VIDEO: Challenges in CLL management

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I think the first challenge comes to deciding who does and doesn't need treatment. Even with our newer treatments, there's no study that has shown starting treatment early in somebody that feels fine and doesn't meet any of the iwCLL criteria, that that ultimately improves their lifespan to start treatment on them early. They've actually just reported a study where they did that in higher risk patients that were asymptomatic by iwCLL criteria, and gave them ibrutinib or placebo, still no difference in survival after many years of following these patients.

So I'd say the first challenge is deciding who does and doesn't need treatment, and it's not always clear, because once you move away from the anemia or thrombocytopenia, which are objective and kind of black and white in terms of are they anemic, do they have low platelets, yes or no? Really, all the other indications for treatment prior to iwCLL criteria are subjective. It's a conversation that can be quite complicated that you have with your CLL patient. You know, I know your lymph nodes are enlarged, are they enlarged enough that they are causing you pain? And if so, is that pain or discomfort, is that enough that you want me to start treatment to shrink those? I know you're having night sweats, are the night sweats frequent enough? They're really interfering with your quality of sleep, and therefore your quality of life, and you want me to start treatment to make those go away? So that's just a couple of examples of some subjective discussions you have to have with patients, and really, it's them guiding, ultimately in those scenarios, whether they feel their issues they're having are enough to dictate needing to start treatment.

The challenges, you know, once you move into treatment, would be managing toxicities and navigating those. I would say sometimes it can be cost of care. These are medicines that are, the pills anyway, are coming from the specialty pharmacy and there's copays associated with that. Luckily, we've had a lot of success with copay assistance programs, but not everyone has had universal success with that. And there's certain qualifications that have to be met to be eligible for those. So that can be a challenge, too. I would say maybe for the indefinite treatments, you know, compliance and keeping patients on treatment as intended can be challenging, as well.