NCCN Guidelines for Patients® | Chronic Lymphocytic Leukemia
36 NCCN Guidelines for Patients ® : Chronic Lymphocytic Leukemia, 2018 4 Treatment guide Treatment options for CLL Clinical trials are the preferred treatment option of CLL experts for people with CLL. If you are unable or don’t want to join a clinical trial, Part 4 lists other treatment options for you. The first sections in Part 4 address treatment for CLL, and the last section addresses supportive care. The information in Part 4 is taken from the treatment guidelines written by NCCN experts of CLL. These treatment guidelines list options for people with CLL in general. Thus, your doctors may suggest other treatment for you based on your health and personal wishes. Fully discuss your treatment options with your doctor. Treatment options for CLL There are multiple treatment options for CLL. Treatment options that are best for you depend on features of the cancer and sometimes your age and health status. Thus, treatment options in Part 4 are grouped by these factors. The cancer feature that is very important for CLL treatment is whether there are missing parts of chromosome 17 or TP53 gene mutation (see page 17 for more details). The standard of care differs based on this cancer feature. The word “del(17p)” is how doctors refer to missing parts of chromosome 17. Abnormal TP53 genes have been seen in patients that don’t have del(17p). If unsure, ask your doctor if tests showed that you have del(17p) and/or TP53 mutation. The treatment options start with a first-line treatment. First-line treatment is the first treatment offered to treat the cancer. When that treatment is finished, your doctor will check if the cancer is responding to the treatment, assessing if it is working or not. Before starting treatment again, your doctor may want to test the cancer again. Features of cancer can change over time, so re-testing may be needed if some time has passed. Testing of chromosomes 11, 12, 13, and 17 with FISH is recommended. Also, TP53 and karyotype will be assessed. Your doctor may advise you to get an imaging test. If del(17p) is found, you will refer to Guides 9 and 10. For some individuals, the next treatment is maintenance therapy. Your doctor may also prescribe maintenance therapy to maintain the good results of your first-line treatment. If the treatment isn’t working or the cancer returns after treatment, other options are considered to treat refractory or relapsed CLL. After these treatment options, other treatment may be considered and include a clinical trial or an allogeneic SCT in some cases. Treatment options by age, fitness, and health When doctors plan treatment for CLL, one of the first steps is to exclude any treatment that is likely to be life-threatening. Chemotherapy is sometimes part of the standard of care for CLL without del(17p). However, some types are more likely to cause life- threatening infections to some people. Your doctor will decide your risk based on your physical ability fitness and health. Treatment options in Part 4 are grouped by your fitness and health. The first section focuses on people who are frail and sick and should avoid purine analogs. The list of treatment options are least likely to cause life-threatening infections. See Guide 3 on page 38 to learn which options are recommended by NCCN experts for this group.