Overview of Chronic Lymphocytic Leukemia (CLL)

Zahra Mahmoudjafari, PharmD, BCOP, DPLA, opens a discussion surrounding chronic lymphocytic leukemia (CLL).

Zahra Mahmoudjafari, PharmD, BCOP, DPLA: CLL [chronic lymphocytic leukemia] is 1 of the most common leukemias in Western countries. Patients can be completely asymptomatic, or they can present with fatigue, recurrent infections, weight loss, bleeding, or bruising. It can be more of an incidental finding when a patient comes in for labs and is found to be cytopenic. Some common characteristics of lab work include a significant number of abnormal lymphocytes that are found circulating in the blood, in addition to being found in the bone marrow and lymphoid tissues. The exact cause is unknown. Risk factors include increased age, exposure to chemicals such as pesticides or radon, family history, and male sex. This tends to be more common in White individuals. It’s mostly diagnosed in older patients with a median age of 72 at diagnosis. Because of this, comorbidities are frequently present. We’ve found that the presence of multiple comorbidities is an independent predictor of clinical outcomes independent of the patient’s age or disease stage.

About 20,000 patients will be diagnosed with CLL, and it accounts for about 1% of new cases overall. Thankfully, the 5-year overall survival of CLL is estimated to be in the upper-80th percentile.

Quality of life is critically important for all patients, but even more so for patients with CLL because they typically have a lot of other comorbidities. A survey of nearly 1500 patients with CLL measured reports of fatigue and overall quality of life. The physical, social, family, functional, and quality-of-life scores of patients with CLL were similar to or better than the general population. However, their emotional well-being scores were significantly lower than those of the general population and patients with other types of cancer. Quality-of-life scores were lower among individuals with advanced-stage disease, and the factors that were associated with a lower overall quality of life include older age, greater fatigue, the severity of comorbid health conditions, and recurrent treatment. CLL has a profound impact on the quality of life at all disease stages.

I always like to also look at the economic impact. A second study took a bit of a different approach and investigated the economic burden on quality of life in patients with CLL. This study found that the annual direct cost per person ranged from approximately $4,400 in Germany to $43,000 in the United States. The share costs attributable to treatment varied between 26.2% and 79%. Indirect costs amounted to a little over $4000 as well. This study also found that the severity of disease was also an independent predictor for quality of life.

More recently, a third study sought to quantify the health-related quality of life and economic burden of CLL, with a meta-analysis of 12 studies. Patients with CLL reported impairment in various quality-of-life domains compared with healthy controls, including fatigue, anxiety, physical functioning, social functioning, depression, sleep disturbance, and pain interference. The key factors associated with the negative impact on this health care–related quality-of-life burden for patients with CLL include female sex, increased disease severity, and the initiation of multiple lines of therapy. What was interesting about this meta-analysis is that in regard to the economic burden, the main cost drivers related to CLL were outpatient and hospitalization-related costs, primarily as a result of chemotherapy and chemoimmunotherapy.

Also, there are significant adverse events related to treatment and disease progression. The treatment with the targeted agents ibrutinib and venetoclax was associated with lower medical costs than chemoimmunotherapy. However, ibrutinib was associated with some increased adverse events costs related to cardiac toxicities. What’s interesting is that cost studies of targeted agents were limited by our short follow-up times that did not capture the full scope of treatment costs. We can definitely say that CLL can significantly impact a patient’s quality of life.

Transcript edited for clarity.

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