patient care perspectives
Challenges in Treating Chronic Lymphocytic Leukemia: The Older Patient and Comorbid Conditions
The treatment of elderly patients with chronic lymphocytic leukemia and comorbid conditions requires an assessment of individual patient factors and disease characteristics. Patient fitness, potential side effects, and long-term outcomes are all important considerations when determining the choice of therapy.
“There are age-related conditions that should be taken into consideration. I always inform patients of the potential side effects of treatment, but I also emphasize that the majority of events are mild and do not lead to treatment discontinuation.”
Susan O’Brien, MD
Risks of advanced age, such as reduced renal function and reduced bone marrow reserve, render fludarabine-based therapy difficult to tolerate. Thus, for elderly patients, reduced-intensity regimens such as bendamustine plus rituximab continue to be used. It remains to be seen how clinical practice will change, however, given the increasing prominence of the novel agents. One could reason that bendamustine plus rituximab would be an appropriate starting point for a relatively fit 65-year-old patient, as the regimen could buy you approximately 4 years, followed by ibrutinib and, later, venetoclax. If you are considering bendamustine plus rituximab, it is incumbent upon you to test for 17p deletion (del[17p]) and TP53 mutation so that you do not inappropriately treat with chemoimmunotherapy.
Moreno C, Greil R, Demirkan F, et al. Ibrutinib plus obinutuzumab versus chlorambucil plus obinutuzumab in first-line treatment of chronic lymphocytic leukaemia (iLLUMINATE): a multicentre, randomised, open-label, phase 3 trial [published correction appears in Lancet Oncol. 2019;20(1):e10]. Lancet Oncol. 2019;20(1):43-56.
Moreno C, Greil R, Demirkan F, et al. Ibrutinib + obinutuzumab versus chlorambucil + obinutuzumab as first-line treatment in patients with chronic lymphocytic leukemia or small lymphocytic lymphoma (CLL/SLL): results from phase 3 iLLUMINATE. Oral abstract presented at: 60th ASH Annual Meeting & Exposition; December 1-4, 2018; San Diego, CA.
Stauder R, Eichhorst B, Hamaker ME, et al. Management of chronic lymphocytic leukemia (CLL) in the elderly: a position paper from an international Society of Geriatric Oncology (SIOG) Task Force. Ann Oncol. 2017;28(2):218-227.
Woyach JA, Ruppert AS, Heerema NA, et al. Ibrutinib regimens versus chemoimmunotherapy in older patients with untreated CLL. N Engl J Med. 2018;379(26):2517-2528.