, the remissions don't last forever. In terms of predicting who might fail one of these drugs when the disease may progress, we can look at the clinical trial results and try to estimate for our patients when a drug may wear off when the disease might become resistant. But for each individual patient, they need to be followed closely by their oncologist so that we can identify some of the blood counts going out of whack or signs of progression do further testing and identify if the disease is indeed worsening. So we do our best using some of the molecular characteristics to predict when a drug may wear off but it really comes down to just following closely with the provider.

Andrew Schorr:
And let's talk about this 17p deletion, we used to call it the dreaded 17p deletion. If you test it early on and found somebody with that, would you say, “well, that means we're going to have to do more aggressive therapy.” I think that's changed some and I do know some people have some 17p but it's never been aggressive. So how do you know whether some of these markers are a bad thing?

Dr. Barr:
That is the one that we perhaps worry about the most. Whether the TP53 gene is deleted, not working or mutated. Both of those aberrations often will confer more aggressive disease, shorter remissions, and generally speaking poor outcomes. So when we identify that marker either early in the disease course, or later on it makes us worry a little bit more. Nonetheless, as you pointed out with the better therapies some patients can still enjoy very long remission. So each individual patient needs to be monitored very closely along the way because some can still enjoy long remissions even with the deletion 17p.

Andrew Schorr:
So what are the things you look at to say, first of all, it's time for treatment or it's time to change treatment and hit CLL harder if you will? What tests are you doing? What are you looking at?

Dr. Barr:
The indications for therapy really haven't changed over the years and decades. We still are watching for the red blood cell counts dropping, platelet counts dropping, symptoms, bulky lymph nodes, the spleen getting larger. So these are all examples of the disease getting to a point where it's hurting the individual patient where treatment is warranted. So whether a patient is just being observed or is on, say a single agent BTK inhibitor, we're always watching for the signs, the symptoms to guide us as to when to initiate or change therapy. We do obviously repeat a lot of the molecular tests, the FISH panel, the sequencing assays to help perhaps understand why the disease has changed course to better inform our patients of prognosis and to choose the right therapy. But those molecular factors don't actually tell us when to start treatment. They help guide it. 

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