How I treat
| Treatment | |
| Patients with 17p deletion | These patients (whether de novo or relapsed) should be offered a clinical trial or receive ibrutinib as initial therapy. The PFS for ibrutinib used in patients with relapsed 17p deletion was 28-32 mo, significantly better than any prior therapy (FCR, alemtuzumab alone, or with steroids) used as frontline treatment of such patients. In the relapsed setting, both venetoclax and idelalisib with rituximab are available. There is no role for chemotherapy in the treatment of patients with CLL and 17p deletion. |
| Patients with previously untreated disease | These patients have many options including chemoimmunotherapy (FCR, BR, and chlorambucil plus obinutuzumab or ofatumumab) as well as ibrutinib. Three recent publications have suggested that FCR resulted in long-term PFS with a plateau on the PFS curve for patients with mutated IGVH, and particularly in those with mutated IGVH and trisomy 12. Thus, in fit patients with good prognostic features, a discussion of the pros and cons of chemoimmunotherapy vs ibrutinib is important. In addition to discussion of short-/long-term efficacy as well as toxicity, the difference in time on therapy is another important component to the discussion. |
| Previously treated patients | These patients have several options. One should consider their prior therapy, cytogenetics, comorbidities, as well as the side effects of the additional therapies being considered. FISH should always be obtained prior to initiating a new therapy. If previously treated with chemoimmunotherapy, then a small-molecule inhibitor is recommended. Choices include: ibrutinib, idelalisib and rituximab, and venetoclax for those with a 17p deletion. If patients received ibrutinib as frontline therapy (a rare group currently but expected to become more common), then considerations may be dependent on their age/comorbidities and FISH results and could potentially include chemoimmunotherapy, idelalisib + rituximab, and venetoclax. |
| All patients with CLL | Clinical trials for all patients with CLL should always be considered. |
| Treatment | |
| Patients with 17p deletion | These patients (whether de novo or relapsed) should be offered a clinical trial or receive ibrutinib as initial therapy. The PFS for ibrutinib used in patients with relapsed 17p deletion was 28-32 mo, significantly better than any prior therapy (FCR, alemtuzumab alone, or with steroids) used as frontline treatment of such patients. In the relapsed setting, both venetoclax and idelalisib with rituximab are available. There is no role for chemotherapy in the treatment of patients with CLL and 17p deletion. |
| Patients with previously untreated disease | These patients have many options including chemoimmunotherapy (FCR, BR, and chlorambucil plus obinutuzumab or ofatumumab) as well as ibrutinib. Three recent publications have suggested that FCR resulted in long-term PFS with a plateau on the PFS curve for patients with mutated IGVH, and particularly in those with mutated IGVH and trisomy 12. Thus, in fit patients with good prognostic features, a discussion of the pros and cons of chemoimmunotherapy vs ibrutinib is important. In addition to discussion of short-/long-term efficacy as well as toxicity, the difference in time on therapy is another important component to the discussion. |
| Previously treated patients | These patients have several options. One should consider their prior therapy, cytogenetics, comorbidities, as well as the side effects of the additional therapies being considered. FISH should always be obtained prior to initiating a new therapy. If previously treated with chemoimmunotherapy, then a small-molecule inhibitor is recommended. Choices include: ibrutinib, idelalisib and rituximab, and venetoclax for those with a 17p deletion. If patients received ibrutinib as frontline therapy (a rare group currently but expected to become more common), then considerations may be dependent on their age/comorbidities and FISH results and could potentially include chemoimmunotherapy, idelalisib + rituximab, and venetoclax. |
| All patients with CLL | Clinical trials for all patients with CLL should always be considered. |
FCR, fludarabine, cyclophosphamide, rituximab; FISH, fluorescence in situ hybridization.