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What You Need to Know – Mayo "Best Practices"

March 18, 2024

We have just published a new article on Topics titled "What You and Your Oncologist Need To Know About CLL". It reviews an important new article from researchers at Mayo Clinic, Rochester, spelling out the modern "best practices" they follow in the treatment of CLL patients. Below is a bullet point list of their best practices. I think it is very important for all of us to be aware of these best practices, so that if our local oncologists do not follow these guidelines, we can ask why not? Here is the full-text original Mayo Clinic article in printable pdf form, Mayo Best Practices.

Chaya Venkat
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Digest

Modern "Best Practices" Standard of Care for CLL

The authors identify several important standards of care that are routinely followed at Mayo Clinic - as patients we can only hope that Mayo's venerable reputation will do something to get these best practices accepted at the community oncologist level in the near future. (I would not count on it, not if my idea of "near future" concerns my own healthcare.) I have summarized and reduced the Mayo approach to the following bullet points:

1. Confirm CLL diagnosis, rule out close relatives like Hairy cell, Mantle cell, etc., by detailed flow cytometry, FISH (identifies mantle cell) and review of morphology by expert pathologist.
2. Clinical work up, including staging, evaluation of symptoms.
3. CBC, CLL FISH panel, CD38 by flow cytometry, B2M.
4. Repeat CBC at defined intervals, to get a fix on lymphocyte doubling time.
5. Bone marrow biopsy is optional, but recommended prior to initiation of therapy.
6. Risk-adapted therapy, particularly for high risk patients, as defined by modern prognostic markers.

• Exclude an infectious cause of fevers, chills, night sweats, or rapid increase in ALC prior to initiating chemotherapy for these symptoms.
• Exclude autoimmune cytopenias (hemolytic anemia, ITP, pure red cell aplasia) prior to initiating chemotherapy to treat cytopenias since autoimmune phenomena may respond less toxic treatment approaches.

7. Since CLL patients have high risk of auto immune hemolytic anemia (AIHA), and this risk is increased by fludarabine therapy, it is important to do a Coombs test for autoimmune antibodies prior to fludarabine therapy, and to avoid it altogether in patients who are have positive Coombs test results.
8. Pre-emptive treatment with medications to protect against opportunistic infections such as pneumonia, herpes, etc., prior to fludarabine therapy. Neutropenia and general susceptibility to infection is quite common after fludarabine therapy. Painful attacks of shingles are quite common.
9. Referral of younger patients with high risk CLL to bone marrow transplant experts, to explore this option.
10. Annual vaccination against the flu, and against pneumonia every five years, starting at the date of diagnosis.
11. Consider CMV infection as a potential cause of fevers in all patients with CLL. Blood test are available to identify CMV infection and oral antiviral medications can effectively treat this infection.
12. Treatment of hypogammaglobulinemia ( too low levels of gamma globulins) with immunoglobin intravenous infusions, at 0.3g/kg at regular intervals.
13. Since CLL patients are much more likely to get aggressive skin cancers, patient counseling about sun protection and regular skin examination is important.
14. Over and beyond skin cancers, CLL patients are three times as likely to get other secondary cancers. Regular screenings (mammograms, colonoscopy, prostate specific antigen testing) are very important.
15. 5% - 8% of CLL patients have their disease transform to a more aggressive diffuse, large b-cell lymphoma (called "Richter transformation"). Richter transformation requires aggressive therapy, implemented quickly. The healthcare provider must be aware of the symptoms of Richter transformation (rapid LDT, massive lymph nodes, rapid onset of b-symptoms, increased lactate dehydrogenase, etc.) and keep an eye out for it.

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