Oncology
Chronic Lymphocytic Leukemia
Watch and Wait in Chronic Lymphocytic Leukemia: Doctor-Patient Dialogue
Overview
Our featured expert describes several points that may help patients appreciate the rationale for the deferred treatment of early stage, asymptomatic chronic lymphocytic leukemia (CLL), also known as the watch-and-wait approach.
Expert Commentary
John C. Byrd, MD
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“Taking the time to have these discussions is an important aspect of patient management.”
For the general oncologist, a patient with CLL that is in its early stages is likely the healthiest patient on their schedule for the entire day, and it may be natural to prioritize patients who are more ill for more time and attention. But for the patient with newly diagnosed, early stage CLL, hearing that their type of cancer is “the good cancer” and that treatment is not yet required can be counterintuitive and anxiety provoking. Taking the time to have these discussions is an important aspect of patient management.
Typically, I start by telling my patients with early stage CLL that their prognosis and the general outlook are usually quite good. In the current treatment era, results of the staging and evaluation of early CLL are more reflective of the time to treatment and are less of an indicator of the patient’s overall survival. We are at a good place right now with our current therapies for most patients with CLL, even once symptoms arise. I might explain that the medications we use are intended to help ensure that the CLL does not shorten their life span, and that early treatment has not been shown to lengthen one’s life span. Then, I may explain some of the studies that have been conducted on early treatment to illustrate the risks. For example, chemoimmunotherapy is associated with a small but significant risk for secondary cancers such as myelodysplastic syndrome and acute myeloid leukemia. That is, we do not want to take on treatment-associated risks when we do not need to. I also talk about the impact of treatments on quality of life. I explain that if a patient is asymptomatic and starts treatment before it is recommended, even with modern targeted medicines, they may develop problems over time that would not have arisen if they had deferred treatment. And these issues would occur in the absence of any demonstrated survival advantage.
I also highlight the significant progress that has been made in CLL management over the last 20 years and how the newer therapies have greatly transformed the lives of patients. A treatment that we might consider today in a study of early intervention for patients with CLL is likely not something that we would use 5 to 10 years from now. And I also think that it is important to remind patients that early treatment, before it is indicated, could potentially compromise the efficacy of a future treatment.
Sometimes it can help to talk with patients about their overall health instead of focusing on the eventual treatment of their CLL. For example, many patients can benefit from lifestyle changes to lower their risk of cardiovascular disease, which is highly prevalent and is also something that can impact both quality of life and survival.
References
Kim C, Wright FC, Look Hong NJ, et al. Patient and provider experiences with active surveillance: a scoping review. PLoS One. 2018;13(2):e0192097. doi:10.1371/journal.pone.0192097
Kranzler EC, Olson JS, Nichols HM, et al. Patient-reported communication with their health care team about new treatment options for chronic lymphocytic leukemia. J Patient Exp. 2021;8:23743735211034967. doi:10.1177/23743735211034967
Langerbeins P, Zhang C, Robrecht S, et al. The CLL12 trial: ibrutinib vs placebo in treatment-naïve, early-stage chronic lymphocytic leukemia. Blood. 2022;139(2):177-187. doi:10.1182/blood.2021010845
Muchtar E, Kay NE, Parikh SA. Early intervention in asymptomatic chronic lymphocytic leukemia. Clin Adv Hematol Oncol. 2021;19(2):92-103.
Rittenmeyer L, Huffman D, Alagna M, Moore E. The experience of adults who choose watchful waiting or active surveillance as an approach to medical treatment: a qualitative systematic review. JBI Database System Rev Implement Rep. 2016;14(2):174-255. doi:10.11124/jbisrir-2016-2270