NCCN Guidelines for Patients® | Chronic Lymphocytic Leukemia

41 NCCN Guidelines for Patients ® : Chronic Lymphocytic Leukemia, 2018 4 Treatment guide CLL without del(17p) or TP53 mutation Guide 6 lists treatment options for if the CLL responds but comes back (relapsed), or if the first treatment doesn’t work (refractory). This is treatment for relapsed or refractory disease for patients who are younger and fit. Before starting treatment, your doctor may want to test the cancer again. Features of cancer can change over time, so re-testing is needed before starting treatment. Tests of the chromosomes in the cancer cells are advised. These tests include FISH and karyotype. Your doctor will also check for a TP53 mutation. If the features haven’t changed, ibrutinib alone and idelalisib with rituximab are preferred options. They are preferred due to good results measured in well- designed clinical trials. There are 13 other options in Guide 6 that are listed in order of preference of NCCN experts. If further treatment is needed, your doctor may suggest you join a clinical trial or consider an allogeneic SCT. The allogeneic SCT is an option if you do not have any serious health problems and your disease is not responding to drugs like ibrutinib or idelalisib. Guide 6. Treatments if prior treatment fails Younger and fairly healthy Treatment options (best options listed first) • Ibrutinib • Idelalisib + rituximab • Venetoclax ± rituximab • Idelalisib • FCR • FC + ofatumumab • PCR • Bendamustine + rituximab • HDMP + rituximab • Ofatumumab • Obinutuzumab • Lenalidomide ± rituximab • Alemtuzumab ± rituximab • Ibrutinib, bendamustine, rituximab • Idelalisib, bendamustine, rituximab

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