Treatment of Chronic Lymphocytic Leukemia

This content has been reviewed and approved by

Hagop M. Kantarjian, MD
Chairman & Professor, Leukemia Department
MD Anderson Cancer Center
University of Texas

Patients classified as having stage 0 to II chronic lymphocytic leukemia (CLL) are considered to have early disease and often may not need treatment.

A variety of factors ultimately influence a patient's decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms, control of CLL, or increase a patient's chance of survival. The potential benefits of receiving treatment must be carefully balanced with the potential risks of receiving CLL treatment.

The following is a general overview of the treatment of CLL. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied. The information on this website is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.

Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments require that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer.

Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news to learn about new treatments and the results of clinical trials.

When to Initiate Treatment?

Patients diagnosed with stage 0-II CLL may remain asymptomatic without treatment for several years. In fact, in several clinical studies, the average time to initiating treatment for patients diagnosed with limited stage 0-II CLL has been 3 to 4 years, with some patients not requiring treatment for as long as 10 years or more.

Because of the slow growth of CLL, initial treatment may not be necessary for several months to years following diagnosis. Many patients, however, will require treatment. Treatment is typically initiated for one of the following reasons:

• To relieve symptoms caused by disease that may include fever, sweating, or weight loss.
• To prevent the disease from growing in an area where it affects other organ functions, such as blockage of the kidneys.
• To improve low blood counts from disease involvement of the bone marrow, which increases the risk of infection, bleeding, or anemia.
• To steady growth or progression of disease.
• Some patients feel uncomfortable living with disease and would prefer to be treated even in the absence of the above reasons.
• Autoimmune cytopenias causing anemia or thrombocytopenia may require treatment.
• Advanced disease, usually CLL stage II-IV.
  
  

The risks and benefits of early treatment should be carefully discussed with your treating physician. Research is in progress to refine existing treatments and develop new ones. For information on some of the techniques currently under investigation, see Strategies to Improve Treatment.

Participation in a clinical trial evaluating new drugs or treatment strategies is an appropriate initial treatment option.

A wide range of treatment options exists for CLL. Although none of the standard treatment options can cure a patient with CLL, they prolong survival. Each treatment is associated with side effects or toxicity from treatment. When a treatment is not curative, it may be more appropriate to select the therapy with the least toxicity.

Currently available standard treatment includes the following:

• Single-agent chemotherapy with Fludara^® (fludarabine phosphate) - Fludara is a type of chemotherapy and is the first of a new class of drugs (purine analogs) active in the treatment of CLL. As initial treatment, Fludara induces complete remission in approximately 40 percent of patients. Recent clinical trials have established that Fludara is the best initial treatment for CLL.
• Combinations of chemotherapy drugs - Several multidrug chemotherapy regimens are available that induce complete remission in excess of 50 percent of patients. These include combinations of Fludara with monoclonal antibodies, such as Rituxan^® (rituximab) (FR) without or with cyclophosphamide (FCR). The FCR regimens appear to produce very high rates of durable responses and may improve survival.
  
  

  Your physician may offer you treatment with fludarabine alone, or a combination of fludarabine plus rituximab, or a combination of fludarabine plus cyclophosphamide, or a combination of all three drugs (FCR). FCR appears to be very effective, but may be more toxic. It is appropriate for younger patients (for example younger than 70 to 75 years).

  All these options are good ones. Some physicians still recommend Leukeran^® (chlorambucil), an older therapy, for older patients; this may also be a good choice. If you have low counts because of an "immune process," you may be offered therapy with steroids, cyclosporine A, antithymocyte globulins (ATG), or others.
  

• Monoclonal antibodies - These include monoclonal antibodies against a marker on CLL cells called CD20, such as rituximab. Another monoclonal antibody against a different marker, CD52, is called Campath-1H (alemtuzumab). This drug has been approved by the FDA for treating CLL after failure of fludarabine. It has also been used upfront to treat CLL, alone or in combinations.
• Radiation - Radiation therapy may be used to treat involved lymph nodes that are not responding to systemic therapy or to rapidly control expanding lymph nodes that interfere with organ function.
• Splenectomy - This is used in patients with large spleen and poor response to therapy. Splenectomy may also improve low counts (hemoglobin, platelets) and control the disease for reasonable periods of time.
  

Research is in progress to refine existing treatments and develop new ones. For information on some of the techniques currently under investigation, see Strategies to Improve Treatment.