Welcome to the twenty second part of a series on Hemato-oncology.
Question: Dr. Chiragbhai, thank you for explaining to us about WHO should be treated in CLL and Why. Can you please tell us about treatment options?
Answer: As we discussed last time, CLL can be divided broadly in 3 groups for treatment decisions, based on cytogenetics i.e.
- Without del 11q or 17p
- With del 11q
- With del 17p
Que: Ok. And how do you differentiate treatment for them?
Ans: The difference is not absolute, but certain agents are preferred, based on probability of lower or higher response rates.
- Without del 11q or 17p – essentially all treatment options can be used.
For older patients or frail patients, chlorambucil (the old gold standard), rituximab alone, or pulse prednisone therapy is used. Rituximab has to be given more frequently, hence it becomes quite expensive and not very effective. We often use CVP type chemotherapy or Bendamustine which are well tolerated and cost effective.
For patients who are younger and fit, preferred option is FCR (fludarabine, cyclophosphamide, rituximab). In a large randomized trial involving 817 patients, comparing FCR with FC, CLL 8 trial, there was significantly better response rate and progression free survival (52 v 33 months). For those who cannot afford, CHOP is also a reasonable option. Other options are BR (bendamustine, rituximab), alemtuzumab, pentostatin, oxaliplatin etc. Alemtuzumab is very effective but comparatively more toxic, very expensive, and not easily available in India.
- With del 11q – options are essentially as above, but it is preferred to include an alkylator agent (cyclophosphamide, bendamustine, chlorambucil, ifosfamide) in first line treatment. In general, FCR or BR is preferred if pt is affording.
- With del 17p – this is the most difficult subset, with low response rates to all existing medicines. Hence preference is to offer them Allogeneic Stem Cell Transplant, whenever feasible. However, it is possible only for a small subset of patients due to fitness, donor availability, cost, and potential side effects. This however remains the only treatment which can offer a substantial chance of results in this subset. Even if they respond to existing therapies, it is mostly short lasting, and hence NCCN guidelines and other experts recommend Transplant even if there is obvious response to first line therapy. About 30% patients achieve long term disease control with transplant.
TRANSPLANT is important for other category patients also who do not respond to first line treatment or relapse within 12 months after initial response.
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