Management of Chronic Lymphocytic Leukemia in 2020 - Episode 11
William Wierda, MD, PhD: We’ve made remarkable progress in terms of frontline therapies. I spend a lot of time these days in clinic talking about health maintenance. I wonder if we could touch on that a little bit and then we’ll move on to relapsed/refractory disease. But Carolyn, can you give us some of the discussions and topics that you speak with your patients about in terms of health maintenance things?
Carolyn Owen, MD: I think also when we talk about BTK [Bruton tyrosine kinase] inhibitors, it’s a great situation to be in if you have choice of different agents. Obviously, hopefully, also costs are reduced by competition between companies. That’s all the better for patients. But one of the big issues that Stephen mentioned is if there are tolerability issues, compliance is going to have a clear impact on efficacy of a drug.
And I think that the CML [chronic myelocytic leukemia] study of years ago proved that as physicians, we’re actually quite poor at assessing compliance or even often encouraging compliance. And it’s a skill that people need to work on and learn about. Just saying to the patient, “Are you taking your drug, or I assume you’re taking your drug,” is usually associated with a positive response. But it isn’t always a truthful response, and so it doesn’t involve a lot of questioning about how the patient is feeling, and doing, and really listening to the adverse effects. But then also there’s the associated medical problems that we are creating with our agents. Atrial fibrillation is not a nice problem for patients to experience. We have to make sure that that’s managed well and we’re reducing the risk of other heart and other organ problems.
Certainly, the patients want to know about whether they can change their diet or their exercise to improve their health. There are excellent studies that show that regular exercise helps people feel better. Even if they don’t have less toxicity, they experience their disease and their wellness in a more favorable light if they have regular exercise. And so, these are the sort of things that I’m forever telling patients to contemplate, like getting a dog. If you can’t be motivated to get up and go for a walk, it’s much easier to do so if there’s somebody else to motivate you out. And often, the caregiver is the most helpful there as well, if you can encourage the spouse to motivate the patient and they feel that that is actually beneficial. It’s hard for an individual to self-motivate and to take up new habits, but it’s much easier if they have encouragement.
Stephen Opat, MBBS: The other thing I’d like to add is also making sure patients are up to date with their immunizations, also monitoring their immunoglobulin levels because we know these drugs are associated with infection, and so there are things you can do in patients with hypergammaglobulinemia. We’re fortunate at our institution to have an immunologist who sees patients; that probably is overkill for most community practice. But I think making sure that patients are up to date with their immunizations and monitoring their immunoglobulins is useful. You might be able to prevent opportunistic infections.
William Wierda, MD, PhD: I’ve heard it asked more than once at this meeting, about the use of prophylactic antibiotics in the setting of treatment. What’s your comment on prophylaxis in frontline, in relapsed, BTK inhibitor-based therapy, and BCL2 [B-cell lymphoma 2 protein] inhibitor-based therapy?
Jacqueline Barrientos, MD: In our practice, we don’t routinely use prophylaxis for PCP [Pneumocystis jirovecii pneumonia], but if the patient has a history of pneumonias or PCP in the past, we do recommend antibiotic prophylaxis. Similarly, with the possibility for zoster, we do recommend daily acyclovir or some other antiviral if they have a prior history or if they’re at high risk, any stressful situation. And we recommend the inactivated vaccine that is available for chicken pox reactivation. We also mention, do not forget to make sure that they follow the guidelines for age appropriate cancer screening, as well. Women need mammogram, Pap smear. Men, prostate examination and skin exam once a year.
William Wierda, MD, PhD: I’ve been struck by the large randomized trials reporting out not an insignificant level of second cancers in patients with CLL [chronic lymphocytic leukemia], both with chemoimmunotherapy as well as with targeted therapy. So we don’t think that that risk for a second cancer goes away with targeted therapy.
Jacqueline Barrientos, MD: We see that the risk is even there, even in MBL [monoclonal B lymphocytosis] patients.
William Wierda, MD, PhD: Do you do any additional screening for second cancers, or do you follow the regular guidelines?
Jacqueline Barrientos, MD: Just the guidelines, unless they have a history of smoking, we might consider doing a CT [computed tomography] scan, but traditionally we just follow the guidelines.
Transcript Edited for Clarity