August 2020 CLL Bloodline
Over the course of a year of monthly meetings, The CLL Society Bloodline will teach the BASICS needed to understand CLL. It will also provide news, help with the acronyms and new vocabulary words, and offer simple fun quizzes. The cycle restarts and it updated annually.
MONTHLY QUIZ: Choose the correct statement below:
- CLL most commonly presents in men and in the elderly (over 70).
- CLL has two peak incidences: a smaller peak at age 50 and a largest one at age 72.
- CLL is most common in women in their 50s and 60s.
- CLL affects men and women equally.
Answer: The correct answer is #1.
CLL is more common in men and the average age at time of diagnosis is 72. It is quite rare but possible for those under 30. It is more common in Ashkenazi Jews and less common in Asians.
THE BASICS: Watch and Wait
Watch and Wait or Active 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, mammograms, colonoscopies and skin check: try to catch the cancer early.
In regard to CLL, until a study reported last year that for asymptomatic high-risk patients, early intervention with ibrutinib improved progression free survival and time to next treatment, there were no data showing that earlier treatment at the time of diagnosis helps in any way. There are two main reasons for this lack of benefit:
- Until recently, all treatment options were either relatively toxic or ineffective.
- Some patients will never need treatment, so treating early only exposes them to toxicities with no benefits.
Even with the positive trial results from last year, the role for early intervention is controversial. Why take a medicine for years that you may never need and has not yet been shown to improve overall survival when taken early? Is taking it when needed just as good? Outside of a clinical trial, watch and wait is still the smart option.
NEWS:
Last month, the CLL Society published an article in the American Journal of Hematology on how CLL specialists around the world were managing CLL patients during the pandemic. Our findings included that for mild cases of COVID-19 that were treated outpatient, 60% of the experts favored discontinuing the CLL treatment with 25% continuing based on the clinical situation. There was a difference in the experts’ approach to the management of Bruton tyrosine kinase inhibitors (BTKi) (ibrutinib and acalabrutinib) vs other treatments. For BTKi, 44% of experts favored unconditional continuation of treatment, compared to only 12% for other agents. I wonder if those numbers might be even higher now based on the recent case reports of blood cancer patients with COVID-19 doing well if on ibrutinib. Free access: https://onlinelibrary.wiley.com/doi/10.1002/ajh.25851
WORD/ACRONYM OF THE MONTH: FLOW CYTOMETRY
Flow Cytometry is a powerful blood test that looks at markers on the cell surface. It is the test necessary to confirm the diagnosis of CLL by identifying the typical clonal population of cells (CD19, CD20(dim), CD23 and CD5). It is also used to assess MRD (measurable or minimal residual disease) down to 1 cancer cell in 10,000.
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