Choose the correct statement below:
CT scans should be used in CLL:
- At the time of diagnosis to establish a baseline
- Before treatment to assess staging
- After treatment to assess response
- Only in combination with a PET scan to assess both anatomy and the metabolic activity of any nodes or masses
- While they may be needed in some circumstances, outside of a clinical trial there is no mandatory role for CT imaging
The correct answer is #5.
While there are many circumstances where a CT may be indicated, their routine use at time of diagnosis or treatment is not generally indicated. PET scans are helpful if there is concern that there might be a second type of cancer as occurs in Richter’s Transformation (RT). RT is faster growing than CLL and therefore more metabolic-active and will “light up” on a PET scan. Outside of clinical trials, CTs (and PET scans) are not helpful in the routine management our CLL. For more details, see: https://cllsociety.org/beyond-thebasics/what-about-ct-scans/
THE BASICS: Watch and Wait
Watch and Wait or Observation or as patients often call it, Watch and Worry is at first glance one of the most counter-intuitive concepts in CLL management. With many types of cancer, early detection is everything and the prognosis gets worse with more advanced stages of the disease. That is the whole philosophy behind regular PAP smears and mammograms and colonoscopies and skin checks- catch the cancer early. But in CLL there is no data showing that earlier treatment at the time of diagnosis helps, and in fact there is some old data that indicates it doesn’t. There are two main reasons for this:
- Until recently, all treatment options were either relatively toxic or ineffective.
- Some patients may never need treatment, so treating them early only exposes them to toxicities with no benefits
This may change for some patients. There are trials looking at early intervention with novel therapies for patients at high risk of progression. Outside of a clinical trial, watch and wait is still the smartest option.
ACRONYM OF THE MONTH
TKI: TKIs or tyrosine kinase inhibitors are drugs that work by blocking activation of different proteins. They inhibit signaling pathways, preventing the expected biochemical event in the cell. Idelalisib and ibrutinib are two TKIs approved to treat CLL and there are others in development and still more that are used to treat other types of cancer.