NCCN Guidelines for Patients® | Chronic Lymphocytic Leukemia
43 NCCN Guidelines for Patients ® : Chronic Lymphocytic Leukemia, 2018 4 Treatment guide CLL without del(17p) or TP53 mutation Guide 8. Treatments if prior treatment fails Older or quite sick Treatment options (best options listed first) • Ibrutinib • Idelalisib + rituximab • Venetoclax ± rituximab • Idelalisib • Reduced-dose FCR • Reduced-dose PCR • HDMP + rituximab • Rituximab + chlorambucil • Ofatumumab • Obinutuzumab • Lenalidomide ± rituximab • Alemtuzumab ± rituximab • Dose-dense rituximab • Bendamustine + rituximab ± ibrutinib • Bendamustine + rituximab ± idelalisib Guide 8 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 frail or sick, whether young or older. Before starting treatment, 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. 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 8 that are listed in order of preference of NCCN experts. If your treatment works, your doctor may consider a stem cell transplant. You must be fairly healthy to have a transplant. A transplant may improve the prognosis of the cancer. If you have a complete or partial response to treatment for refractory or relapsed disease, your doctor may consider a second maintenance therapy with lenalidomide or ofatumumab. Your doctor will test for MRD and decide on your next steps based on those results. It is helpful to ask your doctor to explain any further treatment options you may have.