Welcome to the twenty first part of a series on Hemato-oncology.
Question: Dr. Chiragbhai, it was interesting to note that CLL is a type of lymphoma and that its staging system is named after an Indian Dr. Rai, and the fact that bone marrow biopsy is not required for diagnosis. Immunophenotyping from blood is the test.
What is the evaluation required for patients diagnosed with CLL?
Answer: CLL first needs staging work up, to decide whether treatment is required or not. Interestingly, patients with Rai stage 0, 1, 2 often do not require treatment. Especially those with stage 0. Patients in stage 0 have only lymphocytosis, 1 have lymphadenopathy and 2 have hepato/splenomegaly.
These patients frequently do well for many years without any treatment. Hence they need to be treated only if there are significant symptoms such as marked fatigue, fever, bulky adenopathy or splenomegaly, weight loss, night sweats, less than six months lymphocyte doubling time.
NCCN guidelines mention that patients with WBC count of up to 200,000 to 300,000 should be left untreated if they do not meet above noted criteria for treatment.
Que: This is so difficult to believe. How can you leave a patient with cancer untreated?
Ans: Well, we face the same question from patients as well. It is very difficult for patients to accept that they have been diagnosed with a cancer, they have an obvious high count, and yet we are recommending just follow up and no treatment. It requires prolonged counseling and reassurance, often using examples of other patients to convince a patient that he does not require treatment. Patients with stage 0 have a life expectancy similar to general population, and CLL treatments are non curative. Hence these recommendations are in all guidelines.
Que: I cannot imagine how difficult this would be for patients to accept. Are there any prognostic tests that help you to make treatment decisions earlier?
Ans: There are certain prognostic tests, but still patients with stage 0 and asymptomatic stage 1 or 2 are not treated. This is important as some patients with even so called poor prognostic markers do well without treatment for long periods.
Prognostic factors are more important to decide what treatments to use, once clinically decision is made to treat patient e.g. cytogenetics done by FISH method divides patients in three main groups – those with del (17p); those with del (11q); those without the first two abnormalities (there may be other cytogenetic abnormalities, including some considered favorable such as del (13q).
High CD 38 expression is also a poor prognostic marker, apart from high beta 2 microglobulin.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 98243 12144, 98988 31496
Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com