If you need to start treatment and your general health is good your healthcare team will probably suggest you are given anti-leukaemia drugs (chemotherapy). Drugs called monoclonal antibodies are usually given as well; these are artificial antibodies which can bind to and kill specific cells. Treatment using a combination of chemotherapy drugs and antibodies is called chemo-immunotherapy.
FCR: Fludarabine, cyclophosphamide and rituximab
If you’re fit and have no other medical problems, and you do not have certain genetic characteristics known as 17p deletion or TP53 mutation, then you’re most likely to be treated with FCR – a combination of chemotherapy (cell-killing) drugs and monoclonal antibodies. FCR is given in treatment ‘cycles’.
Each cycle is 28 days long, and you’ll normally have treatment each day for five days and then have a break of 23 days with no treatment. This is repeated up to six times – each period of treatment and rest is called a cycle.
Fludarabine and cyclophosphamide are tablets that you take by mouth (orally). Rituximab is given as a drip or injection into a vein in one of a number of areas – you might hear the terms ‘infusion’, ‘intravenously’, or IV’.
This monoclonal antibody isn’t usually given anymore as it’s now an unlicensed drug and only available through a compassionate access programme. However, it may be used if your cytogenetic blood tests show that fludarabine isn’t likely to work for you.
Alemtuzumab is usually given alone, again in cycles; your healthcare team will tell you exact timings. It’s usually given as an injection just beneath the skin (subcutaneous). You might be given steroids at the same time.
FCR is not suitable for everyone. If you’re older or have other medical conditions, and have CLL requiring treatment, you may be treated with the chemotherapy drug bendamustine. Bendamustine is given as an infusion on the first two days of a four week cycle, for up to six cycles.
Chlorambucil (usually given with obinutuzumab or ofatumumab)
If other treatments aren’t suitable for you, you might be offered chemotherapy with a drug called chlorambucil, combined with the monoclonal antibodies obinutuzumab or ofatumumab. Chlorambucil is given as tablets you take by mouth (orally). Obinutuzumab and ofatumumab are given as infusions and your healthcare team will tell you how many courses you’ll have, and when.
In some cases you may be offered treatment with the monoclonal antibody rituximab alongside chemotherapy drugs. Rituximab is usually given as an infusion.
If you have certain genetic characteristics known as a 17p deletion or TP53 mutation then you will normally be offered treatment with ibrutinib. This is a targeted drug that blocks signals within cells that are important for their survival. You may be offered ibrutinib as a first treatment if other treatments aren’t suitable for you. You take ibrutinib as capsules once a day.
Ibrutinib can also be used as a second treatment if your first treatment hasn’t worked or the CLL has returned after a previous response.
Idelalisib and rituximab
If you have certain genetic characteristics known as a 17p deletion or TP53 mutation and ibrutinib isn’t suitable for you, you may have treatment with idelalisib and rituximab.
Idelalisib blocks some of the proteins inside cancerous blood cells that encourage the cancer to grow. It can also be used to treat some people whose leukaemia has not responded to other treatments.
Recent research has shown that you may be at greater risk of serious and fatal infections if you’re treated with idelalisib. To manage these risks, you will be given antibiotics throughout your treatment as protection (which is referred to as prophylaxis). All drug treatments carry some risk. Your healthcare team will weigh the risks carefully against the benefits when deciding which treatment to offer you.
Venetoclax is a targeted drug which blocks the growth of CLL cells and promotes cell death. In England, Wales and Northern Ireland, venetoclax is used in combination with rituximab for people whose first treatment hasn’t worked, or their CLL has progressed and requires treatment following successful initial treatment. In Scotland, the SMC is currently considering whether to approve the use of venetoclax in combination with rituximab.
Most people with CLL don’t have radiotherapy, but if your spleen is swollen and uncomfortable, local radiation treatment to shrink it might be helpful.
On very rare occasions patients might have an operation to remove their spleen (a splenectomy). You might then get more infections, but your healthcare team will give you advice on how to decrease the chances of this happening. This might include long-term antibiotic treatment.
Stem cell transplant
A stem cell transplant is what used to be called a bone marrow transplant. It aims to give patients healthy stem cells, which then produce normal blood cells.
It isn’t a suitable treatment for most CLL patients. This is because the risks of a transplant aren’t justified for patients with a slowly developing disease like CLL. For some patients – especially those whose disease is progressing more quickly – a transplant may provide a cure, but the risks of a transplant need to be carefully weighed against the potential of a cure.
People with CLL who need a stem cell transplant will be offered one that uses stem cells from a healthy donor (an allogeneic/allograft transplant).
Stem cell transplants using your own cells (autologous/autograft) are no longer used to treat people with CLL as they do not successfully stop the CLL from coming back.
For more information on stem cell transplants download or order our booklet The seven steps: blood stem cell and bone marrow transplants