Introduction
When to Start Treating Chronic Leukaemia
Determining when to initiate treatment for CLL is an important aspect of patient management. Research has shown that starting the treatment of early-stage CLL in patients who are asymptomatic and have no evidence of further disease progression does not prolong the survival of the patient. Thus, there are circumstances that need to be considered by the physician prior to commencing the treatment of CLL. These include the stage of the disease, the clinical symptoms that the patient is experiencing, the results of laboratory tests and the patient’s overall health.
In this article, we will explain what monitoring and CLL treatment are, the indicators for CLL treatment and finally, how CLL treatment is personalised.
Understanding Chronic Lymphocytic Leukaemia
There are many different types of cancer that affect the blood and bone marrow, and Chronic Lymphocytic Leukaemia, or CLL, is a type of cancer that affects a type of white blood cell called a B lymphocyte. B lymphocytes are best known for producing antibodies, which are proteins that help fight off infections and guard against disease. CLL grows slowly by first affecting the blood, but later also the bone marrow, lymph nodes, and spleen.
Chronic lymphocytic leukaemia (CLL) is typically a slow-progressing condition, and many individuals are diagnosed before experiencing any noticeable symptoms. This can lead to uncertainty about the reason for initial testing. After diagnosis, patients may learn that, due to the often gradual nature of the disease, treatment may not be required immediately and the condition may instead be monitored over time.
Common symptoms that may develop over time include:
- Persistent fatigue
- Enlarged lymph nodes
- Frequent infections
- Night sweats
- Unexplained weight loss
- Enlarged spleen
- Easy bruising
- Shortness of breath due to anaemia
No two patients are alike, and thus management must be individualised.
What Does “Watch and Wait” Mean?
While it is natural to assume that early treatment of CLL would be in a patient’s best interest and would improve their survival, this is not the case. In fact, studies have shown that patients with early-stage CLL do not benefit from early treatment. As a result, patients with CLL treatment are typically placed on a “watch and wait” approach until symptoms develop and it is clear that treatment would provide benefit.
During active monitoring, healthcare providers regularly assess:
- Complete blood counts
- Physical examination findings
- Lymph node size
- Spleen enlargement
- Development of symptoms
- Overall health status
By monitoring signs of disease progression, patients can avoid the negative effects of treatment without any therapeutic benefit.
Why Immediate Treatment Is Not Always Recommended
CLL is a chronic disease, and in many patients, the disease is stable for years without causing any complications. Because the current treatments for CLL are only able to control the disease and not cure it, delaying the start of treatment until the disease becomes worse and requires treatment is best in terms of avoiding side effects from treatment and preserving future treatment options for patients.
Another consideration is that initiating treatment too early in the course of CLL may expose patients to potential side effects without clear clinical benefit, whereas delaying treatment until it is medically indicated allows for more appropriate use of available therapies to manage the disease and its associated complications while supporting quality of life. Patients on active surveillance are urged to carry on with their lives as usual but to attend their surveillance appointments as scheduled.
Signs That Treatment May Be Needed
Although many patients are monitored for years without ever being put on treatment, there are many factors that can prompt a physician to start a patient on a regimen of drugs for CLL. It is not a matter of one test result, but rather a collection of clinical variables that can indicate that treatment is warranted.
Treatment may be recommended if a patient develops:
- Significant fatigue that affects daily life
- Persistent fever without infection
- Night sweats
- Unintentional weight loss
- Rapidly enlarging lymph nodes
- An enlarged spleen causes discomfort
- Progressive anemia
- Low platelet counts
- Rapid increase in lymphocyte count
- Frequent or severe infections
The patient’s CLL is now more active, and it is likely that the benefits of any treatment will outweigh the risks of that treatment.
Factors That Influence Treatment Decisions
Because CLL varies between individuals, physicians consider a range of clinical, laboratory, and genetic factors when deciding whether to initiate or adjust treatment.
Important considerations include:
- Age
- Overall physical health
- Existing medical conditions
- Disease stage
- Genetic abnormalities
- TP53 mutation status
- 17p deletion
- Previous treatments
- Kidney and liver function
- Patient preferences
Molecular testing has evolved greatly and has become an important tool for CLL patient to receive a treatment that is more personalised to their specific cancer.
What Happens During Monitoring?
In the phase of active monitoring of CLL, in addition to scheduled meetings with the healthcare professional, the follow-up also involves a series of tests, which help to establish whether the disease is changing and if treatment is required.
During monitoring, patients typically undergo:
- Blood tests
- Physical examinations
- Review of symptoms
- Assessment of lymph node changes
- Evaluation of spleen size
- Discussion of any new health concerns
The patient should inform the health care team about any new symptoms or concerns in between scheduled appointments.
Treatment Options When Therapy Becomes Necessary
Treatment decisions are made by the physician based on the individual patient’s condition and the biological characteristics of the disease when treatment is considered necessary.
Current CLL treatment options may include:
Targeted Therapy
This type of drug attacks the cancer cells by targeting specific proteins that enable them to survive. These are commonly used for the treatment of CLL patients, newly diagnosed, as well as those with relapsed disease.
Monoclonal Antibodies
These types of drugs aid the body’s immune system in recognising and destroying cancer cells. These drugs are often used in conjunction with a targeted therapy to produce the best results.
Chemotherapy
Chemotherapy is no longer the standard of care for treating patients with CLL and is often reserved for certain patients with specific needs.
Combination Therapy
Most CLL treatments are given in combination to attack the leukaemia cells from different angles. This type of therapy is used with the aim of improving disease control in certain patients.
Benefits of Delaying Treatment Until Necessary
Deferring treatment does not mean the disease is being overlooked; rather, it involves initiating therapy at the point when it is most appropriate, with careful consideration of potential benefits and risks.
Potential benefits of active surveillance include:
- Avoiding unnecessary side effects
- Preserving future treatment options
- Maintaining quality of life
- Reducing treatment-related complications
- Preventing overtreatment
- Allowing time for the treatment to be most effective.
Some patients may continue daily activities for extended periods before therapy is required.
Supporting Patients During Active Monitoring
Many patients find living with untreated leukaemia to be a very challenging and emotional experience. They are aware that they have cancer but are not receiving treatment. As a result, they experience great anxiety concerning their health.
Educating patients with CLL about their condition, along with the rationale for active monitoring, plays an important role in overall disease management. This may help reduce feelings of anxiety or uncertainty by addressing concerns that the condition is being overlooked. It also emphasises that, through regular monitoring and communication with their healthcare team, patients remain actively involved in the management of their condition. Patients are encouraged to stay in touch with their treating team, adhere to vaccine recommendations, engage in regular physical activity, maintain a healthy, balanced diet and report any new symptoms.
In addition to receiving appropriate education about their CLL and the rationale for active monitoring, patients can support their care by attending scheduled appointments and follow-up tests, staying up to date with recommended vaccinations, maintaining physical activity as appropriate, following a balanced diet, and reporting any new symptoms promptly.
Future Directions in CLL Management
Ongoing research is focused on improving the management of CLL, including identifying when to initiate treatment for individual patients and selecting appropriate therapeutic approaches. Biomarkers that may help predict disease progression are also being studied to support more personalised decisions about the timing of treatment.
Current areas of research include:
- Earlier identification of high-risk patients
- Improved molecular testing
- Personalised treatment strategies
- Fixed-duration targeted therapies
- Minimal residual disease (MRD)-guided treatment
- Combination treatment approaches
- More accurate information on when to treat and who will benefit from certain treatments.
Conclusion
Deciding when to start the treatment of a patient with CLL is one of the key decisions in the management of patients with this disease. Due to the often indolent course of the disease, most patients are monitored for a long period of time before treatment is required. Even during this period of active monitoring, the patients receive an active form of management of their leukemic disease, and it is during this time that the best treatment strategy can be developed for the individual patient.
When treatment becomes necessary, a range of therapeutic options may be considered based on the patient’s overall health, genetic profile, and disease characteristics. Ongoing monitoring during treatment, along with continued research, contributes to the evolving understanding and management of CLL.
Disclaimer: This article is provided for general educational and informational purposes only and is not intended to replace professional medical advice, diagnosis or treatment. The management of chronic lymphocytic leukaemia (CLL) varies between individuals, and treatment decisions should be made by a suitably qualified healthcare professional based on each patient’s clinical circumstances. Readers should not delay seeking medical advice or make changes to their treatment or monitoring plan based solely on the information provided in this article. If you have concerns about CLL, symptoms or treatment, please consult your doctor or specialist healthcare team.
home » blog » health and wellbeing »
