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Alert Number 196

Management of Early Stage, Newly Diagnosed Patients

Date: September 19, 2006

A while ago I suggested that the mechanism of “Continuing Medical Education” (CME) for local oncologists is changing in our Internet generation.  More often than not, busy local oncologists do not have the time to keep track of all the new stuff coming down from expert centers. The learning process is happening from the bottom up, with well informed patients bringing information relevant to their situation to the attention of their doctors. Frankly, it is very much in your self-interest to make sure your local guy is up the learning curve. If in the process of doing this you also help the next patient who walks in the door and finds a better informed doctor, that is all for the good of our patient community.

This is no longer considered chutzpah; it seems even the experts are beginning to recognize this new mechanism for getting the word out. I now get full text copies of the articles as soon as they are published, often from the authors themselves. Some times they even ask that we review it on our website!

If you are newly diagnosed CLL patient, here is a “Best Practices” article that you and your oncologist should read. The authors are the team at Mayo Clinic (MN) and Dr. John Byrd of Ohio State. That is about as blue-blooded pedigree as you can wish for. The abstract of the article is below. Please do write to us if you wish to read the full text of the article.

Here are some relevant links on our website, if you wish to read more about the issues covered in this article. 

What type of CLL do you have?;
How and Where to Get Prognostic Testing Done;
Are We There Yet?;
FC versus F;
Fludarabine Monotherapy Is No Longer the Gold Standard;
FCR versus PCR;
Shopping For Therapies;
Need To Know (Mayo Best Practices).

Be well,



Initial Management of Newly Diagnosed, Early-Stage Chronic Lymphocytic Leukemia

Tait D. Shanafelt, MD1; John C. Byrd, MD2; Timothy G. Call, MD1; Clive S. Zent, MD1; and Neil E. Kay, MD1

1. Mayo Clinic, Rochester, MN; 2. Ohio State University, Columbus, OH

Chronic lymphocytic leukemia is one of the most common malignant lymphoid diseases in the western world and is frequently diagnosed by internists. There have been clinically significant changes in method of diagnosis, prognostic tools, supportive care, and treatment over the past 2 decades. Most patients with chronic lymphocytic leukemia now have Rai stage 0 or I disease at diagnosis. Patients with early-stage disease are a heterogeneous group: Approximately 30% to 50% will have accelerated disease progression, and the remainder may live for decades and possibly never require therapy.

Recent insights into the biological characteristics of leukemic B cells have led to the discovery of new prognostic tools (immunoglobulin variable-region heavy chain gene mutation status, cytogenetic abnormalities assessed by fluorescent in situ hybridization, and Z-chain–associated protein kinase-70 protein expression) that can identify patients with early-stage disease who are at high risk for early disease progression. These tools allow physicians to individualize counseling, follow-up, and management on the basis of disease risk.

In addition, new treatments developed over the past 2 decades (purine nucleoside analogues, monoclonal antibodies, and combination chemoimmunotherapy regimens) have dramatically improved response rates and appear to prolong survival. In this review, the authors discuss the current work-up of lymphocytosis and highlight how to use recently identified prognostic tools to stratify risk in patients with newly diagnosed, early-stage chronic lymphocytic leukemia. Recommendations for patient counseling, follow-up, supportive care, and initial treatment are presented for each risk category.

Ann Intern Med. 2006;145:435-447.

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