Medically Reviewed by Brian Koffman,(MDCM )retired, MSEd
The treatment landscape for chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) has changed dramatically over time, and CLL / SLL patients are living longer than ever. Chemotherapy-based regimens used to be the standard of care, but they were also associated with significant risks. The introduction of targeted therapies such as BTK inhibitors and BCL2 inhibitors has greatly improved outcomes for patients with CLL / SLL, and it has transformed CLL / SLL into a manageable, chronic condition. However, because patients with CLL / SLL are living longer, they are facing other emerging health challenges. A recent paper entitled “Chronic Lymphocytic Leukemia Care and Beyond: Navigating the Needs of Long-Term Survivors” by Dr. Stefano Molica and Dr. David Allsup of Hull University Teaching Hospitals provides a review of some of the health challenges faced by long-term survivors of CLL.
Immune System Dysfunction
CLL is a cancer of the B cells (the cells that make antibodies), and it also causes dysfunction in T cells (the cells responsible for fighting infections). Patients with CLL have a hard time fighting infections and other diseases because their immune systems don’t function as well as those of healthy people.
- Patients should use common sense infection prevention strategies such as handwashing, avoiding touching your face, and avoiding close contact with people who are sick.
- Immunization is a critical part of preventing infections, and experts recommend that patients with CLL receive yearly doses of the influenza, pneumococcal, and COVID-19 vaccines.
- The varicella herpes zoster vaccine (Shingrix) is recommended for preventing shingles.
- If possible, vaccines should be administered prior to starting CLL-directed therapy.
- Immunoglobulin replacement therapy is an option for patients with recurrent severe bacterial infections.
Cardiovascular Complications
Patients with CLL tend to be older, and at the time of CLL diagnosis or treatment initiation approximately one third of patients already have significant cardiovascular disease (CVD).
- BTK inhibitors may increase the risk of cardiovascular side effects, particularly in those with pre-existing CVD.
- Second generation BTK inhibitors (acalabrutinib, zanubrutinib) are more selective and have lower rates of cardiovascular side effects compared with ibrutinib.
- When selecting a BTK inhibitor, it is important to consider any pre-existing cardiovascular risk factors a patient might have.
- BTK inhibitors should be avoided in patients with a history of heart failure, ventricular arrhythmias, or uncontrolled high blood pressure.
- All patients should be routinely monitored for any damage to the heart.
Secondary Cancers
The risk of developing secondary cancers has increased, because patients with CLL are living longer. Some of the most common secondary cancers in patients with CLL are skin cancers, lung cancer, colon cancer, acute myeloid leukemia, and thyroid cancer.
- Patients should receive regular screenings for colon, breast, cervical, prostate, and lung cancers.
- Annual skin examinations should be performed.
- Smoking cessation counseling should be offered, if applicable.
Bone Health
Patients with CLL tend to be older, and they are at increased risk of bone fractures. Additionally, approximately 30% of patients with CLL have vitamin D insufficiency.
- Calcium and vitamin D supplementation are recommended as well as regular exercise for preventing osteoporosis.
- For patients who have signs of osteoporosis on bone density scans, initiation of antiresorptive therapy (a class of drugs that prevents bone loss) may be appropriate.
Frailty and Quality of Life
Patients with CLL are typically 70 years of age or older, and they often have other ongoing health issues. They also may be experiencing age-related declines in their physical and cognitive function such as muscle weakness, slowness, reduced stamina, and low general fitness. Additionally, receiving a diagnosis of CLL is stressful and can lead to heightened anxiety and emotional distress. This combination of physical and emotional stress can greatly impact patient quality of life.
- Effective CLL management must address a patient’s physical, social, and emotional well-being.
- It is important to assess a patient’s overall ability to perform everyday self-care tasks and to assess their quality of life in order to get a more complete idea of their overall well-being.
- Families and caregivers are an important source of support, and it is important to include them in conversations and communicate consistently with them.
Conclusions
Advancements in CLL therapies have improved patient outcomes and extended patient lifespan. However, patients with CLL are at higher risk for other health conditions which can substantially impact their overall health. Patients with CLL need a holistic approach that addresses their many different needs during their disease journey including medical treatment and monitoring, mental health support, social support, lifestyle guidance, and help with future planning.
