Treating asymptomatic early-stage CLL does not improve survival, so an initial ‘watch and wait’ approach is recommended. Disease-directed therapy should not start unless there are disease-related symptoms or evidence of disease progression.

Establish intent of treatment

• Curative
• Anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
• Symptom palliation

Systemic therapy has established curative potential for the subset of patients with favourable biologic features (IGVH mutated status and no TP53 dysfunction), and can be considered in younger, fit patients with adequate renal function.

In patients with significant comorbidities or impaired organ function, less intensive chemoimmunotherapy is also available. These treatments can be life-prolonging but do not have curative potential. Note due to poor efficacy, chemotherapy is not recommended for patients with TP53 mutation or del(17p).

Allogeneic bone marrow transplant can cure patients with CLL but is rarely indicated.

Targeted therapies and immunotherapy are the preferred treatment approach in all patients with TP53 mutation or del(17p) and can be considered in other patient subgroups.

Radiation therapy can be used to treat obstructive/bulky nodes or massive enlargement of the spleen causing symptoms, or to reduce symptoms during palliative treatment.

Palliative care

Early referral to palliative care can improve quality of life and in some cases survival. Referral should be based on need, not prognosis. For more information, visit the Palliative Care Australia website.

Communication

The lead clinician and team’s responsibilities include:

• discussing treatment options with the patient and/or carer including the intent of treatment as well as risks and benefits
• discussing advance care planning with the patient and/or carer where appropriate communicating the treatment plan to the patient’s GP.

Checklist

• Intent, risk and benefits of treatment discussed with the patient and/or carer
• Treatment plan discussed with the patient and/or carer and provided to GP
• Supportive care needs assessed and referrals to allied health services actioned as required
• Early referral to palliative care considered and advance care planning discussed with the patient and/or carer

Timeframe

Systemic therapy treatment is rarely urgent. Timing should be discussed to align with the patient’s preferences but not delayed to the point where impaired performance status, compromised organ function or recurrent severe infections occur.

Radiation therapy should start within 72 hours where organ preservation is the goal. For symptomatic/palliative goals, timing is guided by the severity of the relevant symptoms but is rarely urgent and can start within 2 weeks in most cases.