NCCN Guidelines for Patients® | Chronic Lymphocytic Leukemia

23 NCCN Guidelines for Patients ® : Chronic Lymphocytic Leukemia, 2019 3  Treatment guide First-line treatment First-line treatment Before starting first-line treatment, your doctor may want to test the cancer again. Important markers are del(17p), TP53 mutation, karyotype, and IGHV mutation. Imaging may also be done. If CLL is now a different type of cancer, read the section, Transformed CLL , in this chapter. Options for first-line treatment are listed in Guide 2 . They are grouped by whether del(17p) or a TP53 mutation is present. A clinical trial may be an option for you. NCCN experts recommend a clinical trial when CLL cells have del(17p) or a TP53 mutation. Ibrutinib Ibrutinib is the preferred first-line treatment, especially if you are older. In well-designed studies, it had better results than the treatment to which it was compared. Other treatments Other options in Guide 2 are listed in alphabetical order. For CLL with del(17p) or TP53 mutation, chemotherapy does not work well. Antibody treatment has better results. If the cancer growth is controlled, keep taking the antibody treatment until your doctor tells you to stop. For CLL without del(17p) and TP53 mutation, chemoimmunotherapy is a common treatment. An alkylating agent—bendamustine or chlorambucil— with a CD20 antibody may be an option. If you are younger and healthy enough, fludarabine-based chemoimmunotherapy may be received. Fludarabine is a purine analog, which can cause serious infections. If you can’t take chemoimmunotherapy, there are other options but more research is needed. For CLL without del(17p) and TP53 mutation, there are first-line options not widely supported by NCCN experts. Research showed that PCR ( p entostatin, Guide 2. First-line treatment del(17p) or TP53 mutation is present What are the options? • Clinical trial • Ibrutinib (preferred) • Alemtuzumab ± rituximab • High-dose methylprednisolone + rituximab • Obinutuzumab del(17p) and TP53 mutation are absent Older or sick What are the options? • Ibrutinib (preferred) • Bendamustine + CD20 antibody treatment • Chlorambucil + CD20 antibody treatment • High-dose methylprednisolone + rituximab • Ibrutinib + obinutuzumab • Obinutuzumab Younger and fairly healthy What are the options? • Ibrutinib (preferred) • Bendamustine + CD20 antibody treatment • FCR (fludarabine, cyclophosphamide, rituximab) • FR (fludarabine, rituximab) • High-dose methylprednisolone + rituximab • Ibrutinib + rituximab