Chronic Lymphocytic Leukemia Treatment
As home to one of the world's leading leukemia programs, MD Anderson's Leukemia Center and Stem Cell Transplantation and Cellular Therapy Center bring together internationally renowned physicians with a specialized support team to customize your care. These highly experienced experts communicate and collaborate daily, ensuring you receive comprehensive leukemia treatment.
Many of these doctors focus not just on leukemia, but on specific types of leukemia, giving them a deep level of knowledge and experience to draw on when designing treatment plans.
The goal of leukemia treatment is to put the disease into remission and ultimately cure the patient. For leukemia, complete remission usually means that the patient’s bone marrow has no detectable microscopic evidence of the disease and his or her blood counts have returned to normal.
Even with normal blood counts, many leukemia patients require ongoing maintenance therapy to stay in remission. In some cases, patients in remission undergo a stem cell transplant to maintain remission.
Patients who remain in continued complete remission for an extended period of time are considered cured. This means they have an extremely low chance of recurrence. The exact amount of time it takes to be considered cured differs among leukemia types, but it is typically measured in years.
Chronic lymphocytic leukemia (CLL) treatment plans
Clinical studies have not shown a benefit to beginning treatment immediately after diagnosis in many patients. Because of this, doctors often recommend active surveillance for early-stage CLL.
During active surveillance, patients undergo regular blood tests to monitor the disease’s progress. Specifically, doctors look for an increase in leukemia cell count and decrease in hemoglobin and platelet count. Symptoms are treated as they arise.
If and when the disease progresses to a set point (called an indication for treatment), initial treatments can include targeted therapy and a combined chemotherapy/immunotherapy treatment.
In most cases, these treatments put patients into remission, meaning most or all the signs and symptoms of cancer have disappeared. Some patients may need continued treatment to maintain remission. For others, remission is complete and they may stop treatment.
All CLL patients in remission are at risk of recurrence, meaning the cancer could come back and require further treatments. These treatments could include new cancer drugs or drug combinations as well as a stem cell transplant. Patients typically go through multiple courses of treatment through the span of their disease.
Chemotherapy
Chemotherapy drugs kill cancer cells, control their growth or relieve disease-related symptoms. Chemotherapy may involve a single drug or a combination of two or more drugs, depending on the type of cancer and how fast it is growing.
Learn more about chemotherapy.
Targeted therapy
Targeted therapy drugs are designed to stop or slow the growth or spread of cancer. This happens on a cellular level. Cancer cells need specific molecules (often in the form of proteins) to survive, multiply and spread. These molecules are usually made by the genes that cause cancer, as well as the cells themselves. Targeted therapies are designed to interfere with, or target, these molecules or the cancer-causing genes that create them.
Learn more about targeted therapy.
Stem cell transplantation
A stem cell transplant (also known as a bone marrow transplant) is a procedure that replaces cancerous bone marrow with new, healthy bone marrow stem cells. Stem cell transplants are usually given after an intense round of chemotherapy that kills the patient’s existing bone marrow cells and prepares the body for transplant. Patients usually must stay in the hospital for three to four weeks after the procedure.
A stem cell transplant may be needed for patients whose leukemia has returned or has not responded to standard treatments. It may also be recommended if the patient has a high-risk form of leukemia that would make a cure with standard treatments unlikely. This treatment can be physically challenging, so it is typically not given to patients who are older or otherwise unhealthy.
Learn more about stem cell transplants.
Clinical trials
As a top-ranked cancer center, MD Anderson offers multiple clinical trials for CLL. Many of these cannot be found anywhere else. Trials explore new drug combinations and new drugs, including targeted therapies and immunotherapies.
After completing a course of treatment, there are few words that sound better to a patient than “complete remission.” It’s an indication that the treatment has worked, and there is no evidence of cancer based on scans or lab tests.
However, there is a different phrase that can be somewhat confusing to patients – minimal residual disease (MRD). This term is used often by physicians when treating patients with blood cancers, such as leukemia, lymphoma or multiple myeloma.
MRD refers to cancer cells remaining after treatment that can’t be detected by those same scans or tests. But what exactly does it mean for patients?
To learn more about minimal residual disease, we spoke with leukemia specialist Ghayas Issa, M.D., of MD Anderson’s Myelodysplastic Syndromes (MDS) and Acute Myeloid Leukemia (AML) Moon Shot® team. Here’s what he shared.
How do you explain minimal residual disease to patients?
Minimal residual disease is a small number of cancer cells left in the body after treatment. These cells have the potential to come back and cause relapse in our patients.
In leukemia, for example, we look for response after chemotherapy treatment by looking under the microscope for cancer cells present in a bone marrow biopsy. When there are no cancer cells present, and the bone marrow is making normal cells, we call that a complete response.
However, we know that if we don’t do further treatment, a portion of these patients will experience a relapse. That means there were some leukemia cells hiding that we weren’t able to detect under the microscope. That is minimal residual disease, or perhaps a better term is measurable residual disease. Typically, these cells don’t cause any symptoms, but they have the potential to lead to a relapse.
If we can’t detect minimal residual disease under the microscope, how do we test for it?
We now have much more sensitive assays available to us that allow us to quantify MRD. These could include next generation genetic sequencing, where we can analyze bone marrow samples for genetic mutations. If there are mutations present, that means there is minimal residual disease, even though we can’t see anything under the microscope.
We can also use a technique called flow cytometry, which allows us look in the same samples for abnormal proteins on the surface of cells. By determining how many cells have abnormal proteins detected, we can get a better sense of residual cancer cells. Using these new assays, we routinely try to quantify whether a patient has MRD following standard treatment.
What are the implications for a patient who has evidence of minimal residual disease after treatment?
That’s difficult to say, because it’s not the same across all types of blood cancers. Some patients with MRD will have different responses than others. In general, if a patient has MRD, we need to do additional treatments to work toward the best outcome. If we do nothing, we know that the residual cells will cause a relapse.
It also depends on the timing of the MRD test. In my leukemia patients, if there is MRD after the first cycle of chemotherapy treatment, it tells me that I probably need to give more treatment — either a different medication or a different course of treatment. If there is still MRD after many rounds of chemotherapy, that is an indication that the patient may need to have a stem cell transplant, when otherwise it might not have been appropriate.
Ultimately, MRD is a marker that we need to be more aggressive in our treatment to try and prevent the cells from coming back.
What can cancer researchers learn from the residual cancer cells?
We can learn a great deal. These cancers can adapt to treatment, meaning the cancer we start with is not the same as what we have after treatment. By studying the minimal residual disease, we can learn more about what is left after treatment.
That helps us to do several things. First, it allows us to modify our treatment, either by adding medications that target specific vulnerabilities in the cancer cells, including medications that are especially good at killing even residual cells, or doing a stem cell transplant, which is able to take care of residual cells.
Currently, I work with a wonderful team through the MDS and AML Moon Shot to study these residual cancer cells in order to find new vulnerabilities. Through our research, we’re hoping to identify new treatments that we can use in the future to specifically eliminate minimal residual disease.
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