H e m a t o lo g y E d u c a t io n - European Hematology Association

Table 2. Treatment recommendation for patients with reduced physical fitness (SLOW GO).
Binet Stage Prognostic factors First line treatment
A, asymptomatic B not relevant None, except in clinical trials
C, symptomatic B
Early PD (< 1–2 years) = refractory disease
Supportive care and quality of life
all, except 17p- CLB
Treatment strategies in elderly CLL patients should
rather aim for symptom control than for induction of
high complete remission rates. Therefore, besides supportive
care, improvement of health-related quality of
life should play an important role in this group of
patients. However, so far only a minority of clinical trials
evaluated health-related quality of life in elderly CLL
patients.
One of the major problems in the treatment of elderly
patients is the impaired capacity of bone marrow recovery.
The role of hematopoietic growth factor administration
in patients with CLL is not clear, because data
from randomized trials are missing. In patients with
solid tumors erythropoietin (ESP), administration may
have a negative impact on survival. 64,65 Therefore,
hematopoietic growth factors (G-CSFs, ESPs) should be
used only in accordance with the current guidelines in
CLL patients. 66,67
Another problem in the elderly is an increased rate of
impaired renal function, which can be frequently detected
also in patients with normal serum creatinine, when
the creatinine clearance is calculated according to the
Cockcroft formula. 68 Tumor lysis syndrome was an
uncommon complication in CLL so far. 69 However, with
the introduction of more effective chemoimmunotherapy
regimens, tumor lysis syndrome might become more
frequent, especially in those patients with an impaired
renal function. Along with hydration and urinary alkalinization,
allopurinol should be used in the elderly to
accompany chemotherapy. The administration of rasburicase
in patients with high uric acid serum levels
might be indicated. 70
Though larger studies are pending so far, health-related
quality of life is a major issue in the elderly. Possible
changes of quality of life should be considered before
treatment initiation. On the one hand, quality of life
decreases very fast in elderly patients as soon as they
become more symptomatic. 71,72 On the other hand,
health-related quality of life might decrease due to the
toxicities of chemotherapeutic regimen. Moreover, socio -
demographic factors, such as marital status or employment
play a major role for quality of life. 73 Therefore, the
treatment decisions in elderly are carefully to be made in
each patient individually considering also the patients’
physical condition and his social environment.
Conclusion
London, United Kingdom, June 9-12, 2011
17p- No standard; try alemtuzumab (plus steroids); clinical trials
Prognosis Second line treatment
all, except 17p- No standard; try dose reduced FC or FCR, BR, PCR
17p- Alemtuzumab; within clinical trials: lenalidomide
Late PD (> 1 -2 years) all repeat first line
PD = progressive disease, CLB = chlorambucil, F = fludarabine, C = cyclophosphamide, R = rituximab, P = pentostatin, B = bendamustine.
Treatment decisions in elderly CLL patients need special
consideration due to the fact that aggressive treatment
regimens are mostly poor tolerated in this group
of patients. On the other hand, treatment strategies in
the elderly focus rather on symptom control than on the
induction of high complete remission rates. Due to the
relevance of the burden of comorbidity in cancer
patients, it appears reasonable to distinguish rather
between physically fit and non-fit patients for treatment
decisions than between old and young patients (Figure
1). By using tools as the CIRS score three different
patient groups can be distinguished:
1.Medically fit patients with no or mild co-morbidity
and a normal life expectancy. These patients should
be treated intensively with chemoimmunotherapy,
irrespectively of their chronological age (principle of
action: ‘GO GO’). However, whenever possible, treatment
of such patients should be performed in the context
of a clinical trial.
2.Medically less-fit patients with multiple or severe
comorbidities and an unknown life expectancy.
Practitioners should try to enroll such patients in a
clinical trial designed for comorbid CLL patients.
Outside clinical trials, the treatment should be carefully
adapted to the comorbidity burden and a higher
risk of both toxicity and disease progression must be
kept in mind (principle of action: ‘SLOW GO’).
3.Medically frail patients with fatal comorbidities and a
very short life expectancy. These patients will not
benefit from any CLL treatment and therefore should
not receive any chemotherapeutic drugs (principle of
action: ‘NO GO’).
For the elderly or ‘SLOW GO’ group of patients, chlorambucil
still remains the standard treatment of choice,
until randomized settings have shown that chlorambucil
plus antibody is significantly more effective (Table 2).
Within clinical trials, purine analogue-based regimens
Hematology Education: the education programme for the annual congress of the European Hematology Association | 2011; 5(1) | 109 |