CLL Program Highlight

The ASH (American Society of Hematology) Annual Meeting is the world’s leading conference on blood cancers and disorders, like leukemia, lymphoma, and multiple myeloma where top doctors and researchers share the latest breakthroughs. The below program excerpt if from our recent discussion with CLL expert, Dr. Jeff Sharman on news that came out of that meeting that could impact CLL patients like Serena.

CLL patient advocate and long-time health journalist Andrew Schorr sat down with Dr. Sharman to break down the most important updates for you.

Insights on CLL Treatment Advances

Andrew Schorr: So, Jeff, I’ve been living for many years with CLL. Some people who will watch this program are newly diagnosed. I went through all the stages you go through, and I’m sure you see it every day in your practice. What is this? I’m really scared. I have a blood cancer. Will my life be shorter? Am I going to die anytime soon? Please, doctor, what do you have that’s effective to treat me? And if that doesn’t work, do you have something else? We’re going to get into all that, but just at a high level, Jeff, how do you feel for today’s patients?

Dr. Jeff Sharman: You know, Andrew, it’s a great question and I have a very large practice of CLL patients. I take care of about 400 CLL patients and meet each of them. For many of them, I’ve been their first doctor. That’s the nature of my practice. So, for a lot of folks I take care of, I’m their first contact with the medical system in terms of understanding CLL. And I think what you highlight is something I see time and time again, which is a very understandable fear patients come in with.

It’s very common, you say “leukemia” and you see their eyes widen, you see them sit up a little straighter, and what you recognize under there is just a great deal of distress that any cancer would cause. 

That’s a really optimistic message that most patients aren’t going to pass away from their disease.

And I think that one of the things we do as a doctor is figuring out how to measure out and administer the unique medicine we give, which is the medicine of hope. And how do you communicate that to patients in the midst of some of the worst days of their lives where they’re like, oh my God, I’ve been diagnosed with cancer? And I do reference quite frequently; there’s a study done in the Italian group that showed that if you’re age 65 and above and have been diagnosed with chronic lymphocytic leukemia, they have demonstrated that you really can’t measure a statistical impact on survival, that most patients are going to outlive their diagnosis. And I think that’s a really optimistic message that most patients aren’t going to pass away from their disease. And my own experience bears that out. The number of patients that I can think of who die of complications of CLL is really a very small fraction even in my large CLL practice — only a small number, maybe two or three per year.

So, a lot of it is communicating that there’s a lot that we’ve got for you. And it’s not the traditional chemotherapy you used to have. We’ve got targeted agents, immunotherapy, and so forth.

Andrew: You already mentioned that sort of people aren’t going to need chemo. We’ve got this whole class of medicines, BTK inhibitors, and even new generations of that which we can talk about. So, first of all, the approved therapies. You have quite an arsenal now, where you can use drugs either by themselves or together, maybe for a bigger impact, right?

Dr. Sharman: Right. You know, I think the way I look at this is that there are three main classes of chronic lymphocytic leukemia drugs. You mentioned BTK inhibitors. I would add to that BCL-2 inhibitors, and then I would add immunotherapy to that.

I think the status of the field right now is trying to figure out the best combination and the best sequence, and those are the big questions shaping the field right now. But the good news is, of course, these drugs are FDA-approved and they’re available to patients. So those are the kind of core questions.

Andrew: So, I’m sure there are patients listening, and their heads are spinning. And they’re saying, well, the different BTKs or a next-generation BTK, with or without venetoclax, with or without obinutuzumab. And I guess what I know is not all CLL patients are the same. 

Dr. Sharman: Yeah.

Andrew: This is an individualized choice, right?

Dr. Sharman: Yeah, absolutely. Some patients take the physician’s perspective. Others are involved in their care and want to take an active part in the decision-making. I think that’s great. They should play an active role in it. And there are times when a patient might have their own preferences, but I may have different preferences based on how I’m thinking about their treatment. And sometimes, it’s a matter of calling to attention some of the potential side effects in a certain circumstance. Maybe somebody wants to do fixed duration, but their kidneys aren’t working too well any longer, or they’ve got a really bulky disease, or there could be various reasons why we might pick one over the other. Or even just how we think about, if we’re going to do this first, what do we do second? What’s going to be third? And if we’re going to pick this first, what’s the patient going to look like five to seven years from now when we might need to do the second therapy? So, you have to have a game plan in mind for somebody from the outset.

Andrew: Yeah, that is really well said. Now, I want to back up for a minute. We’ve got several questions from patients. One of them is like me. I said I went four and a half years without treatment. I felt pretty good. Then, I started to develop some lymph node issues, and my white blood count, fueled by lymphocytes, rose to about 283,000. My friend Dave is even higher than that. He hasn’t had treatment, and he feels fine. So, when should a new patient start treatment?

Dr. Sharman: So, for a chronic lymphocytic leukemia patient who’s climbing quite rapidly, what we talk about is the lymphocyte doubling time. Generally, when that number is going up more than twofold in less than six months, that’s our clue that we need to do something. But there are other reasons we might treat decide to somebody, such as bulky lymph nodes, if they start developing marrow dysfunction, if they’re getting anemic, or if their platelets are starting to go down — those can be reasons.

The one that does come up periodically is fatigue. Some patients have disabling fatigue. They might be 55 years old, they’re not depressed, their thyroid is fine, they’re not iron deficient, but they can only go to work for four hours before they have to come home.  

So, disabling fatigue, that’s a reason to treat it, but these are all pretty well spelled out in what we call the iwCLL criteria. Rate of change, symptomatic bulky lymph nodes, marrow dysfunction, and others as well. Those are the reasons we treat patients.

… our therapies are just as effective for younger individuals than for older individuals, and in some cases, maybe even more effective for younger individuals.

Andrew: Some people on Facebook, for instance, are under 50 with chronic lymphocytic leukemia. And I know it’s not all that common, but there are people like that. And they say, well, is my age of diagnosis a bad thing? In other words, am I going to have a rougher time with CLL because I’m diagnosed younger? Would I not live as long? What do you tell a younger patient based on their age?

Dr. Sharman: Yeah, that’s a great question. I like to think of these patients in terms of having to plan not for the next 10 to 15 years but for the next 30 years. And I think that, to some degree, we celebrate that we have a lot of these new tools to control the disease. But I think it is a reasonable question to say, can you use these tools to control it for twice as long or three times as long as somebody who’s diagnosed, maybe at age 80? So, it requires a different game plan. And yes, our therapies are just as effective for younger individuals than for older individuals, and in some cases, maybe even more effective for younger individuals. But I think it does require some thoughtfulness to consider that we need to come up with something that’s going to keep this disease in control for quite a bit longer.

Now, the other thing is, this field is moving so fast that those tools that we’ll be using five to seven years from now may not even have been conceived of yet. And we don’t have a ton of time to talk about bispecific antibodies or other drug targets and so on. But to benefit those who are diagnosed younger, I think it’s fair to assume that there will be more tools in the tool shed down the road.

For the rest of this interview, watch our program replay ON DEMAND.

Learn what’s changing, how it impacts treatment decisions, and what it all means for patients today.

Webinar: CLL Treatment Advances: Moving From Research to Reality

Hosted by The Patient Story

The world of CLL treatment is evolving fast, with new breakthroughs offering more options. This program breaks down the most important updates from recent research and clinical trials.

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