A team of health professionals decides if you need treatment straight away. They also decide what treatment options you have.
The most common treatments for chronic lymphocytic leukaemia (CLL) are:
- targeted cancer drugs
Deciding which treatment you need
A team of doctors, and other professionals discuss the best treatment and care for you. They are the multidisciplinary team (MDT). Your MDT might include:
- a haematologist - a doctor specialising in blood cancers
- a haemato-pathologist – a doctor who examines bone marrow or lymph node biopsies
- a radiologist – a doctor specialising in reporting x-rays and scans
- a specialist haematology nurse – also called a clinical nurse specialist (CNS)
- a palliative care doctor - a doctor specialising in controlling cancer symptoms
You may not need treatment straight away. Your team decides whether you need treatment depending on your:
- stage of CLL
Everybody who has CLL should have the diagnosis confirmed by a specialist at the hospital. But in some cases, the GP will lead the care of your CLL. This might be the case if, for example, you are diagnosed during a routine blood test for something else.
If you need treatment, your team plans it depending on:
- whether there is a change (mutation) in the TP53 gene
- your general health and level of fitness
- personal wishes
Your doctor will talk to you about your treatment options. They will discuss the benefits and the possible side effects with you.
The main treatments
You are likely to have a targeted cancer drug. You might have this on its own or combined with chemotherapy.
The main aim of treatment is to control your cancer and get you into remission. Remission means there's no sign of active leukaemia in your body. And you don’t have any symptoms. You may then have a period where you do not need any treatment. This remission can last for years.
Targeted cancer drugs
Targeted cancer drugs can change the way that cells work and help the body control the growth of cancer. There are different types for CLL. The 2 main types are:
- Bruton Tyrosine Kinase Inhibitors (BTKi), such as ibrutinib and acalabrutinib
- B-cell lymphoma inhibitors (Bcl2) such as venetoclax
Some targeted drugs are also a type of immunotherapy. These are called monoclonal antibodies (MABs). Rituximab and obinutuzumab are examples of MABS for CLL. When you have these drugs with chemotherapy, this is called chemoimmunotherapy
Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate throughout the body in your bloodstream. Fludarabine, cyclophosphamide, bendamustine and chlorambucil are examples of chemotherapy drugs for CLL.
You usually have chemotherapy combined with targeted cancer drugs.
There are several stages of treatment for CLL. These are:
- watch and wait
- first line treatment
- treatment when CLL comes back
Watch and wait
Your doctor might decide not to give treatment if you don't have any symptoms and your CLL is at an early stage. Instead, they keep a close eye on you. You might hear this called watch and wait.
Your doctor chooses to do this because you have no symptoms bothering you and your CLL can be very slow growing. At the moment there isn’t any evidence to show that treatment helps people in this situation.
Your GP or haematologist will keep a close eye on you and check your blood cell count. They are looking for any changes in your CLL. You start treatment if your CLL gets worse or you develop symptoms.
It can be difficult to cope with not having treatment especially when you have been told you have leukaemia.
First line treatment
This is your first treatment. Your doctor might offer you treatment if you have symptoms, or if your CLL is at a more advanced stage.
The treatment may get your CLL under control (in remission). You may then have a period where you do not need any treatment. This remission can last for years.
The treatment you have depends on whether your CLL has a change (mutation) in the TP53 gene.
If your CLL doesn’t have a change (mutation) in the TP53 gene
You might have:
- a targeted drug on its own, such as acalabrutinib
- venetoclax and obinutuzumab
- chemotherapy with a type of targeted immunotherapy drug (this is called chemoimmunotherapy)
Some of the common chemoimmunotherapy combinations include:
- fludarabine, cyclophosphamide and rituximab (FCR)
- bendamustine and rituximab (BR)
- chlorambucil and obinutuzumab (CO)
You might not be fit enough to have these combination treatments. If this is the case, you can have chlorambucil chemotherapy tablets on their own, or steroids. You can take these at home.
If your CLL has a change (mutation) in the TP53 gene
You don’t have chemotherapy. You usually have treatment with targeted cancer drugs such as:
- venetoclax and obinutuzumab
- idelalisib and rituximab
Treatment when CLL comes back
CLL tends to come back after a period of time. This is called a relapse. You might need more treatment if this happens. But some people don’t need treatment straight away. The next lot of treatment you have is called second line treatment.
Many people with CLL can have further remissions with more treatment. The remissions tend to get shorter, the more treatment you have.
Your doctors consider many factors when deciding about your treatment. There are lots of different options for second line treatment. These include:
- venetoclax on its own, or with rituximab
- idelalisib and rituximab
Other treatments you might have for CLL include:
- stem cell transplant
- supportive treatments such as antibiotics, blood products or steroids
Your doctor might ask if you’d like to take part in a clinical trial. Doctors and researchers do trials to make existing treatments better. And to develop new treatments.