Use of comorbidities to determine CLL patient fitness

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Published: 30 Mar 2011
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Dr Francesc Bosch - Hospital Vall d'Hebron, Barcelona, Spain

Dr Francesc Bosch discusses the importance of looking at comorbidities rather than age when deciding upon treatment for elderly chronic lymphocytic leukaemia (CLL) patients. There is currently no standardised way of assessing comorbidities but physicians should use these factors as opposed to the patient age to identify fit older patients who are suitable for more intensive treatments. Dr Bosch identifies FCR (fludarabine cyclophosphamide rituximab) as the best available treatment for CLL, explains what would make a patient unsuitable for this treatment and outlines promising initial results that suggest maintenance therapy with monoclonal antibodies or lenalidomide may be an effective way of improving patient outcome further still.

Blood Cancer in the Elderly: European Expert Forum, Rome, 19—20 March 2011

Dr Francesc Bosch (Hospital Vall d'Hebron, Barcelona, Spain)

Use of comorbidities to determine CLL patient fitness

More now from the Blood Cancer in the Elderly meeting here in Rome and the important issue of chronic lymphocytic leukaemia. Francesc Bosh, you are working very intensively on chronic lymphocytic leukaemia, and I know that you think that elderly patients are important and need to be defined in various ways. Comorbidities is one thing you’ve highlighted, what are you saying about comorbidity?

So far, comorbidities have not been assessed properly in CLL so patients have been treated according to the age of the patient but comorbidities are not a tool usually used for decision of treatment or to guide the physician in CLL.

Do you have any ideas that you could suggest to doctors for how clinicians could, in fact, assess comorbidity and then change their approach?

The important point is to think of the general status and comorbid situation of the patient instead of the age. So physicians have to analyse which kind of comorbidities has the patient; if he has no comorbidities the patients are candidates for intensive treatments. Otherwise, patients are candidates for less intensive or less toxic treatments, according to the comorbidities.

So in practical terms what might happen? For instance, there’s a typical patient comes to see you, how do you go about your job?

So I’m asking for hypertension, I’m looking at the renal function of the patient. Of course I’m looking at the general status – if the patient is fit, if he has a normal life, if somebody is taking care of him or her, and surmising all those data and making a decision if the patient is a candidate or not for the best treatment that we have now. So I’m not considering the age by itself, I’m considering all the comorbid states that the patient has.

So is age a factor at all?

We are treating intensively patients that are really old but we have to consider and we have to teach physicians that most of the patients that were not candidates until now for intensive treatments should be reconsidered for that.

So what sorts of treatment are you now recommending for fit elderly patients?

For fit, really fit, elderly patients considering that they have normal renal function, the most important treatment now and the gold standard for treatment is the combination of rituximab, fludarabine, cyclophosphamide. This combination is giving the best results so far in the history of CLL. We know that this treatment is improving survival in the patients so that’s the gold standard for fit patients, even if they are elderly.

So you are quite bullish about using intense treatments like FCR, how do you know when FCR is not suitable for an elderly patient?

The most important consideration for FCR is the renal function. So fludarabine is metabolised in the kidney, so if the patient has an impaired renal function then the toxicity is high for this treatment. So we have to consider, the first thing is the renal function. Other things are lung infections or hepatitis or other comorbidities that are infrequent, but the most important issue for FCR is the renal function, even in young patients of course.

I know you are personally working on maintenance with a number of agents, how much can maintenance therapy help the ultimate outcome of the patient?

There are no randomised studies so far to know whether maintenance is increasing the duration of the response but from phase II studies we know that the disease progression is prolonged with extent when the patient is receiving maintenance. But these are preliminary data.

And maintenance with what might be candidates?

There are two groups of drugs: first monoclonal antibodies. Monoclonal antibodies have been proved useful in follicular lymphoma and other lymphomas related to CLL so probably monoclonal antibodies will be useful in CLL. And lenalidomide – lenalidomide is an immunomodulator that is improving the immunological response of the patient and this is helping to control the disease.

Is it possible that some of these directed therapies could be more gentle and could extend the scope for treating older patients?

Of course. These two therapies are not cytotoxic therapies, they are two therapies directed to the tumour cell so they can be applied even in elderly or comorbid patients.

Meanwhile there’s a lack of data because many older patients have not been included in the past in randomised trials. What would you say, finally, is your advice to practising clinicians about how to manage their patients with CLL when the patients are older?

First try to include patients in clinical trials that are considering old patients. This is going to give us answers to those questions related to the age. The second: change your mind on the treatment you can apply to old patients. I think this is an important message because CLL has been treated for general practitioners, general haematologists, just with chlorambucil and those patients were not considered for more intensive treatments. So we need general physicians to change their mind for the treatment of those patients.

Francesc, it’s very good to have you here on Thank you for joining us.

Thank you.