The Evolution of CLL Testing and Treatment Over the Past Decade

In the last decade, testing for and treatment of chronic lymphocytic leukemia (CLL) had undergone substantial changes with new testing that can personalize therapy and new agents that provide more clinical benefit.

A new paper in Cancer evaluated changes in real-world testing and treatment by comparing 1008 patients who were diagnosed with CLL in 2008 with 1367 patients diagnosed in 2014. The authors used data from the Surveillance, Epidemiology, and End Results Patterns of Care, which was sponsored by the National Cancer Institute.

The authors found that a greater proportion of patients with CLL were tested using fluorescence in situ hybridization (FISH) within 2 years of diagnosis in 2014 (44% in 2008 vs 51% in 2014). Immunoglobulin heavy-chain variable region gene (IgV_H) mutation analyses were performed infrequently in both periods (6% vs 11%), and bone marrow biopsies decreased (46% vs 39%) while lymph node biopsies increased significantly (5% vs 27%).

“To the best of our knowledge, the reasons for a lack of testing remain unclear, although we identified disparities in the likelihood of testing by insurance type and age, with older patients and those without private insurance less likely to have testing performed over time,” the authors wrote.

In 2014, FISH testing was more common in teaching hospitals compared with nonteaching hospitals, although testing increased across the board from 2008. These differences are important, the authors noted, since FISH testing is high-value and its cost would be waived under insurance plans that have value-based insurance design.

In both cohorts, the majority of patients with CLL were untreated in the first 2 years after diagnosis (74% in 2008 vs 71% in 2014). Of those who were treated within the first 2 years, fludarabine, cyclophosphamide, and rituximab (FCR) was most often used in 2008, but in 2014 bendamustine and rituximab was used most often.

Patients identified as having higher risk CLL were treated more frequently in both cohorts. In 2008, the majority of patients with del17p disease were treated with FCR and in 2014, the majority were treated with ibrutinib.

“Given the rapid therapeutic developments in CLL, we anticipate dynamic changes in its future treatment patterns, and possibly therapies emerging free from standard chemotherapy,” the authors concluded. “Fully evaluating the use of these therapies by practice type, and the access to these therapies among different patient populations, will be a vital focus of future studies.”

Reference

Seymour EK, Ruterbusch JJ, Beebe-Dimmer JL, Schiffer CA. Real‐world testing and treatment patterns in chronic lymphocytic leukemia: A SEER patterns of care analysis. [published online October 21, 2018]. Cancer. doi: 10.1002/cncr.31738.