Choosing CLL treatments for older patients

This review discussed the treatment options for older adults with chronic lymphocytic leukemia. This article recommends that CLL patients should have a fitness test before starting treatments to determine which treatment would suit them best.

Chronic lymphocytic leukemia (CLL) is a blood and bone marrow disease. It most often occurs in older adults, with the average age of 71 years. Traditional drug treatments can often be difficult for older patients to tolerate. Treatment choices for CLL will depend on the stage of disease as well as the age and overall health of the patient.

This review offers recommendations on treatment choice for older CLL patients.

CLL patients can be low-risk or high-risk depending on their genetics. Low-risk patients generally have a mutation (permanent change) in the IGHV gene. They also will not have certain other genetic abnormalities, such as the 17p deletion, 11q deletion and TP53 mutation. High-risk patients may have these genetic abnormalities, and will not have an IGHV mutation.

It is recommended that treatment be started in patients who have symptoms. These could include swollen spleen or lymph nodes, or quickly rising levels of lymphocytes (the type of white blood cell affected by CLL).  Before treatment is chosen, the patient’s history, risk level, and overall health and fitness should be discussed.

Ibrutinib (Imbruvica) is an effective treatment for older CLL patients. One study noted an 88% decrease in the risk of progression or death in fit patients over the age of 65. Reported side effects have been mild. These have included diarrhea, nausea, infection, and fatigue. It is also useful in unfit or relapsed patients.

For low-risk fit patients a combination of the chemotherapy bendamustine (Treanda) and rituximab (Rituxan) is recommended.  Rituximab targets a protein on leukemia cells, leading to cancer cell death.

Low-risk unfit patients may benefit from a combination of the chemotherapy chlorambucil (Leukeran) and the immunotherapy obinutuzumab (Gazyva). This combination improved time to disease progression (31.1 months) compared to chlorambucil alone (11.3 months).

High-risk and relapsed patients should consider venetoclax (Venclexta) and idelalisib (Zydelig). These treatments have been shown to improve time to disease progression as well as survival time. Venetoclaz has been associated with tumor lysis syndrome. This complication occurs when dying cancer cells are released into the blood stream.  

Older patients may experience more side effects than younger patients. This can lead to treatments being stopped, which makes them less effective. It is recommended that patients be closely monitored for side effects, and supportive care given to decrease their effects. 

This article recommends that treatments should be chosen based on overall health and risk level in older patients with CLL.