Personalizing Management of CLL: From the Advanced Practitioner Perspective
Posted: Monday, November 9, 2020
“Genetic risk of chronic lymphocytic leukemia [CLL] will definitely guide treatment and prognosis,” commented Sandra E. Kurtin, PhD, ANP-C, AOCN, Director, Advanced Practice and Clinical Integration and Assistant Professor of Clinical Medicine, The University of Arizona Cancer Center, Tucson, in her presentation during the 2020 JADPRO Live Virtual conference, the annual meeting of the Advanced Practitioner Society for Hematology and Oncology. Initially focusing on key factors to consider when selecting treatment for patients with CLL, Dr. Kurtin then briefly reviewed some of the therapeutic options available and how to manage adverse events.
The clinical stage of disease ranks among the top considerations in selecting treatment for CLL. “Not all patients are going to need treatment right away, so we would look at how aggressive or bulky their disease is,” Dr. Kurtin mentioned. Other considerations include patients’ symptoms, fitness status, concomitant diseases; tumor burden; bone marrow failure; immune dysfunction, and genetic risks. For instance, a patient with a 13q deletion as the sole genetic abnormality is considered to have favorable-risk disease, with a median treatment-free survival of close to 8 years. However, she added, a person who has a 17p deletion is considered to have unfavorable-risk disease, with a median treatment-free survival of about 9 months.
According to Dr. Kurtin, “there is very little role for standard chemotherapy anymore in the treatment of CLL.” The focus has turned toward personalizing treatment by targeting the disease's molecular attributes, such as CD20, CD52, Bruton’s tyrosine kinase (BTK), PI3K, and BCL2, with monoclonal antibodies, BTK inhibitors, BCL2 inhibitors, and PI3K inhibitors.
Dr. Kurtin reviewed the advanced practitioner's role in the prevention, mitigation, and management of adverse events associated with this array of treatments. She highlighted the common toxicities with monoclonal antibodies of infusion-related reactions and rare, but severe mucocutaneous reactions; the “unique” toxicities of BTK inhibitors (hemorrhage, infections, and cardiac arrhythmia); the risk of tumor-lysis syndrome associated with BCL2 inhibitors; and the hepatic and gastrointestinal symptoms often observed with PI3K inhibitors.
Finally, Dr. Kurtin emphasized the role of minimal residual disease (MRD) status in evaluating response to treatment. Evidence from clinical trials has suggested that undetectable MRD at the end of treatment is an “important predictor of efficacy.” Moreover, MRD status is being incorporated into all clinical trials.
Disclosure: Dr. Kurtin has served as a consultant for Celgene and Incyte.