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Treatment of Chronic Lymphocytic Leukemia

Background

Currently, many doctors will recommend that prognostic parameters are surveyed before starting treatment. Some will emphasize these results in choosing treatment, but at present it is unknown whether a risk-adapted treatment strategy is advantageous.

An exception for this may be if del17p exists at the start of treatment. Because these patients are often chemo-refractory, there may be reason to consider alemtuzumab (anti CD52 antibody) as primary treatment. It has not been shown by clinical studies that such an approach to primary treatment provides a gain in survival time.

Chlorambucil monotherapy, fludarabine monotherapy, and fludarabine/cyclophosphamide combination treatment are alternative first line treatments.  

 

Treatment responses to treatment alternatives
Treatment  Complete response Partial response No response/progression
Chlorambucil  8 % 64 % 28 %
Fludarabine 15 % 66 % 19 %
Fludarabine/
cyclophosphamide
39 % 55 %  6 %
Fludarabine/
cyclophosphamide/
rituximab
52 % 43 %  5 %

 

It appears that combination treatment is the most effective as it leads to more responses, more complete responses, and longer disease-free survival than the two other treatment alternatives. However, the total survival is the same for all four treatment alternatives. This is because second line treatment and possible later treatment are also successful, especially in those primarily treated with chlorambucil.

Corticosteroids have traditionally been used in combination with alkylating chemotherapy drugs, such as chlorambucil, for chronic lymphocytic leukemia and other lympho-proliferative diseases. Corticosteroids in addition to chlorambucil do not give a higher response rate, longer remission time, or longer progression-free survival than chlorambucil alone. 

Corticosteroids are not appropriate for treatment of chronic lympocytic leukemia unless there is a special indication for it. Prednisone/prednisolone is indicated for autoimmune hemolytic anemia and immune-mediated thrombocytopenia. It has also been common to initially recommend corticosteroids for treatment of patients with significant anemia, thrombocytopenia, or granulocytopenia, as a result of bone marrow failure (1 mg/kg/day for 2–3 weeks before starting chemotherapy). However, this treatment is not well documented.

Allogeneic stem cell transplant

An allogeneic stem cell transplantation may be a treatment alternative for younger patients, especially patients who are refractory to conventional treatment. The benefits of an allogeneic stem cell transplantation for acute lymphocytic leukemia are not yet clear.

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