Post-Conference Perspectives: Chronic Lymphocytic Leukemia - Episode 12

Looking Toward the Future of CLL Management

An expert hematologist/oncologist highlights key takeaways for the future management of chronic lymphocytic leukemia given an evolving therapeutic landscape.

Tara Graff, DO, MS: If somebody asked me the most important things to do with a newly diagnosed patient with CLL [chronic lymphocytic leukemia], first and foremost—I can’t say this enough—it’s so important to check all the different genomic aberrations. You need to know. We’re always used to, “13q, they’ve got great disease, they’re never going to need treatment.” But that’s a knee-jerk reaction. It’s important to know that, but there are so many other molecular aberrations that we need to know about, specifically 17p, TP53, and the IGHV mutational status. We need to know that. Looking back, when I’ve picked up patients who may have been seen by another provider, those weren’t checked. We could have potentially done them a disservice in the past if we gave FCR [fludarabine, cyclophosphamide, rituximab] to a patient who had an unmutated IGHV. They have a really poor response to chemotherapy-immunotherapy, but we didn’t always know that. That wasn’t always being tested routinely.

In a practice, it’s really important to adopt a uniform way of testing so that those key elements don’t get missed. I can’t say that enough. I built an order set in my own practice for established patients with CLL and for newly diagnosed, so the boxes are already clicked. Unless you unclick them, those things should be getting done. That way you don’t have to worry about which color tube is being done and drawn. The right things are being done. You need that. As I said, we’re in the day and age of personalized medicine, so why not give your patient the best benefit of their therapy by picking the right drug for their mutational status?

We’re lucky enough that a lot of our targeted agents are doing great in a high-risk patient vs a standard-risk patient. It’s not hurting anybody, but we need to know that because that’s how we’re going to be able to predict how many years they can go until they might need therapy. Patients are reading and looking into this. They know these things now. They’re coming in and saying, “I know someone who had this tested. What’s my IPI [International Prognostic Index] score? When am I going to need treatment? Am I ever going to need treatment?” We can’t always predict that, but they want numbers. By having that information and plugging those mutations into the CLL-IPI [International Prognostic Index for Chronic Lymphocytic Leukemia] calculation, we can give them some statistical evidence of what they may be looking at in terms of their disease, which makes them and their families feel better.

At the end of the day, it makes our jobs easier, because we’re giving them reassurance that we’re doing right by them. That’s my biggest take-home suggestion point. We need to be testing for the genomic aberrations, mutations, or whatever you’d like to call them, in all our newly diagnosed patients and again at relapse. Before you start any treatment on a relapsed patient, you need to recheck. The IGHV does not need to be rechecked, but with all the other ones, you need to make sure a new clone hasn’t emerged, and that you’re treating your patient appropriately.