Patients, care partners, and a panel of CLL experts including Dr. William Wierda, MD, Ph.D. from MD Anderson, Dr. Nicole Lamanna, MD from the Columbia University Medical Center, Dr. Adam Kittai, MD from the Ohio State University, and Jackie Broadway-Duren, PhD, DNP, APRN, FNP-BC from MD Anderson gather to share the latest in CLL research, clinical trials, treatments, and comprehensive care strategies.
Guided by the insights of patient advocate moderator Jeff Folloder, the discussion will bridge the gap between medical expertise and patient perspectives, creating a truly comprehensive dialogue.
This interview has been edited for clarity and length. This is not medical advice. Please consult with your healthcare provider for treatment decisions.
Updated October 9, 2023. Originally broadcast September 20, 2023.
Quality of life and precision are top of mind for chronic lymphocytic leukemia (CLL) patients. Understanding the complexities of available treatments can help you optimize your CLL care and prioritize the questions to ask your doctor.
During this live conversation, panelists Dr. M. Yair Levy, director of hematologic malignancies research at Texas Oncology, and Dr. Catherine Coombs, a hematologist oncologist at UCI Health who specializes in CLL, discussed the latest in CLL care. The discussion was hosted by CLL patients, advocates, and administrators of the CLL Support Facebook group Michele-Nadeem Baker and Jeff Folloder.
This discussion covers the current landscape of CLL treatment and care options, as well as new CLL treatments awaiting FDA approval, factors doctors consider when starting or switching a patient’s treatment, encouragement for CLL patients to advocate for themselves, and each doctor’s outlook on CLL treatment and patient quality of life.
There is hope. Hope to live a normal life, and hope to see your kids and your grandkids grow up. There’s always hope on the horizon, in my opinion.
Dr. Catherine Coombs
Thank you to AbbVie and BeiGene for their support of our patient education program! The Patient Story retains full editorial control over all content.
This interview has been edited for clarity and length. This is not medical advice. Please consult with your healthcare provider for treatment decisions.
Michele-Nadeem Baker: I’m Michele-Nadeem Baker. I’m a medical and health journalist, but in addition to that, I am also a patient. I started advocating for other patients on my first day of treatment when I realized that there was so much unknown out there and to demystify things for my fellow patients and help them through their journey.
Jeff Folloder: My name is Jeff Folloder. I am a passionate patient advocate. I am now in year 14 of my little journey with CLL and I am living a great life. That’s why I became a patient advocate because I want to make sure that everyone knows that it is possible to live a great life with CLL.
First up, I get to introduce Dr. Catherine Coombs. She is a hematologist oncologist with UCI Health and she specializes in chronic lymphocytic leukemia. She also helps lead clinical trials, trying to find better ways to treat CLL. Dr. Coombs, tell me what drew you to specializing in CLL. We don’t hear that a lot.
Dr. Catherine Coombs: It was a long road. I went into medical school knowing I wanted to be a cancer doctor. I didn’t have any doctors in my family, but I do have a lot of family members with cancer. It always inspired me to be on the patient end of the oncologic relationship. That’s always what I thought I would do.
Now, I didn’t decide on CLL until my residency years. I looked for a research project right away, because that’s the only way to get into a good fellowship program is by doing research. It always was something I wanted to do regardless. I found a wonderful mentor in my time at Duke University as a resident, Mark Llaneza, where I focused on the underlying genetic risk of CLL as my residency project. That drew me to the field right away.
Then I saw all these other benefits of being a CLL-focused clinician, which is that the patients do really well and they live a long time. I love having that long-term relationship with my patients. I love blood cancers in general, but I would say the acute leukemias, which I had focused on a bit earlier on in my time as a faculty when I was doing a bit of both were hard because there are a lot of patients that we lose and I really admire the docs that do it. But I think for my long-term well-being, I know that it’s just so much more gratifying and less emotionally traumatic to be able to have patients that thrive for so many years and be able to really enjoy those relationships as the added benefit.
The therapeutics have just continued to improve over the 13 years since I first graduated medical school and started doing research.
Michele: We need more doctors like you. Dr. Coombs, thank you so much. I’d also like to introduce Dr. Levy, who is a hematologist oncologist at Texas Oncology. He is the director of Hematologic Malignancies Research and specializes in CLL. He’s also helped lead clinical trials in CLL. Dr. Levy, what drew you to CLL?
Dr. Yair Levy: Before moving to Texas, I actually did mostly chronic lymphocytic leukemia, but I’m a little older than Dr. Coombs. So back when I was doing it, it was still a relatively better outcome for this cancer, but we still lost some folks to chronic lymphocytic leukemia. However, if I reflect on my current experience, I don’t believe that I have lost a patient to chronic lymphocytic leukemia in the past decade. This is not because I have a shortage of patients. I’ve probably accumulated about 150. I’m not saying that the patients don’t die, but they don’t die of CLL.
So to live a normal life is the goal. Even though we still think of CLL as a treatable but incurable malignancy, for the most part, people are doing relatively well. Not to mention, not only are our treatments better in terms of efficacy, but they’re so much better tolerated.
If I reflect on my current experience, I don’t believe that I have lost a patient to chronic lymphocytic leukemia in the past decade. This is not because I have a shortage of patients. I’ve probably accumulated about 150. I’m not saying that the patients don’t die, but they don’t die of CLL.
Dr. Yair Levy
Jeff: We have an interesting topic for today’s program, Shared Treatment Decision Making: How To Be An Empowered Patient. This is something that strikes me right in my heart. I am a firm believer that patients who take an active role in their own care tend to have better outcomes, and this is actually borne out of clinical research.
I took an active role in my own care. I chose not to go in the specific direction that my first doctor wanted to go in, and I wound up at a large research hospital participating in a clinical trial. I’ve been living a great life as a result.
Michele: For me, treatment decision-making also came down to becoming an empowered patient and becoming health literate in CLL. The more I could learn from credible sources, for me, was better. I realized all patients are different and doctors, you can probably relate to this more than anyone but the world has changed quickly and pretty drastically for clinicians, researchers, and those of us who are patients.
I was diagnosed 11 years ago, not quite as long ago as Jeff, but still a long time ago. My frontline treatment started in 2015 and things were even different back then. I was on a trial that combined ibrutinib, which at the time was not approved yet for frontline treatment. It had been for relapsed and refractory but not frontline treatment. It was combined with FCR, the standard at the time, fludarabine, cyclophosphamide, and rituximab. Things have changed so quickly even since then. In my frontline treatment, I’m now on a different treatment. I had relapsed in between.
Dr. Coombs, could you tell us how the landscape of treatments for patients has vastly changed over the last couple of years?
BTK Inhibitors
Dr. Catherine Coombs: Over the past decade, but even over the past few years, we’re seeing advances. When I first got into the field, yes, it was chemoimmunotherapy for patients fit enough to receive it like FCR and BR. With the introduction of targeted agents, largely chemoimmunotherapy is not widely used. However, we still do see about a third of uptake looking at these large-scale studies across the country.
I’d say that doctors who are focused on CLL realize that chemoimmunotherapy is not worth the toxicity. Its efficacy is also inferior to these novel drugs that are more efficacious, so more likely to put the CLL at bay, in remission, and delay time until ultimate progression, but also hugely safer. That was first ibrutinib, as you wisely know from your own personal experience and your knowledge over the time of your journey as a patient. But now we have a lot of newer and better drugs. Ibrutinib has been amazing and revolutionary, but it does have some side effects. Fortunately, they’re not so common, but they still can be clinically significant.
The first category of drugs that have really changed in the past few years is newer generation BTK inhibitors. Ibrutinib was the first in class. It inhibits this critical protein that’s part of CLL cell machinery, BTK, but it’s not totally selective for its target. We now have 2 additional drugs that inhibit BTK – acalabrutinib and the most recent addition, zanubrutinib which was FDA-approved in January.
The advantage of both of these drugs is that they’re more selective for their target, BTK. That, fortunately, has translated to improved safety, where both drugs have been compared head to head with ibrutinib and they demonstrate improved tolerability, specifically lower rates of atrial fibrillation for both drugs. Acalabrutinib also has the advantage of lower rates of hypertension.
What we don’t know is whether zanubrutinib is better than acalabrutinib or acalabrutinib is better than zanubrutinib, because we don’t have that comparison. But I think they’re both excellent options and both offer advantages over the ibrutinib days when we were dealing with a lot of atrial fibrillation. There’s a lot less in the way of that.
The other huge class of drugs that I haven’t mentioned is a completely different way of treating CLL, so I’ll mention it briefly. I don’t know if we’re going to get more into the nitty gritty on this, but these BTK inhibitors work wonderfully at controlling CLL, but they’re considered as treat-to-progression regimens, meaning that patients go on and stay on as long as they’re, number one, tolerating it and their CLL is responding favorably.
Some patients don’t like the idea of being on a drug indefinitely, so the other huge therapeutic advance over the past few years that’s been widely available is the drug venetoclax. This is typically combined with another drug called obinutuzumab when used in the frontline setting. Because it can so effectively kill off the CLL to very deep levels, patients are able to completely stop treatment after one year and then eventually relapse, but it can take a long time. That’s one of the other major, major changes in CLL just over these past 5 years or so.
I’d say that doctors who are focused on CLL realize that chemoimmunotherapy is not worth the toxicity. Its efficacy is also inferior to these novel drugs that are more efficacious, so more likely to put the CLL at bay, in remission, and delay time until ultimate progression, but also hugely safer.
Dr. Catherine Coombs
Michele: Dr. Levy, what else would you add?
Dr. Yair Levy: Dr. Coombs, you hit the nail on the head. It’s a dramatic change from chemoimmunotherapy. In the chemoimmunotherapy era, our high unmet need was what we considered high risk which were ones that harbor a 17p deletion, or a mutation in this TP53 tumor suppressor protein, or these cells of origin that are called pre-germinal cells of origin. So a more immature cell that had gone bad, and we’ve known that they have done historically quite poorly with chemoimmunotherapy.
As Dr. Coombs mentioned, the biggest improvement that we saw was when we actually recognized druggable targets within the B-cell receptor pathway. The first such drugs were actually not Bruton’s tyrosine kinase (BTK) inhibitors, and they are largely relegated to the history of the B-cell receptor pathway now. But these were the PI3K delta inhibitors. Those worked irrespective of cell of origin, and they also worked in the 17p deletion. So again, they did certainly have some tolerability issues and the efficacy was not comparable to those of Bruton’s tyrosine kinase inhibitors, which is one of the big reasons that those have really fallen out of favor.
As Dr. Coombs mentioned, the BCL2 inhibitor venetoclax has also been a game changer. We’ve been utilizing these agents, either alone or in combination with CD20 monoclonal antibodies. Now, the European Medical Association has even approved the combination of a BCL2 and a BTKi. This is something that we’re doing further studies on within the United States as well because we’re seeing that people achieve very impressively high rates of response. More importantly, very deep responses can allow, hopefully, a very long treatment-free interval, and perhaps even in some cases, a functional cure.
So, in the beginning, we were saying that CLL is largely treatable but incurable, but we put an asterisk on that. Even with chemoimmunotherapy, there was a subset of CLL that may have been cured by chemoimmunotherapy, or at least a functional cure. I think we’re going to see the same thing with these other combinations as well.
We’re seeing that people achieve very impressively high rates of response. More importantly, very deep responses that can allow, hopefully, a very long treatment-free interval, and perhaps even in some cases, a functional cure.
Dr. Yair Levy
How CLL doctors are providing CLL patients with precision care
Jeff: This is exciting stuff. We’re talking about an awful lot of options for patients, but before we can get to those options, we need to figure out how we get to that point. So let’s chat a little bit about the tests that are needed to diagnose and then accurately inform those potential treatments.
A lot of us in the support groups and on social media love tossing around the cute names, the FISH test, the flow test. Not a lot of people truly understand what’s going on with those tests. They don’t understand the concept of chromosomal abnormalities that may be going on with a patient at the time of diagnosis. Dr. Coombs, can you briefly give us a top line as to what these tests are doing and more importantly, what they’re telling you in terms of prognostics?
Dr. Catherine Coombs: Absolutely. Before the advent of all these, let’s call them sophisticated tests, we would stage patients. That’s always what I think cancer patients think of, what stage am I? We do have a staging system called the Rai Staging System that we use in the US. In Europe, they use this Binet Staging System. But the idea is, how much is this really affecting me? Rai stage 0 is when it’s just a high white count to Rai stage 4 when you have low platelets from the CLL.
I’m taking a step back because there were, for decades, ways of saying this a good or a bad CLL. However, what we’ve learned over the years is that there are some patients with really early-stage disease that would follow very aggressive clinical courses and then some that may have been technically a Rai stage 4 that were totally stable for decades. The goal with all these more sophisticated tests was to better predict, how is this person’s CLL going to behave, which then helps us as clinicians know what to expect. It helps the patient as far as what he or she should expect.
So taking a step back, we now have a lot of advanced testing that we can send. The good news is that these can be sent on the peripheral blood so it’s not necessary to get a bone marrow biopsy early on. Of course, we do consider these at the time of therapy, but we can send these tests in the blood because the CLL, by its nature, is circulating in the blood. So we can pick up different abnormalities that can tell us, this is a good or a bad CLL or maybe somewhere in the middle to help us, number one, know if we should follow this person more closely. Number two, is this someone that perhaps it’s less likely to cause more trouble than not?
The categories of tests are looking at the DNA, which is either via a FISH test which uses fluorescent probes to find common abnormalities that are known to be seen in CLL. The most adverse is the 17p deletion. On the other spectrum, the most favorable is an isolated 13a deletion.
However, what we’ve learned is that this is only looking at certain probes. Sometimes you can have other abnormalities that aren’t present as part of the FISH panel. In my own practice, I also send a karyotype test which looks for the same thing, abnormal chromosomes. Instead of using a preselected panel of common abnormalities in CLL, it just looks at all the chromosomes. The chromosomes, just for the patient’s knowledge, are just the big chunks of DNA that live inside every one of our cells. We’re focusing on what these abnormalities are in the cells because there are common patterns. There are good patterns and bad patterns.
It’s also bad to have a complex karyotype, meaning 3 or more abnormalities in any given cell, so that’s one category. The 17p deletion I mentioned is known to behave more aggressively. It’s still a chronic disease, but those are often the bad actors, especially back in the chemo days when chemo doesn’t work well at all. It does do better with our new drugs, but that is a particular problem because it deletes a copy of this very important gene called TP53.
We used to think the only way of losing that gene was by completely deleting the part of the chromosome where it’s contained. What has been learned over the past 10 to 15 years now in CLL, is that it may not be deleted, but it could be mutated. That’s another test that I think is very wise to send, especially in patients who are going to need treatment because a TP53 mutation is largely the same as a 17p deletion. There are a little bit of nuances there, but these are 2 separate tests. They both give similar information because those 2 abnormalities are treated as one and the same as far as their impact on prognosis.
The next category of testing is looking at the immunoglobulin heavy chain status, so a normal B-cell over its life. CLL is a cancer of B-cells that undergoes a process of somatic hypermutation where it just acquires mutations. It’s actually good to have a mutated, immunoglobulin-heavy chain. The bad finding is for that to be unmutated, which suggests this is a bit more primitive of a cell. And what’s been borne out through a lot of studies is that patients with unmutated are the ones who need therapy quicker and they don’t respond as well to certain therapies. Now, again, the negative predictive impact of some of these abnormalities is somewhat outdated. Sometimes they do just as well with our new treatments, but they definitely don’t do as well with the old treatments.
The other test I always send is the beta-2 microglobulin (B2M), mainly because that goes into our scoring system for CLL, the CLL International Prognostic Index, but it’s an adverse finding to have that elevated. I think that wraps up the bulk of all the prognostic tests that I send at the time of meeting a new patient and trying to help understand what is our future going to be like.
The goal with all these more sophisticated tests was to better predict, how is this person’s CLL going to behave, which then helps us as clinicians know what to expect. It helps the patient as far as what he or she should expect.
Dr. Catherine Coombs
Jeff: Let me play that back for just a second and put it in terms that are not quite so technical. You have a toolbox, and that toolbox has a lot of really nifty tools in it, where instead of saying you have leukemia or you have chronic lymphocytic leukemia or you have one of these genetic abnormalities, you’re able to hone down to a very precise level of differentiation. That’s where the term personal and precision care comes in. Correct?
Dr. Catherine Coombs: Excellent explanation. Yes.
Michele-Nadeem Baker: I love this term and how that is happening more and more for patients. Dr. Levy, before planning treatment, what do you like to understand from your patients so that you can learn more about them when it comes to prescribing their treatment?
We need to speak with the patient and find out what is most important to them and explain everything about the treatment, including side effects, logistics, expected outcomes if you choose one route versus another, and the cost of travel. There are a lot of things that go into everything.
Dr. Yair Levy
Dr. Yair Levy: We’re all different and everybody’s cancer is also different. The reason that we have jobs as oncologists is because, I’m not sure that’s true here, but hopefully we know more about CLL and the treatment options than the patients. It’s our job to explain to them all their various options and then help them arrive at a choice that makes the most sense for them.
I think Dr. Coombs mentioned that we have a lot of options, but they haven’t necessarily been compared head to head. So we can’t tell you prospectively how treatment A compares to treatment B or treatment C. There are certain guidelines of what’s called preferred therapies and other alternative therapies that are also acceptable. We need to speak with the patient and find out what is most important to them and explain everything about the treatment, including side effects, logistics, expected outcomes if you choose one route versus another, and the cost of travel. There are a lot of things that go into everything. This is our job to get them to ask the right questions and then answer those questions.
The role of patient comorbidities in CLL care
Michele: And what about comorbidities? Is it important for patients to discuss their other health issues with you, such as cardiac issues? There’s a myriad of so many other types.
Dr. Yair Levy: Absolutely. This is what we were saying is, we’re all different, we all have different things that matter, and we are all in a different place in our lives. We take all of that into consideration, there’s no question about it.
The comorbidities are incredibly important, but we certainly advanced past where we were 15 or 20 years ago when we were looking at whether patients are fit enough to take therapy versus not because right now we’re not necessarily looking at fitness for therapy as much as we’re looking at what is the optimal therapy for them.
Many of the therapies that we have, if you take a look at what’s called the Preferred Category 1 recommendations from the NCCN Panel, were all studied in what we would have technically called a non-fit population before. It’s wonderful that we have all these highly effective therapies that we can give to people, even if their fitness is not optimal.
The benefits of watch and wait
Jeff: We’ve been talking about a whole bunch of novel therapies, stuff that has really impressive outcomes these days. Michele and I will both be able to tell you without hesitation, that the first thing that most patients encounter is not treatment. It’s this thing that we call watch and worry. You guys call it watch and wait. CLL does not always need to be treated right away. Your medical team is going to work with you to decide when it’s best to start treatment. In the meantime, the patient’s worry. Did I sum that up correctly, Michele?
Michele: We sure do, even though we tell everyone not to and to take a breath when they’re first diagnosed. Jeff, you and I both know that we still go through that when we’re back in that time period. It’s just so counterintuitive to not be treated right away when the disease has not progressed where it ends up going when you do get treated.
Dr. Coombs, what are you looking for when it’s time to treat? You go through years, hopefully, during watch and wait. Worry and wait, as patients call it. But what is it that you’re looking for and is there any benefit to treating it sooner as with some of the other cancers out there?
Dr. Catherine Coombs: I’m coming straight from my clinic. I’m in a clinic room. I just had this conversation with a patient who is newly diagnosed about watchful waiting, which I totally understand why it’s watchful worrying for many. I always see it as my duty to help them understand why this is our approach. I acknowledge this is not what we do for many other cancers where you hear, find it early, treat it early. I wish our treatments were so good that treating it early would knock it out and you’d never have to worry about it again. In 2023, we haven’t been smart enough to come up with something that will do that for CLL.
The way that I help put that in context for my patients is this disease can be so indolent that maybe up to 1 in 3 patients never need treatment in their lifetime. So if we treated everyone, inherently we’re over-treating people. I hate giving people things they don’t need because every treatment comes with a cost, whether it’s financial or side effects. That’s my one very strong argument for not over-treating. But also, none of the early treatments that we have tried and done clinical trials on have been shown to make patients live any longer. That is just where we are.
I definitely could understand the frustration on the part of patients because that leaves you with these worries. I do see those getting better in patients as time goes on. There’s this initial period of uncertainty, but then as you see what your pattern is, that either tells us, maybe we are approaching the time for therapy or nothing’s really changing, I feel fine, and this is something I can accept.
Now, obviously, we never know which camp a patient is going to fall into in these prognostic tests. They help us have a general sense of, maybe this will be a super slow CLL versus one that progresses more rapidly, but nothing is certain. I do personally have enthusiasm for making this change.
There is an ongoing countrywide clinical trial looking at early intervention for patients with high risk. That is open at my own institution and across many, many institutions in the country. I really hope things will change so we can improve patients with early disease. I don’t think it’s going to be every patient because of this third that never needs treatment. I don’t ever see a reason to just treat everyone, but the trial specifically is focusing on high-risk patients. Maybe there will be some movement there. It’ll probably take about 10 years to find the results of the study because you have to follow patients for a really long time.
For now, my job is to not over-treat and not make people who are feeling good feel worse. If you’re asymptomatic, then the best I can do is leave you alone, but hopefully calm some of whatever natural anxieties come about with what is a life-changing diagnosis.
This disease can be so indolent that maybe up to 1 in 3 patients never need treatment in their lifetime. So if we treated everyone, inherently we’re over-treating people.
Dr. Catherine Coombs
Michele: We have some questions coming in from our audience. Dr. Levy, here’s one of the questions for those of us with liver enlargement. Should we watch and wait?
Dr. Yair Levy: I completely understand the anxiety that comes along with this. I’ve been treating indolent lymphomas for a couple of decades now, and I’ve got the same experience. You talk with patients, you tell them they have cancer, and then they’re saying, “You tell me I have cancer, but you’re not going to treat me now. Are you sure you went to medical school?” I had that come up several times.
By the way, we don’t do watchful waiting anymore. We call it active surveillance. Nobody likes watchful waiting, but if we’re saying we’re actively surveilling you, that sounds certainly a lot better.
The way that I explain it is, that there are really only two good reasons to treat you for anything. This isn’t just an oncologist, it’s in all of medicine. My wife is a real doctor, she’s an internist. She has the same parameters for treatment. So, number one, if you can make somebody feel better, that’s absolutely a great reason to treat them. Number two, if you can make them live longer.
What we’ve seen, as Dr. Coombs was saying in chronic lymphocytic leukemia, as well as a variety of other indolent non-Hodgkin’s lymphomas is that early treatment does not confer a benefit in survival. In other words, if we treat you when you’re asymptomatic, you’re not going to live any longer than if we wait to treat you when you are symptomatic. This is important because as we were talking before, our treatments are changing and changing for the better.
The treatments are becoming more effective and better tolerated. And remember, something is only incurable until we’re able to cure it. So there are a lot of good reasons to wait. Dr. Coombs mentioned this as well. If I can’t make you live longer by treating you earlier with our current therapeutics, the question is, can I make you feel better? If you’re asymptomatic, I can’t make you feel better. I can make you feel worse. I can spend a lot of your money, but I’m not helping you. You are the most important part of that equation.
If somebody has liver enlargement, the question is, are they symptomatic? Are they having pain? Are they having any other symptoms from their liver involvement? If they’re asymptomatic, I would not necessarily treat them just for liver enlargement. The same thing is true with spleen enlargement as well, which is a far more common finding in chronic lymphocytic leukemia.
If we treat you when you’re asymptomatic, you’re not going to live any longer than if we wait to treat you when you are symptomatic.
Dr. Yair Levy
Michele: I experienced that when I relapsed, but along with other things as well, which led to my going back into treatment. Dr. Levy, thank you. You brought up a lot of great reasons why people are not rushed into treatment which also hints at all the things that you do look at when it is time for treatment, which we’ll continue to talk about as we go through with our program today. Thank you very much.
Considering the duration of treatment for CLL patients
Jeff: We spoke earlier about a bunch of the newer options that are available. We know that the treatment landscape is changing by the minute. I’m going to tee this up in terms that forum participants and our support group participants, they all had the same questions.
Yeah, the drugs are great. Am I going to have to take them for the rest of my life, or is there a chance that I can do it for a fixed duration? Dr. Levy, let’s break down what those current treatments are, what baskets they fall into and is this a lifetime activity or could we end it in 6 months? Could we end it in one year? You’ve got a lot of stuff that ends in -ibs, and -tas, and -mabs, and all that. Explain to us what’s going on.
Dr. Yair Levy: Again, this treatment progression model is a relatively new phenomenon for us in the treatment of malignancies. We used to treat with a fixed duration of therapy when all we had was chemoimmunotherapy. You can understand why. Once we give chemo, we can’t take it back. Certainly, the effects of cytotoxic chemotherapy are not something that you want in a cumulative manner.
Because of the logistics of how cytotoxic chemotherapy works, we could not give that till progression because that would be a very difficult life. Everybody thinks that the worst thing in the world is dying, and no, the worst thing in the world is not dying. The worst thing is a long, crappy life. That’s what we would assure we would do to people if we continued them on chemoimmunotherapy.
If you take a look at our approved therapies right now, basically it’s two categories. Bruton’s tyrosine kinase inhibition, BCL2 inhibitors, and monoclonal antibodies, can be sprinkled on any of these regimens. In terms of approved fixed durations of therapy, it’s only with the BCL2 inhibitors. The reason for that is that’s the most ideal drug that we have seen in the treatment of chronic lymphocytic leukemia. What I mean by that is it is a killing machine. It kills so well that we had to attenuate the dose because if you kill things too quickly, that can also become a problem.
We’re able to get those very, very deep responses. These deep responses, even if they’re what’s called MRD, which stands for minimal residual disease, really should be measurable residual disease. Even if people achieve a level of disease below where we can measure it, we know that in many cases it still returns. We really need to get that logarithmic killing. We really need to reduce their tumor burden by many zeroes in order to give them that long treatment-free interval. Currently, that’s possibly more likely with a BCL2 inhibitor venetoclax.
As we were alluding to before, we are seeing combinations of Bruton’s tyrosine kinase inhibitors like ibrutinib, acalabrutinib, or zanubrutinib in combination with venetoclax. Again, this was based on these laboratory models in which they actually saw whether or not these cells were primed for death with this combination. They actually saw synergy, meaning that the drugs worked better together than the sum of their parts.
As we mentioned, this is a fixed duration of therapy that’s actually approved in Europe right now, but not here in the United States. In the United States, we certainly can give a fixed duration of therapy with venetoclax and a CD20 monoclonal antibody. I can tell you that anecdotally, I’ve also done that with Bruton’s tyrosine kinase inhibitor and a monoclonal antibody if I can achieve that very deep response.
In terms of approved fixed durations of therapy, it’s only with the BCL2 inhibitors. The reason for that is that’s the most cidal drug that we have seen in the treatment of chronic lymphocytic leukemia.
Dr. Yair Levy
Factors in choosing a first-line treatment for CLL
Jeff: Excellent. Lonnie’s got a great question. Since we’re now considering treatments, he wants to know what are the primary factors to consider in choosing a first-line treatment. Dr. Coombs How do doctors and patients make that call? How do you choose which drugs are up on deck first?
Dr. Catherine Coombs: I think there are disease-related factors and patient-specific factors. We tackle those one at a time. I think there is an important role in knowing what an individual’s CLL risk findings are because those can help inform how likely a treatment is to lead to prolonged remission. Specific to a venetoclax-based approach in the front line, what we do know is that there are shorter remissions in patients with the 17p deletion or TP53 mutation and also shorter remissions for individuals with unmutated IGHV.
I tend to be an optimist and so my view is that these therapies, venetoclax-based, work way better than chemotherapy ever did for patients with these high-risk features. We can still see lengthy remissions on the order of a little over 4 years for the 17p patients for progression-free survival or around 5 some years for the unmutated IGHV. That is shorter than if you don’t have those markers.
I do think it helps weigh expectations on what to expect from a time-limited regimen. If you have high-risk markers, if you have all favorable markers, venetoclax also works really well and it just works longer than if you had negative markers.
Now, Bruton’s tyrosine kinase inhibitors as a class that have really leveled the playing field. If we divvy up patients with the unmutated and the mutated IGHV and the chemo days, the unmutated would relapse years faster than the mutated. There’s not much of a difference, and so those drugs work really for everyone. Now, they’re just so different conceptually and side effect-wise, which is why it is so important to weigh the patient’s comorbidities.
In addition to these disease-related factors that could help gauge the relative success of any given therapeutic approach, there are patient-specific factors. That’s why it’s so important for me to know, not only the details of the CLL but also the details of your specific comorbidities. Do you have a high degree of cardiac comorbidities where maybe we might be a little bit nervous about the BTK inhibitors, which can have cardiac side effects?
I will say the newer drugs are much better than ibrutinib, but it is something I weigh whether you have significant kidney disease, which might be a little bit risky. When we think of a drug like venetoclax that causes tumor lysis syndrome – none of these are complete no-goes, but they help tip the scale of which one are we favoring a bit more.
Then, of course, I want to know what other medications you’re taking, because a lot of medications can interact. That’s something we have to make sure of. Often that’s not a big deal, we just switch one out, but we have to know.
Lastly is social factors. What are your preferences? Are you the type of person who wants to do everything and doesn’t mind a frequent schedule, but wants that payoff of then being done with treatment in a year, where we might lean more towards venetoclax-obinutuzumab? Or are you someone who wants to spend as little time at a doctor’s office as possible and is okay with indefinite treatment where we may lean more towards BTKi? Those are the 3 major categories I think of – disease factors, patient comorbidity, specific factors, and then social and preference.
My view is that these therapies, venetoclax-based, work way better than chemotherapy ever did for patients with these high-risk features.
Dr. Catherine Coombs
The benefits of monoclonal antibodies for some CLL patients
Michele: Dr. Coombs, thank you for talking about the biomarkers that might indicate someone is a high risk, such as 17p or TP53. I am high-risk, but I don’t have either of those. I have the other that you had discussed being unmutated IGHV, and that actually impacted my treatment decision when I relapsed. I just finished. I am on acalabrutinib and was on a blinatumomab until a couple of weeks ago. It was obinutuzumab for 6 months along with the acalabrutinib.
Now, I will be staying on acalabrutinib indefinitely because I am considered high-risk. I had originally stated before that I started on ibrutinib. BTK inhibitors work for me and I just had adverse events initially and that’s why I went off. I had a couple of years of a drug holiday and then my doctor decided that while BTK inhibitors were still working, let’s go for it. I would still have another option with venetoclax.
Dr. Levy, why does a monoclonal antibody help? What does it add to the one-two punch? I know you talked about the different things that they’re addressing and being a killing machine, but why is it only for some patients? For example, what I’m on, acalabrutinib and obinutuzumab trials have shown that it specifically works the best. One trial was presented at ASH this past year for people like me who were unmutated. So, why only for some patients is it a benefit?
Dr. Yair Levy: Well, that’s a great question. The CD20 monoclonals were our first immunotherapy in the treatment of many B-cell malignancies. When we combined them with some of the targeted therapies, we didn’t necessarily see what we were expecting. In all of the trials with chemoimmunotherapy, adding a CD20 monoclonal improved progression-free survival. But interestingly, when we took a look at some of the studies that had arms that contained both ibrutinib, our first, covalent Bruton’s tyrosine kinase inhibitor in combination with a CD20 monoclonal or without those progression-free survival curves were superimposable. I think we were really surprised by that.
By the way, I need a button that says “I agree with Dr. Coombs.” Dr. Coombs was actually mentioning the fact that there are differences among these covalent Bruton’s tyrosine kinase inhibitors, and our first one had a less focused kinase profile. In other words, it hit other kinases, not just Bruton’s tyrosine kinase that we were trying to inhibit. One of the other kinases that it inhibited was something called ITK or IL-2-inducible tyrosine kinase. This led to antagonism of the CD20 monoclonal, which is why we got no benefit from the addition of the CD20 monoclonal.
This is not true for the other covalent BTKi, zanubrutinib and acalabrutinib. However, you’re seeing the combination with acala because that is FDA-approved and zanubrutinib does not have an FDA label in combination with a CD20 monoclonal. Do I have any reason to think that it wouldn’t work as well? I do not. There’s certainly data that supports that as well, that there are differences in terms of PFS for folks receiving the combination of zanubrutinib with a CD20 as well as without.
Now you can say, so why doesn’t everybody get a CD20 monoclonal? The answer is that there are trade-offs. Everything in life is a risk-benefit ratio. We know that, for example, there is this virus here in Texas, I don’t know if you guys have it too, called COVID. We know that for COVID, the CD20 monoclonal certainly antagonized an immune response to vaccination, as do the BCL2s and Bruton’s tyrosine kinase inhibitors.
Certainly, you are at more risk for adverse events and complications when you add additional drugs, so everything is a trade-off. We’re getting additional efficacy but at a cost. Our job is not to tell patients what to do. Our job is to have a discussion and come up with a solution that works best for them after we have a discussion and they are fully informed.
Now you can say, so why doesn’t everybody get a CD20 monoclonal? The answer is that there are trade-offs. Everything in life is a risk-benefit ratio.
Dr. Yair Levy
What CLL doctors consider before ramping up treatment and dosing
Michele: Thank you. Dr. Coombs, let’s talk about ramping up treatment. When you start treatments such as with venetoclax or even obinutuzumab, you start with smaller amounts and then ramp up to full dosing. Why is that?
Dr. Catherine Coombs: It’s different based on the drug. Let’s tackle obinutuzumab first. Obinutuzumab is the monoclonal antibody that can be paired with either venetoclax or acalabrutinib. It can also be used by itself less often. It’s a hugely effective drug, and it doesn’t really have that many side effects except for one that’s almost universal, which is these infusion-related reactions. Of course, it has other side effects such as impaired vaccine efficacy infections. It can cause low blood counts, but the one that’s universal is infusion-related reactions.
Instead of just giving patients their full dose of 400 mg daily, we…slowly introduce it so we’re more slowly killing off the cells in a way that’s friendly to the kidney and friendly to the rest of the body to minimize any potential risks from all this dead cancer cell debris.
Dr. Catherine Coombs
What they’ve learned over the course of developing this drug in clinical trials is that, instead of blasting patients with the full dose on the first day, the reaction seemed to be more manageable if you split the dose. The traditional way of administering obinutuzumab, the full dose is 1000 mg.
Instead of doing that all at once, which would make for a very colorful reaction in the infusion suite that no one nurse nor patient wants to be involved with is giving 100 mg on day one and then the other 900 mg on day two. Then of course you follow along with the rest of the schedule. The reactions, fortunately, are almost always on the first 1 or 2 days and then not long-lasting except for rare exceptions. That’s the reason for ramping up obinutuzumab, to make the reactions more manageable.
Venetoclax is a different story. As Dr. Levy mentioned, this drug is remarkably effective at annihilating CLL cells. But it’s not a good idea to kill any cancer just too quickly, because when you kill a cancer cell, all this dead cancer cell debris gets released into our bloodstream and our kidneys can’t handle that, even the best kidney in the world.
Instead of killing cancer rapidly by administering the full dose, it’s been learned through very well thought out and designed clinical trials that patients tolerate it better with less chance for dangerous tumor lysis syndrome, which is the term for complications from cancer dying too quickly, is to ramp it up. Instead of just giving patients their full dose of 400 mg daily, we give them a little whiff of venetoclax in week one, 20 mg, a little whiff the next week, 50 mg, and slowly introduce it so we’re more slowly killing off the cells in a way that’s friendly to the kidney and friendly to the rest of the body to minimize any potential risks from all this dead cancer cell debris.
Considering the side effects of CLL treatments
Jeff: Dr. Levy, I love the fact that you used the term risk management because that’s pretty much how I approached my entire journey, with risk management. We know that for most people there are going to be some side effects. There’s going to be some challenges when they start treatment. Can you give us a minute on, are they all going to happen upfront? And how do you manage them?
Dr. Yair Levy: That’s a great question. As Dr. Coombs mentioned, for the CD20 monoclonals, most of the reactions occur early and typically improve as you receive more of the drug. This is also true for the oral medications that we have. Most of the side effects, if you look at what’s called adjusted incidence, meaning how likely is it to happen per amount of time, it’s more likely to happen in the beginning. However, as we talked about, some of these therapies are indefinite progression or intolerance.
If you take a look at the cumulative incidence of events that continue to go up, there are certainly some events that are much more difficult to come back from. One that we worry about in particular is what’s called ventricular tachyarrhythmias, so getting a funny heart rhythm can actually lead to sudden death. It’s tough to come back from sudden death, isn’t it? One person’s done it right. They wrote a book about Him. One Person came back from the dead. A very popular book, but nobody else has done it since so we want to make sure that we give patients the safest possible therapeutics that we can.
Reasons to switch a CLL patient’s inhibitor
Jeff: Sometimes patients are told that they need to switch out their BTK inhibitor. There are a lot of reasons why this could be done. Dr. Coombs, can you tell us what’s going on with this?
Dr. Catherine Coombs: That is a common question, and that’s something that’s evolved over the years from having one option, just ibrutinib, to now having multiple options. In my own practice, I actually have switched patients for a number of reasons. I would say the reason that I consider switching a patient off of a BTK inhibitor to a different BTK inhibitor is if they’re having some side effect that’s negatively impacting their quality of life. I have switched patients from ibrutinib to acalabrutinib with very good success. I’ve also switched patients from ibrutinib to zanubrutinib, and I’ve even switched patients from acalabrutinib to zanubrutinib.
There have been studies looking at switching for side effects. About 70% of the time, the patients have improved tolerability on one of the newer drugs. There have been studies looking at switching to both acalabrutinib from ibrutinib and then switching to zanubrutinib from both ibrutinib and acalabrutinib and it seems to be a pretty uniform result where more often than not, the newer drugs are better tolerated than our oldest drug, specifically ibrutinib. I think that’s a very valid reason to switch.
The education point is, I would not switch in the setting of progression. That just is not a strategy that works more than a month or two and it isn’t really worth it. If you’re progressing on a BTK inhibitor of these FDA-approved ones, again, not speaking to switching from any of the approved ones, ibrutinib, acalabrutinib, or zanubrutinib, that is not recommended.
Now, I’ve heard of some occasional doctors just switching everyone off of ibrutinib. I’d say I talk to a lot of the community. I think most of us don’t do that because the side effects that occur most of the time are early on. I don’t use ibrutinib for my new starts, but I definitely have patients in my clinic who have been on it for years and they’re doing well. The old expression is if it ain’t broke, don’t fix it. Some people think, well, let’s just switch everyone. I don’t think that’s wrong, but it’s just not something that I’ve done for the reason I mentioned.
Jeff: Thank you for that. Makes complete sense.
I would not switch in the setting of progression. That just is not a strategy that works more than a month or two and it isn’t really worth it.
Dr. Catherine Coombs
New CLL treatments awaiting FDA approval
Michele: Doctors, there are so many types of treatment and clinical trials. Dr. Coombs, which ones are you most excited about that are getting closer to FDA approval?
Dr. Catherine Coombs: There are two that I’m going to mention. I’m excited about a lot of things, but the ones that I think are the closest to being approved potentially, I have no window into when the FDA actually approves things. One is a drug called pirtobrutinib. This is a drug that inhibits the same target as ibrutinib, acalabrutinib, zanubrutinib, and BTK, but instead of inhibiting it irreversibly, it is a reversible inhibitor.
The reason that that’s important is that when patients develop resistance to ibrutinib, acalabrutinib, and zanubrutinib, the resistance is shared by all of these drugs. So you can’t switch from acalabrutinib to zanubrutinib or ibrutinib to zanubrutinib, etc., if your patient is resistant because they develop most commonly mutations where the drugs bind. Pirtobrutinib binds at a different mechanism. It’s in a different part of the BTK molecule protein and it has shown very excellent efficacy in a very large study. I do think that that may attain FDA approval for CLL in the coming days.
It’s already FDA-approved for mantle cell lymphoma as of January, so there are ways to get it off-label, but I would much rather see it get full FDA approval to help with insurance paying for the drug when it’s needed. It fills a huge unmet need for patients who have progressed on covalent BTKis, especially after patients who have progressed following venetoclax where we don’t really have good options.
The other big category that Dr. Levy has alluded to is the combination of a BTKi plus venetoclax. Europe approved the combination of ibrutinib with venetoclax, which did not get approved in the United States. I can’t really speak about the reasons because I’m not involved with those discussions. I do wonder if some of it may be the toxicity of that regimen, which can be somewhat hard to tolerate, especially for older adults.
But what we know is that we have better BTK inhibitors with respect to tolerability. So there are a couple of trials that are looking at the combination of acalabrutinib and venetoclax that I do think hopefully will be positive trials that lead to FDA approval. That’s the other major category that I’m looking forward to. Those would be frontline treatment. You would use that combination as your first treatment. Whereas pirtobrutinib, if it gets approved, would be a relapsed treatment, at least for now. Things obviously change as time goes on.
It fills a huge unmet need for patients who have progressed on covalent BTKis, especially after patients who have progressed following venetoclax where we don’t really have good options.
Dr. Catherine Coombs
Michele: So your top two are pirtobrutinib and the combination of–.
Dr. Catherine Coombs: A BTKi plus venetoclax.
Michele-Nadeem Baker: Dr. Levy?
Dr. Yair Levy: I agree once again. There are other small molecule inhibitors, again, targeting that B-cell receptor pathway, which has really revolutionized the way that we treat a lot of these B-cell NHLs. In addition, the bispecifics, are certainly working their way into our armamentarium for non-Hodgkin’s lymphomas as well as CAR Ts.
Interestingly, one of the first articles that came out about CAR T was in chronic lymphocytic leukemia, despite the fact that our current constructs, these current autologous derived products are certainly not showing the same level of efficacy in chronic lymphocytic leukemia as they are in diffuse large B-cell lymphoma, for example. Nevertheless, I think that we are going to see some tremendous improvements in terms of the CAR Ts in chronic lymphocytic leukemia as well as the Bispecifics.
CLL doctors’ top takeaways
Jeff: So, Dr. Levy, I’m going to put you on the spot. What is the number one takeaway that patients should be grabbing from this discussion that we’re having today? What’s the top of the list?
Dr. Yair Levy: We’re doing so much better. As I mentioned at the beginning of the conversation, I have not had a patient die of CLL in the past decade. When we take a look at the high unmet need and again, Dr. Coombs was alluding to that. Folks who have progressed on a Bruton’s tyrosine kinase inhibitor and a BCL2 inhibitor are certainly the unmet need. We have a tough time finding those folks.
We’ve had some studies that have been languishing for accrual because it required folks to become double refractory. Again, we have a tough time finding those patients, which is wonderful. I don’t want to find those patients. I’ve put 2 people on in the past 5 years, and one of them was actually not even really refractory. He just wasn’t taking his medication. With CAR T, once I give it to him, he can’t take it, so this was more of me being paternalistic.
We’re doing so much better. As I mentioned at the beginning of the conversation, I have not had a patient die of CCL in the past decade.
Dr. Yair Levy
Jeff: Dr. Coombs, what is the single most important thing that you want patients and their caregivers to take away from this discussion?
Dr. Catherine Coombs: Jeff, we are friends now. It’s going to be hard to narrow down one thing, but I think if I have to say one thing, it’s there is hope. Leukemia is a horrifically scary word to hear for the first time, or maybe even after years of knowing that this is what you have. But all the treatments work extremely well and they work for an extremely long time. There is hope. Hope to live a normal life, and hope to see your kids and your grandkids grow up. There’s always hope on the horizon, in my opinion.
Encouragement for CLL patients to advocate for themselves
Jeff: What can patients and their caregivers do or ask if their local hematologist-oncologist isn’t quite looking at this new wonderful stuff that’s on the plate right now? What if they’re just going with the old stuff?
Dr. Catherine Coombs: That’s such an important question. And, you know, I think it’s tricky. I think it depends on what your personality type is. My personality is that I want to make everyone happy. I never want to offend anyone. I certainly understand the hesitation to question your doctor. But I think in the end, you just have to realize this is your life. If your doctor is not sounding up to date or if you’re just not getting your questions answered, then you deserve more than that.
I just think it’s so important to advocate for yourself or advocate for your loved ones if things aren’t adding up. I think our community docs are amazing. The ones that I interact with, I have no idea how they keep up with everything they keep up with. To put things into context, there are around 20,000 cases of CLL diagnosed a year.
When you think about the common cancers that have a majority of patients, they’re seeing lung cancer, breast cancer – those are like 200,000 plus cases. CLL ends up just being a much smaller slice of what they’re seeing every day, and it’s just very hard to keep up. I would say most community docs I work with very much welcome the second opinion because I can teach them something and then we now have a relationship where they’ll ask me questions and we can work together.
So, number one, don’t be worried about offending your doctor. Number two, most doctors aren’t going to be offended. Number three, if they are, well, I don’t know what to say about that, but I don’t get offended. Back when I was at UNC, I had patients go to Duke and the Duke patients would come to me. Sometimes it’s just good to hear things twice. I think if your doctor is offended, that’s a red flag on their own ego. I think all that we should want as your doctors is for you to get the information you need. That is your job to advocate for yourself, and almost all doctors are going to be totally happy with it. We can learn something from each other as we share in your care journey going forward.
There is hope. Hope to live a normal life, and hope to see your kids and your grandkids grow up. There’s always hope on the horizon.
Dr. Catherine Coombs
Jeff: Thank you for that and I love the way you put it. Patients should not be concerned about asking questions. They shouldn’t be concerned about saying, why not? If they’re having trouble getting along with their doctor, like you said, that’s a red flag.
Navigating what symptoms you should share with your doctor
Michele: We have some more patient questions, so here’s one of them. Sara N. asks, “How do I know when I should contact my doctor between visits? Do they need to know about every infection or just about CLL symptoms?”
Dr. Catherine Coombs: Sara, that’s a great question. I think in the digital age, we certainly can let doctors know about every single detail, but I think it’s good to set up expectations. I try to do this on my first visit or maybe my second visit if we don’t have time to cover it.
But what things do I always want to know about, and then what goes into the other category? I always educate my patients on red-flag symptoms. Things that for my patients on watch and wait, watch and worry, active surveillance, things that make me think, we need to get you in right away. Unintentional weight loss, drenching night sweats, fevers. I go through the list of the things I always want to know about – a rapidly enlarging lymph node, etcetera.
Then there may be other symptoms, and the ones I want to know about are the ones that are worrying you. I don’t want you to go to bed freaking out about something that may be nothing. Just send me a message and I’ll tell you, that’s nothing or I need more information. Maybe let’s have you come in. I’d say, it’s never wrong if it’s something worrying you. But of course, we all have to acknowledge it could get to be a lot of messages if it’s every single thing. I think you just learn that over time as you establish with a doctor, but I think it’s good to go through what things should I let you know about right away, and what things can wait. Then obviously there’s some gray zone where it doesn’t hurt to just pass the info along and then you can get back a message and not worry about that.
Michele: In looking at a patient holistically, so to speak, regarding these little things that we may not think are important, such as all these various infections – I keep getting sinus infections. I’m trying to think of some other types of infections. Maybe you could list those for patients, some of the ones that they might be seeing that you want to know about.
Dr. Catherine Coombs: We do see an increase in infections in our patients with CLL. I do like to get a general sense of how often patients are getting infections. If they have a primary care doctor who’s very responsive, I’m okay with them treating these infections. I’m also okay taking the lead, whatever works best.
But when they become really frequent, especially if it ends up with the patient landing in the hospital, I absolutely do want to know about that. There are some strategies we have to lessen the incidence of these infections.
Patients with CLL, a proportion of them, don’t make enough immunoglobulins. If you’re landing in a situation where you’re having a lot of severe infections, meaning pneumonia that you’re in the hospital for, or terrible sinus infections, etc., that may be a reason to consider this intervention called immunoglobulin infusions.
I definitely like to know about things that I can fix. I’m okay knowing about things I can’t fix too. The ones where it’s like, this would change what we do, those are especially important. The patients may not know that before messaging me, and that’s okay. It’s okay to just message because you don’t know and then I’ll tell you there’s nothing to do or let’s bring you in and talk about X, Y, Z.
I always educate my patients on red-flag symptoms…Unintentional weight loss, drenching night sweats, fevers.
Dr. Catherine Coombs
Jeff: Fantastic. I’m going to make this a little bit personal as far as what I hope people are taking away from this discussion. When I was first diagnosed with CLL, my doctor told me straight up that I was going to die in about 6 years, and that doctor got fired. My next doctor told me, “Don’t worry, we’ve got this. You might die with this, but you’re not going to die from this.”
Listening to both of you fantastic doctors talk about the landscape of CLL and even use the 4 letter word “cure,” I am convinced that I am going to be able to continue doing everything that I want to do, and I want to do an awful lot of things at some point. If my daughters’ are cooperative, maybe I’ll become a grandfather, but I’m going to continue knocking out half-marathons. I’m going to continue knocking out full marathons. I’m going to drink good wine and good whiskey. I’m going to eat well. I’m going to laugh a lot. I’m going to smile a lot and I’m going to share my story so that patients and their caregivers know that that can be their life, too. Michele, how about you?
Michele: I agree some of my key takeaways are that there are so many things in research and we have the potential of being approved in the somewhat near future, which is yet another option for us. As you had explained, it does work in a different way than the traditional types of BTK inhibitors we now have. I think this is fabulous to have yet another option for patients.
Also, I love what you said about what you really need to look for in your own doctor and not be worried about offending your doctor. This is so vital for patients. I ask a million questions and I encourage patients to do so so that they can become more empowered for their own care and self-advocate for themselves.
It’s been so great hearing you and Dr. Levy both talk about patients asking questions and encouraging them so that patients are not afraid of this. This is again, one of the things I had started doing to try to get rid of the mystique around care and treatment with people’s doctors. I continue to do that.
In addition with Jeff – and we’ll be toasting soon, hopefully in person about this with something more than water, which we’ve been drinking during the program – and that is to live life to its fullest and to live a normal expected life span thanks to doctors like you, Dr. Coombs and Dr. Levy. I thank you so much for joining us, both of you and I thank all of our audience members watching us.
Dr. Catherine Coombs: And thank you both for all the work you do in patient advocacy. Like 10, 15 years ago when the Internet wasn’t available, I think there’s so much more fear. To be able to bring light in a way that patients can understand is so hugely important. So thanks for what you do as well and for having me.
Special thanks again to AbbVie and BeiGene for their support of our patient education program all about building shared treatment decision-making! The Patient Story retains full editorial control.
Watch-and-wait strategies can be confusing for both cancer patients and their care partners. The Leukemia and Lymphoma Society defines this approach as “closely monitoring a patient’s condition without administering any treatment until symptoms appear or change.”
But how does this approach affect the day-to-day life of a cancer patient? In this live discussion held in May 2023, we explore everything you need to know about the watch-and-wait strategy, including red-flag symptoms, safe activities, and tips for maintaining good health.
Michele Nadeem-Baker: I am a CLL patient, but I’m also a medical journalist and a really passionate CLL patient advocate trying to help all of us understand better just what CLL is and SLL in everyday language.
So probably like the majority of you, I was pretty surprised when I was diagnosed with CLL and thrown into something called watch-and-wait, which made absolutely no sense to me. It was pretty illogical. The doctor walked in. I had no clue there was anything wrong with me and he said, “You have the C word, but it’s the best you can have.” Doesn’t that kill you when they say that? Nothing made sense to me. How anything with cancer could be the best. And then he told me that he’d see me in four months and then I’d be fine. So all of this was pretty illogical to me, having to grasp all of this at once and understand.
But during this time of watch-and-wait, what I did is I got a second opinion and then I started what you would call front-loading information. I was trying to find out the most credible places to go for information, but also the most current. And that’s something we have to watch out for with Dr. Google. So I learned Dr. Google is not necessarily the doctor, you want to listen to and also to go to find where we can find some credible answers. And so in that time, I also found great CLL specialists, the latest in treatment, and it’s good to stay on top of what those treatments are.
I made sure that I took a lot of stress out of my life. My job was a 24/7 job and when I tell you that, that’s not an exaggeration. I slept 2-4 hours a night — Dr. Rogers, can you believe this? — for years because that was my job. I thought, “I think I need to get a little healthier.” I upped my game on working out and on eating healthy and I started doing yoga and meditating and trying to do everything I could to be the healthiest I could be for when it was time to start treatment. And in treatment didn’t happen for some years.
Jeff Folloder: I am a passionate patient advocate. And there’s a reason for that. The reason is I am living an excellent life with CLL. And my goal, my mission is to make sure that others know it is possible to live a great life with CLL. A little bit about me. I love fast red cars, I love expensive whiskey, and I love sharing stories and learning about this ugly journey of cancer that I’m dealing with and helping people figure out better ways to deal with it.
Catherine Ferguson: My name is Catherine Ferguson.
I live just outside of Boston and am a retired college professor. I’m a vet tech and I work in surgery. And I’m also a CLL thriver — not only surviving but thriving.
Dr. Kerry Rogers: I just love doing this type of thing and I really enjoy talking to my patients in the clinic and I enjoy talking about CLL in general. I’m a hematologist, I’m a physician-scientist, and I’m an associate professor in the Division of Hematology at the Ohio State University. I see people with both CLL and hairy cell leukemia in my clinic and do research mainly in investigational therapeutics. And I enjoy talking about CLL with people, but I also really enjoy college football and was just reminded it’s only three and a half months or so until we have college football back.
Why is watch-and-wait used for CLL Treatment?
Dr. Kerry Rogers: The majority of people diagnosed with CLL won’t need treatment right away. And, in fact, with people getting routine blood work now so often, the most common way to be diagnosed is getting a blood test and then finding out you have CLL without any symptoms. It is very confusing for people when you’re told you have a cancer and most of the things you hear about all forms of cancer is that you have to treat it, catch it early, and be aggressive with treatment, and that’s not really the scheme in CLL.
The reason for that is that we know that treating it earlier doesn’t help people live any longer or any better. So way back when we used to use chemotherapy to treat CLL, there was more than one randomized study where they took people who were recently diagnosed with CLL that did not have any of the traditional reasons to treat it, like symptomatic lymph nodes or blood counts that were abnormal enough to need treatment. So they took people who were asymptomatic or minimally symptomatic with no issues that required treatment and randomized them to either be observed and then get treatment when they needed it or to get treatment right away with chemotherapy. And there was more than one study and this is, again, back when chemotherapy was the thing we used.
Does immediate treatment for CLL/SLL improve overall survival compared to the watch-and-wait approach?
Dr. Kerry Rogers: And, actually, there was no difference in overall survival, which is how long people were living between the two groups. People treated when they needed it or people treated immediately had the same survival so we know it doesn’t help you live longer. And, actually, it looked like there was a slight trend towards shorter survival in people treated immediately because chemotherapy is not overly good for people and they got chemotherapy they didn’t need yet.
The way I like to view it is CLL is not something that we can currently cure with conventional treatments. We expect people to live a very long and rich lifespan with it. And so given that, why expose someone to side effects from treatment earlier? Because the sooner you take it, the sooner you get side effects from treatment. And why expose he CLL cells earlier to agents they could become resistant to, shortening the amount of someone’s lifespan, where they might be expected to have their CLL controlled by targeted agents?
So if you think about it, there are a couple of reasons not to do early treatment because of side effects and the risk of resistance to the treatment. And we know it doesn’t help people live any longer in fact, it might help them live worse if they’re getting side effects. So that’s the rationale on the science side behind watch-and-wait, which I like to call observation.
Is there a percentage of patients that go immediately into treatment?
Dr. Kerry Rogers: That’s a good question. I do think that percentage is probably decreased over the years so I’m sure someone has looked at that as a straight percentage, but I’m not sure that really applies anymore. But it is really the vast majority of people that are in watch-and-wait, at least for some time. It’s a much, much less common thing to need treatment immediately.
Are there ongoing studies with newer drugs to determine if treating early improves survival?
Dr. Kerry Rogers: As a scientific question, they are repeating some of these studies with the newer drugs to see if this is still true, that it doesn’t improve survival for people, which is how long they live with their CLL, to treat early. Those studies are being done. The German CLL study group has one with ibrutinib as an early intervention. And then there’s one that’s occurring in the United States called EVOLVE that’s looking at venetoclax-obinutuzumab either immediately or delayed. We will get more information about that. Because people live so long, it will take over a decade or more to see if there’s a survival difference because people don’t die, which is great. I think that when you think about other types of cancers, like colon cancers or breast cancers, the reason to find them early is that you can cure them. And if you don’t find them and treat them earlier, people die of them.
When you’re looking at CLL, you’ve got a lot of people who, even though they have it, are unlikely to die of it — that’s not everybody, but a lot of people are unlikely to die of it — and we can’t cure it so you don’t get to do treatment and go back to whatever indefinitely, right? If you do treatment now, even with our newer drugs, these still have side effects.
What are the potential risks and drawbacks of treating CLL/SLL early with targeted treatment?
Dr. Kerry Rogers: Anyone that thinks they’re getting treatment with no side effects, you never get anything for free, right? Why expose someone to risks of high blood pressure, diarrhea? And then also we know that once you start exposing CLL cells to these targeted agents we use, there’s an amount of time that the disease will respond before the cells become resistant and their CLL comes back. If you start treatment 5 years before you had to, that’s 5 fewer years where someone’s CLL could be controlled by that drug so you might actually shorten someone’s lifespan by giving them a drug that you didn’t have to by either causing a severe side effect or causing their cancer cells to become resistant earlier.
Understanding the challenges of diagnosing and treating CLL/SLL
Dr. Kerry Rogers: And those schemes for screening, treat early — and I get asked this all the time, “But what if my cancer has spread? What if the CLL has spread? How will I know if it’s spread?” And I’m like, “Okay, this is really hard because it’s a blood cancer, right? So it goes everywhere the blood goes.” And they’re like, “Well, that’s everywhere.” And I was like, “I know,” and it’s so upsetting to think that. I can just see how upset people are by this idea. But for CLL, it’s actually okay. We expect it to be everywhere the blood can go and that doesn’t make it any less treatable or make our therapies any less effective.These conventional things that apply to solid tumors are not really the same as applied to these blood cancers and then there’s a huge difference between aggressive cancers that can be cured or cause symptoms immediately and some of these cancers.
And just for context, I have some patients that were diagnosed with CLL when I was in high school and have never needed treatment and it’s been over 20 years — actually over 25 now; I’m getting old.It’s hard to say that you can improve someone’s life by treating early and aggressively when the last two-plus decades have been them living their lives without anything hurting them from the CLL. So when you see that, then you think. it’s not a good idea to expose these people to things they don’t need. You can’t improve on feeling well, right?
Mental and emotional health effects
Jeff Folloder: The most debilitating part of CLL for me is the mental burden of this. We can be candid with each other. watch-and-wait is not a normal thing for anyone. And when you’re told you have cancer and you’re told you’re going to watch, you’re going to wait, you’re going to have to be vigilant, you’re going to have to go into observation mode, that becomes a mental burden. I will admit that I did not deal with that mental burden very well when I first went through watch-and-wait.
Michele Nadeem-Baker: Jeff had been through treatment. I’m like, “How did you do this? I didn’t have control over what my own body was doing and that is really difficult, especially for someone like myself who really likes to be in control of things. I think I’m doing everything I can. Is there anything more I can do? No, there really isn’t and it just doesn’t matter and that is so difficult.
And also my dad passed away from mesothelioma, a lung cancer. He was diagnosed and in two weeks, he died. So it’s just like, to me, that’s like, “You don’t treat? Oh my gosh, that’s what happens.”I got all worked up there from when I was going through it the first time because you really don’t know what it looks like. You don’t know what it’s like.
Catherine’s experience before front-line treatment
Catherine Ferguson: I dealt with it about the same as you guys initially. When I was diagnosed, I was at one of the top hospitals in Boston, but when they said they weren’t going to treat it, I was like, “Oh my God, I’m going to have to go to Dana-Farber.” So I went for a second opinion over to Dana-Farber and they told me pretty much the same thing.
My personality is I’m a go-getter. I want the plan. I want to get it done. I want to get it started and I want to get it ended. So for the first couple of weeks, it was probably all-consuming for me, honestly. I could have gone down the rabbit hole really quickly.
I look at my dogs and I’d think, “Am I going to outlive them or are they going to outlive me?” But pretty soon thereafter, I had an epiphany where one day, I thought,” I could go walk off the curb tomorrow and get hit by a car,” and then I spent my last days on this earth worrying about when I might die somewhere down the line.
For me, that set something off in my head that life is for living right now and none of us know what tomorrow brings. It’s not a guarantee for anybody. So for me, I try and just live my life. I’m basically an optimistic person in general, by nature. So for me, I try and just believe that] I do the things that I can do for myself and stuff like that. I take care of myself. I listen to the doctors. I get my screenings. I do all the things I’m supposed to do in watch-and-wait. And then I just continue to live my life. I have to say, the second time around, it’s been much better.
How did you cope with the emotional toll?
Catherine Ferguson: When I was first diagnosed, I was diagnosed with intermediate markers. I wasn’t high risk, I was intermediate on the genetic markers and so I knew I was going to likely need treatment. What the doctor couldn’t tell me is when. So I knew that sooner or later, I wasn’t going to be one of those people that was going to go forever without needing treatment.
And so around the 4-year mark, I started to get really anemic. I started getting really, really tired. I had a couple of nodes that were big, but that was it. Everything else — my platelets, my white blood count — was perfectly fine. We found out I was iron deficient so I did iron infusions. It helped initially, but when we rechecked it again two months later, it had dropped again.
Because I didn’t have any other symptoms other than I was anemic, we kind of assumed that it might be the CLL progressing at that point. I had a bone marrow biopsy done and it came back as Hodgkin’s lymphoma from a Richter’s transformation. So Richter’s transformation is when the CLL transforms into something much more aggressive. Usually, it’s not a Hodgkin’s, usually it’s something worse so I actually got the better of the two, if you want to see that. See, that’s the optimism.
I had to do a regular six months of chemo every other week. High-dose chemos. And for me, I’ve been in remission since I finished that chemo and that was five years ago. I have never had any more issues with the Hodgkins or the Richters.
What are some tips for guys dealing with watch-and-wait and how can they learn to talk to people about it?
Jeff Folloder: We’re at a point where I’m supposed to give some pro tips about how guys deal with watch-and-wait. And we’re going to go straight to a poll that Stephanie’s going to introduce in just a second. I’m going to give you a sliver of the pro tip because it’s part of dealing with this whole mental health aspect that we’re going to be focusing on a bit here.
Michele talked about it. She talked about being in control.] Guys, we all try to be type A and we try to always be in control. The answer is not always, “I’m fine.” The answer is not always, “I’m good.” You’re going to need to learn how to talk to people.
How do patients and care partners cope with watch-and-wait from an emotional and mental health standpoint?
Dr. Kerry Rogers: As you were saying that don’t just say, “Oh, I’m okay,” I have people’s partners all the time say, “Will you just go ahead and tell her what’s on your mind? You need to actually tell people what’s happening.” And I was like, “I’m here to listen to you about what’s happening.” I observe that quite a bit. We get so many people now diagnosed at a time when they have no symptoms — their blood tests are abnormal, they get diagnosed with CLL, they don’t need treatment, and they had no symptoms and say they felt perfectly fine and had no idea something was wrong until this happened —for this group of people, sometimes I think the hardest aspect of having CLL is knowing that they have it.
I see people where the worst part of it for them is not physical symptoms, but it’s living with knowing you have it. And I try to tell people, “You’re feeling well from this.” I’ve said, “Based on the disease features, I don’t expect this to be something that shortens your lifespan, even though you might need treatment at some point. Please don’t let knowing you have this ruin your life] Don’t let just knowing you have this fear in your life.”
We have great programs here at Ohio State at the James, like psychosocial oncology, which is mental health professionals that can help with this. I try to offer what I can, but this is something that I don’t have formal training in helping people cope with some of these aspects, which really can be much more impactful on their lives than the physical symptoms of CLL.
I think people knowing they have it can actually be much harder for them than any physical symptoms they’re experiencing. I can see sometimes people that have spouses or partners or caregivers or people in their lives that come to the clinic with them, it’s really helpful because sometimes, something, their friends, family, or loved ones are observing is something they choose to share during the visit and that helps me know that there’s something else that needs to be addressed.I think sometimes it can be hard for other people to know how to support their loved one that has CLL. I find that the majority of people help facilitate some of the communication in clinic and have been good.
Jeff’s experience with watch-and-wait: learning to communicate with healthcare team
Jeff Folloder: I want to share just a little bit about my experience with watch-and-wait I learned through going through all the questions and answers at the hospital that I chose that I wasn’t being candid with my healthcare team. I believe the military says I was exhibiting a lack of candor.
Well, the problem was I didn’t know how to answer their questions. I didn’t know what was important when they said, “So what’s going on? How are you dealing with things? Is there anything that we need to know about?” Things like night sweats. I associated it with my love of Thai food. You eat too much hot chili, you’re going to sweat at night, right? No. Going through all of this watch-and-wait was learning how to communicate with my healthcare team and not knowing what was going to be the tripwire for treatment meant that I was learning new things about communication.
I started treatment when my doctors discovered that my fatigue had become so debilitating that I couldn’t do the normal things I needed to do in my daily life. I couldn’t lift certain things. I couldn’t stay awake long enough. I couldn’t do this. I couldn’t do that. That was the tripwire for, “Okay, watch-and-wait is now over. Now it’s time to move into treatment.”
Dr. Rogers, explain to us what you’re doing with all these questions and answers. What are you looking for? What is happening during this period? And what should the patients and their caregivers be looking out for?
How to determine symptom severity and potential causes
Dr. Kerry Rogers: There are a few things that we always look for. We always check people’s lymph nodes. But just because we found some lymph nodes, it’s okay. It doesn’t mean you need treatment. But if people notice a bunch of lymph nodes everywhere that’s bothering them and keep getting bigger, then that might be important that we should do something to improve that for them. And then we look at the blood counts, which people don’t usually see their blood counts between visits that often and so that’s something that’s really important.
But in terms of what people tell us, it’s always good to hear about how people are functioning. If they have things that are interfering with their professional, leisure, or preferred activities, if it’s fatigue, if it’s something else, we always ask about night sweats. And then if someone’s like, “Yeah, I’m going through menopause,” I’m like, “Right, so that’s cool.”
The difference between normal night sweats and abnormal night sweats
Dr. Kerry Rogers: There are people with night sweats where everyone in bed with them is wet. They’re wet, their wife is wet, and the dog is wet. They had to change all the sheets. That’s actually a problem. And it’s hard because people don’t know that that we think there’s a difference between, “Oh, yeah, my neck got sweaty at night,” because they got hot versus, “Everyone in the entire bed with me is soaked because I’m so sweaty.” Those are the things we try to figure out by asking questions when people like to come to see us. Finding out about night sweats is fine and we can help people determine what might be normal like you were saying, the Thai food versus not really normal, right?
The significance of reporting severe fatigue and sleep issues
Dr. Kerry Rogers: Fatigue is the hardest because there are so many things that can add to someone’s fatigue. Every once in a while, we get someone that has fatigue that’s really quite severe and it’s actually sleep apnea. So we get their sleep apnea treated and they’re like, “Oh, I feel like a million bucks.” And you’re like, “I’m glad we didn’t treat your CLL because of that,” because that’s not going to fix your sleep apnea, right?
Part of what we do when symptoms are reported is not like, “Oh, you have fatigue, you need treatment,” but have more questions about what’s going on, and what might be causing that. One patient I talked to said, “I have fatigue, but I haven’t slept.” She only slept 2 to 4 hours a night. People are tired when they’re busy and they have something going on. A lot of the stuff we look for is not only asking those questions but severity and follow-up questions about some of those symptoms.
What is the average watch-and-wait period for intermediate and high-risk CLL/SLL patients, and does it vary by mutation type?
Dr. Kerry Rogers: The answer is yes, there is. This has been done in more than one study where they’ve looked at the time from diagnosis to first treatment. It’s hard to pinpoint from these studies what will happen to any one person though. So these are studies that look at a group of people diagnosed with CLL and how long between the time they are diagnosed and treated. Then they look at different disease features — so high-risk features like deletion 17p in the CLL,ow-risk features like IgHV mutated status, and then they look at the median. You can think of the median as a little bit like the average. It’s not exactly the same thing, but the median number of times for the 100 people in that group to start treatment.
Dr. Kerry Rogers: For things like deletion 17p, the median in one study was around a year and a half between diagnosis and needing treatment. But within that group, some people needed treatment right away, some people didn’t need treatment for five years. There’s a staging system called Rai staging that can help predict the time to the first treatment. But you never know what’s going to happen for an individual person so I try not to get people too wrapped up in that because you don’t know how it’s going to turn out for them.
Activities, supplements, and exercise
What activities can you do during watch-and-wait?
Dr. Kerry Rogers: I’m going to go with all of them that are recommended for people. People ask me this all the time, “Can I do this? Can I do that? Can I do the other thing?” I’m like, “Yeah, do all of it.” And then they’re like, “Can I do something crazy that really nobody should be doing?” I’m like, “No, don’t do that.”
“Can I drink beer because I have CLL? I like drinking beer and watching football.” I’m like, “Me too. That’s the best.” And they say, “I want to drink one beer watching football.” I’m like, “Okay.” Or they say, “Sometimes I like to drink two beers while watching football.” I’m like, “Yeah, that’s fine. Really just don’t get drunk every day and that’s not because of the CLL, that’s just general advice.”
If you think of someone with CLL, people in observation do live with a higher risk of infection and other forms of cancer. So I do think the COVID-19 pandemic was much more limiting for people with CLL in observation than for the rest of the public so there are a few things like that. But aside from going somewhere where you can’t access medical care if you’re about to need treatment or some really dangerous activities that are not recommended for anybody, I tell people to just go ahead, enjoy their lives, and do whatever they want to do.
How can we extend the watch-and-wait period and slow down CLL or SLL progression?
Dr. Kerry Rogers: Not that I’m aware of. There are a couple of things, right? There’s a study with green tea extract tablets like a high dose that can lower the white count, but I don’t know that there’s any data that really help people live longer or really prolonged watch-and-wait.
There are things that I’m sure help people in general. You were saying you did some things to make sure you’re fit and rested and eating healthier. Those things can make people feel better and be better with their overall health. But I don’t know of anything people can do specifically to increase the amount of time before they need treatment.
Matcha green tea and supplements: Are they effective in managing CLL or SLL?
Dr. Kerry Rogers: Not that I know of for CLL. Vitamin D does have a variety of health benefits. If you’re deficient, getting that replaced is important for other health metrics. But I don’t know of anything specific that will help the CLL. [Supplmenents] aren’t regulated so it’s helpful to go on the Internet and look at some of the companies that rate the quality of supplements before you buy them.
Green tea, it was an extract used in a study. You’d have to drink more than one can physically drink in a day to get the same benefit if you’re going to drink the tea. So if someone wants to try that, I strongly recommend finding a high-quality green tea supplement because it’s just physically not possible to drink that much green tea in a day.
Can jumping rope be beneficial for managing CLL/SLL?
Dr. Kerry Rogers: Exercise is good for people, right? But there’s no data that jump rope actually helps CLL. Probably won’t help your joint health but will help your cardiovascular health. But it doesn’t do anything to impact the CLL specifically.
Managing CLL/SLL Comorbidities
Jeff Folloder: One of the things that I have learned through my 13 years of dealing with CLL, I finally believe my first CLL specialist. He said, “I’m more worried about the comorbidities than I am about the CLL. If you will actually put time and effort into taking care of those comorbidities, you’ll actually make my job easier.” So I have embraced that.
I know it’s going to sound pedantic, but you can exercise more, you can eat better, you can eat less, and you can do all the things that you need to do to reduce your comorbidities. And, truthfully, there is no upper ceiling for it. I’m currently training for a marathon. I’m relapsed and training for a marathon, so yay.
Dr. Kerry Rogers: Modifying your other risk factors for your other health conditions because that is something everybody can do in watch-and-wait. And I would say more people with CLL my clinic die of heart attacks than die of CLL. So just please keep that in mind. And, of course, keeping up with cancer screenings and vaccines is very important.
When to start treatment for CLL/SLL
What are the indicators that it’s time to end watch-and-wait and start treatment for CLL/SLL?
Dr. Kerry Rogers: There’s a group of people where they have no symptoms, lymph nodes aren’t big, blood counts look fine, and you say absolutely there’s no reason whatsoever to treat this person. There is no cut-off on white blood cell count where you need to do treatment. I do think if you get above 400 or 500, usually other reasons develop and it’s about time, but there’s no cutoff like, “Oh no, my white count hit 50. We need treatment.” That’s not a thing. And yes, there is a thing with doubling, but that’s only with higher white counts. So it’s not like, “Oh, it went from 10 to 20, I need treatment.” That’s not a thing. You can actually be very flexible with the white blood cell count. Don’t think of a hard number there.
There are people who I think could be ready for treatment.] The blood counts are going in the wrong direction so you can see the hemoglobin and platelets are dropping, white counts going up, and lymph nodes are getting big, but they’re not actually really problematic for the person. Maybe they’re having some fatigue so there’s a window where you could say like treatment’s reasonable.
The span from, “We shouldn’t do treatment,” to “We should have done this sooner,” especially for a first treatment can be over a year. You’ve got a very long window and that gives you some time to decide, along with your doctor, what treatment’s best for you and things like that. It’s uncommon that you hit something and you need treatment tomorrow. It’s more like an ongoing discussion for a while.
The things I see that I notice sometimes are, “The white count shooting up pretty fast, along with the hemoglobin and platelets kind of dropping.” Or every time people come back, there are more lymph nodes and they’re losing some weight. There are a lot more lymph nodes and you see this trend happening. And then I do see some people that develop a lot of fatigue that suddenly starts to interfere with their personal and professional activities and that would be a reason to say, “We should really do something before this really impairs your life more.”
Are there any specific signs to watch for?
Dr. Kerry Rogers: Every once in a while, I have a patient who develops a significant health concern that they think is in another area, like severe diarrhea or chest pain, that’s not addressed by going to like their cardiologist or something else. When people develop health concerns, weird symptoms — and not like, “Oh, my toe is itchy one day and then it’s not the next day,” that’s fine; that happens to everybody – something significant, impacting their life, weird that maybe other doctors they thought might help them with this can’t figure it out, that is always something to check in and ask, “Hey, could this be related to CLL?”
Because there are some weird things that happen to people with CLL and certainly the physician caring for anyone with CLL should be able to figure it out. If anyone develops weird health concerns that are really symptomatic or problematic that other doctors can’t figure out, always a good chance that it could be CLL related and you should check in.
Does CLL increase the risk of other cancers?
Dr. Kerry Rogers: Yes, it is true. CLL is a cancer of immune system cells called B lymphocytes so it changes the way the immune system works because the CLL cells are there. By the way, treatment to reduce the CLL cells doesn’t fix this — only makes the problem worse. Your immune system is what protects you from other cancers by killing abnormal cells that your body forms as it makes new cells over time so cancer screening is important.
The top ones we see are actually skin cancers and, of course, lymphomas, as was pointed out earlier, do occur in people with CLL but those are kind of related types of cancers. But skin cancer’s actually one of the top ones so I try to get everyone’s skin cancer screening.
Side effects of treatments
Fatigue caused by CLL treatment
Catherine Ferguson: That was the worst part of it for me, honestly. I could deal with any of the other side effects even when I just finished a clinical trial a year ago. I’ve been undetectable MRD and in remission now for a year and I feel so much better. But that fatigue, even during treatment. Everybody said once you start treatment, the fatigue goes away, but I still had the fatigue even during treatment till I got off of the meds.
I work out a lot and I went to the gym every day and I tried to just keep up my routines. I’m generally an active person anyhow so I try not to give into it.
For a time period there, I would fall asleep while I was working on the computer with my hand on the mouse and my wife would look over and say, “Cathy,” and then I just wake up and I’d start to keep on moving again like I didn’t do anything. But I didn’t decide I was going to take a nap; I would just fall asleep. It’s just really hard.
How do new CLL/SLL treatments differ from traditional ones and what are some of the latest options available?
Dr. Kerry Rogers: I like to say that about a decade and a half before this kind of chemotherapy or chemoimmunotherapy, which is chemotherapy with an antibody works real well. In last decade and a half have been all about targeted agents. We actually no longer use chemotherapy to treat CLL. We do use it to treat other lymphoma successfully, but the whole name of the game is oral targeted agents and these are drugs that interfere with proteins in the CLL cells that make them behave like cancer cells.
The two main classes of drugs are something called BTK inhibitors and venetoclax, and they are extremely successful with virtually everyone achieving a remission, and just work very well.
The field is currently looking at newer generation agents of these different dosing schemes or different combinations to try to make treatment more effective but also easier to do for people and to have fewer side effects.
Is it crucial to see a CLL specialist immediately after diagnosis, or can it wait?
Dr. Kerry Rogers: It’s actually an individual decision. There are some reasons that people actually definitely need to see a CLL specialist. One is just if things aren’t going well, right? So not responding to treatment, developing side effects, not being offered acceptable options from your general hematologist oncologist — things aren’t going well, always see an expert.
Some other good times are planning a treatment, any treatment, because, usually, the CLL specialist will be able to have a good and, hopefully, more detailed discussion about treatment options or even offer participation in a clinical trial, which has a lot of advantages. But this doesn’t always have to be done at the time people are diagnosed just because if you’re in watch-and-wait and you’re happy with what’s going on,] it doesn’t mean you have to run out and see a CLL specialist right away, especially if you don’t live near a CLL specialist.
If you live in Boston, it’s very easy to go see one of my colleagues at Dana-Farber and other excellent doctors in that area. But if you live in rural Ohio or West Virginia, we get people that come from West Virginia. It’s like a three-hour drive so it’s a big burden to do that right away
And then I guess at diagnosis, one of the main reasons to see a CLL specialist is to get questions answered and to learn about CLL, which I think benefits all people. Most people do want to learn more about it, but there’s] a group of people that cope by putting CLL from their mind and they can certainly delay seeing a CLL specialist until there’s a reason like needing treatment.
