CLL: A Heterogeneous Disease

Anthony Mato, MD, MSCE: Hello, and welcome to this OncLive® Insights program on treatment approaches to chronic lymphocytic leukemia [CLL]. My name is Dr Anthony Mato, I’m the director of the CLL program at Memorial Sloan Kettering Cancer Center [MSK]. I’m pleased to discuss how we approach patients with newly diagnosed CLL, along with my colleague Kristen Battiato, who is a nurse practitioner in the outpatient clinic. She works with me at MSK. Let’s get started. Kristen, we see so many patients with CLL together every time we have clinic. Of course, some patients present atypically, but there are patterns that we see. I was wondering if you could discuss how CLL patients typically present. What are the signs and symptoms? What’s the usual story where there’s some consensus about presentation?

Kristen Battiato, AGNP-C: We get an array of patients coming in. Some of them present with an incidental CBC [complete blood count] finding and lymphocytosis. They feel fine, and they’re shocked. Others present with significant fatigue that they’ve had for months and that’s just getting worse. New or increasing lymph nodes or lymphadenopathy that’s mildly becoming worrisome or bothersome. Sometimes they present with drenching night sweats, and they don’t know why. Sometimes they have symptoms of early satiety, unintentional weight loss, and frequent infections, and they don’t know why.

Anthony Mato, MD, MSCE: I would take you 1 step backward. Would you say that probably the most common presentation is a patient with no symptoms?

Kristen Battiato, AGNP-C: Yes, a lot of them are shocked by their diagnosis. They’re scared to hear the diagnosis of leukemia, and they have to come to terms with the diagnosis and the monitoring that it requires throughout their life.

Anthony Mato, MD, MSCE: What you were also touching on are the indications for starting therapy for patients. In your estimate, what proportion of patients do we just watch? What proportion of patients required treatment immediately vs maybe a delayed start?

Kristen Battiato, AGNP-C: The majority of patients don’t require therapy immediately; they’re on watch and wait. It depends. We got a broad spectrum of patients because we have a lot of clinical trials. We draw from all over the country, where people are interested in clinical trials. But the patients who are newly diagnosed can remain in observation, and about a third of them will remain in observation for their entire life. They won’t require treatment because they have indolent disease.

Anthony Mato, MD, MSCE: A third will be treated immediately and a third somewhere down the line, 5 to 7 years later. It’s mixed. In terms of the presentation—the symptoms and severity of the symptoms—of all the leukemia, this might be the most heterogeneous 1 in its presentation because we see very sick patients all the way to patients who might not have ever known they had this disease if not for routine CBC testing performed by their primary care physician.