Treatment Options When Slow-Moving CLL Speeds Up
- When CLL begins to advance, doctors first determine how fast it’s moving. Rapid changes can signal a more aggressive condition like Richter’s Transformation, which requires different treatment.
- “That is something we need to rule out … so that we’re treating appropriately,” Dr. Alan Kerr, a malignant hematologist at Tampa General Hospital Cancer Institute, tells SurvivorNet.
- Dr. Kerr stresses that for disease that has not transformed but has progressed, modern therapies can offer years-long remissions.
- Targeted drugs such as BTK inhibitors achieve response rates above 90%, and newer combination regimens can lead to deep remissions lasting five or more years — sometimes allowing patients to pause treatment.
- Sensitive MRD testing helps doctors decide if it’s safe to pause therapy.
“The important things to note are how rapidly the disease is progressing,” Dr. Alan Kerr, a malignant hematologist specializing in lymphoid malignancies at Tampa General Hospital Cancer Institute in Florida, tells SurvivorNet.
Read MoreWhat is Richter’s Transformation?
CLL is typically a slow-growing, or “indolent,” cancer. But in rare cases, it can transform into a fast-growing, aggressive lymphoma — a change called Richter’s Transformation. WATCH: Richter’s Transformation ExplainedThis happens in roughly 2-10% of CLL patients, and it requires a different, more aggressive treatment approach than typical CLL — often chemotherapy-based regimens rather than the oral targeted drugs used for standard CLL.
Since the treatment path is so different, doctors rule this out first in any patient whose disease is progressing quickly.
Modern CLL Treatment
“The good news about our treatments that we have now for CLL, is that the majority of patients respond,” Dr. Kerr explains. “At least the initial response, we are seeing 90% or higher in many of these trials.”
When BTK inhibitors, a type of targeted therapy, were first introduced as CLL treatment, they were often given alone, Dr. Kerr notes. While successful, combining BTK inhibitors with other drugs has led to even longer remissions.
Newer approaches combine a BTK inhibitor pill with venetoclax, another type of targeted drug — sometimes with a third drug, an antibody given by infusion, added in.
Dr. Kerr says “some patients can even come off of therapy and might stay in remission for four, five, six years before they need any therapy again.”
This is a meaningful shift from earlier CLL treatment. When ibrutinib (an earlier BTK inhibitor) was first used, patients typically stayed on the pill indefinitely — similar to a blood pressure medication.
Newer combination approaches are designed to be finite, with a goal of reaching remission and then stopping, rather than staying on a pill for life. Shortening treatment time may also help reduce the risk of side effects that build up over years.
How Doctors Decide When to Stop Treatment
To know whether it’s safe to stop treatment, doctors use a specialized test called minimal residual disease (MRD) testing. This test checks for extremely small, otherwise undetectable amounts of leukemia DNA in the blood.
If MRD testing shows no detectable disease, a patient may be able to stop treatment and move to regular monitoring instead — essentially taking a break from active therapy while still being watched closely for any signs of return.
Questions To Ask Your Doctor
- Is my CLL progressing quickly or slowly, and does that change my options?
- Should I be tested for Richter’s transformation?
- Am I a candidate for combination (doublet or triplet) therapy?
- At what point would you consider stopping my treatment?
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