Chronic lymphocytic leukemia (CLL) is the most common form of chronic leukemia in Western countries. The disease is most often diagnosed between the ages of 67–72. A patient is diagnosed based on the results of a bone marrow aspiration, peripheral blood sample, or a lymph node biopsy, along with diagnostic imaging studies. When it comes to survival, that may depend on molecular analysis, complete blood count (CBC) values, and the extent of lymph node, spleen, and liver involvement.
The treatment of patients with CLL was a topic of discussion at the Oncology Nursing Society’s 40th Annual Congress, held April 23-26 in Orlando, Florida. Tracy Krimmel, RN, NP, AOCN, an advanced practice nurse at Rutgers Cancer Institute in New Brunswick, New Jersey, discussed the various treatment modalities for patients diagnosed with CLL.
Understanding when to treat patients with CLL is key, as acute vs chronic treatment widely differs. Depending on staging (stage 0–IV), many patients are observed until disease progression occurs. For example, a patient with no anemia or platelet abnormalities, a lymph node size of less than 1.5 cm, and an absolute B-cell count of less than 5,000, would be treated by frequent follow-up clinic visits.
When disease progression occurs, various combination treatment regimens including chemotherapy, monoclonal antibody drugs, and/or targeted therapies may be indicated. Krimmel stressed that National Comprehensive Cancer Network (NCCN) guidelines be followed when considering treatment for this patient population, as biomarker status and patient age will influence proper treatment options.
When it comes to seeking a cure for CLL, allogeneic (donor) stem cell transplantation is the only known therapy with curative potential.
Considering many CLL patients tend to be elderly, transplant may not be the best option, especially for older patients and those with existing comorbidities. Ongoing palliative medical treatment may be a better option. For those patients diagnosed with CLL at a younger age and with poor-risk disease, a transplant may be necessary—but stem cell transplantation isn't without serious risks.
Acute complications associated with transplantation are graft-vs-host disease (GVHD), the risk of serious infections, pulmonary and hepatic toxicities, and severe renal impairment. Acute GVHD (aGVHD) generally occurs within the first 100 days after transplant.
Treatment for aGVHD may depend on the extent of symptoms. Most commonly, patients will receive steroid treatment and/or localized treatment with ultraviolet light therapy for those experiencing rash.
If patients complain of adverse symptoms a few months or longer after their transplantation, they are experiencing what is known as chronic GVHD (cGVHD). This is the major cause of late-onset death and requires immediate attention.
Considered a long-term effect of allogeneic stem cell transplantation, cGVHD is an immune-mediated disorder that occurs in 30% to 70% of patients. Aside from cGVHD, secondary malignancies, severe infections (cytomegalovirus), extensive skin/oral involvement, pulmonary, cardiac, and endocrine disorders are just some the issues that can arise post transplantation. The treatment is similar to that of aGVHD, except other therapies such as monoclonal antibodies and tyrosine kinase inhibitors may be added.
So, why does this occur? While the pathophysiology behind GVHD is not clearly understood, it is thought that the immune reaction between donor T cells and host cells create a cascade of events, leading to the aforementioned disorders above.
While this may be review for many of you, the goal of this ONS session was to help participants have a better understanding of the issues associated with bone marrow transplantation in CLL patients. In addition, the speaker addressed important nursing implications in transplant care: patient education, focused assessments, monitoring for treatment-related toxicities, and providing ongoing emotional support for CLL patients.