Establishing a Background on Chronic Lymphocytic Leukemia
Expert panelists Troy Trygstad, PharmD, MBA, PhD; Michael Reff, RPh, MBA; Christina Patterson, PA-C; and Kirollos Hanna, PharmD, BCPS, BCOP, provide a background on chronic lymphocytic leukemia with regard to presentation and patient demographics.
Troy Trygstad, PharmD, MBA, PhD: Hello, and thank you for joining us today. There has been a shift in cancer treatment from traditional chemotherapy toward targeted immunotherapy. While this may provide improved long-term outcomes and improved quality of life for patients, there is a medical-expense aspect that needs to be examined. In this Specialty Pharmacy Times® Peer Exchange
discussion, I am joined by a panel of experts who will highlight the challenges and provide practical approaches to the accessibility of oral oncolytics for patients with chronic lymphocytic leukemia.
I am Dr. Troy Trygstad, the vice president of pharmacy programs at Community Care of North Carolina in Raleigh, North Carolina. Participating on today’s distinguished panel are Michael Reff, a pharmacist and the executive director of NCODA, which is the National Community Oncology Dispensing Association in Cazenovia, New York; Christina Patterson, a physician assistant at Cancer Care Associates of York in York County, Pennsylvania; and finally, Kirollos Hanna, an assistant professor of pharmacy at the Mayo Clinic College of Medicine and Science and a hematology and oncology clinical pharmacist at the University of Minnesota Medical Center, which is in Minneapolis, Minnesota, and at Mayo Clinic. I look forward to a great discussion. Let’s begin. So let’s start with an overview of chronic lymphocytic leukemia. Christina, CLL, tell us about that condition.
Christina Patterson, PA-C: Chronic lymphocytic leukemia is a chronic condition usually of the older age group. This is something that they usually present as asymptomatic with, typically found during labs. They may have an anemia or high white blood cell counts, and their primary care provider refers them to our office. Sometimes the patients may also have B symptoms, what we call fever, chills, night sweats, weight loss, and those kinds of symptoms.
Troy Trygstad, PharmD, MBA, PhD: And so as the typical patient, maybe I go to my primary care provider. I’m doing scheduled lab work, I’ve got some symptoms. I get those results back as a primary care provider and say, “This is a little bit off. I’m going to send you to somebody who’s going to further look into this.” That’s the typical presentation and movement toward specialty care.
Christina Patterson, PA-C: Yes. Often, Troy, a patient will be referred to an oncologist to evaluate the lab tests, a hematologist-oncologist.
Troy Trygstad, PharmD, MBA, PhD: So you’re a physician assistant, and you’ve got this interesting dual role in which you work in the exam room, but you’re also responsible for the medication services within the practice. In that exam room, that patient walks in and says, “I just left my primary care office. I’m here now.” What’s the typical presentation?
Christina Patterson, PA-C: Typically, when they come in, they’ve had labs for maybe several years that you can look back to and see that that white count has been slowly trending upward. So a normal white count is between 4000 and 11,000, and now suddenly you’re seeing it grow over the years from maybe 11,000 to 20,000. And what you’re looking for is, is there a doubling time because the white count doubled within a 3-month period or a 6-month period? Or are the red blood cells or platelets dropping? Those are things that you’d be looking for.
Troy Trygstad, PharmD, MBA, PhD: Are there patients who don’t have signs or symptoms or who are asymptomatic? Is it in their blood work, but they’re asymptomatic, and they can catch it because it’s in the blood work even though I don’t have any signs, symptoms, or complaints?
Christina Patterson, PA-C: The majority of the patients who come in are asymptomatic; you find it on the lab. But then there may be patients who come with an enlarged spleen. And those patients are usually presenting with the fever, chills, night sweats, drenching sweats, loss of appetite, or early satiety, and they’re eating very small amounts of food and filling up very quickly. Or with bulky lymph nodes. They’ll say, “I have these lumps in my neck or underarms,” and you’re feeling these big bulky nodes.
Troy Trygstad, PharmD, MBA, PhD: And are most primary care sites or places of referral pretty adept at picking up on this, or is there still work that’s needed in identification?
Christina Patterson, PA-C: I think most primary care sites do pick up on it fairly early. We usually see the referrals earlier rather than later. We’re usually seeing those patients when the labs are changing as opposed to when they they’re presenting with the bulky adenopathy.
Troy Trygstad, PharmD, MBA, PhD: Got it. And so, Mike, what’s the prevalence of this condition: thousands, tens of thousands, 1% over the course of a life? What’s the prevalence?
Michael Reff, RPh, MBA: As Christina mentioned, it’s a very rare to an extremely rare diagnosis. Less than 200,000 patients per year are diagnosed with CLL.
Troy Trygstad, PharmD, MBA, PhD: In the United States or worldwide?
Michael Reff, RPh, MBA: In the United States. And one in about 175 is the incidence, and there’s a tendency for males to be diagnosed with CLL, just a slight increase in males, versus females. And it’s mostly in the elderly population. It’s extremely rare in younger patients.
Troy Trygstad, PharmD, MBA, PhD: So over the course of a lifetime, it’s a 1-in-175 chance?
Michael Reff, RPh, MBA: Yes.
Troy Trygstad, PharmD, MBA, PhD: In the entirety of a lifetime.
Michael Reff, RPh, MBA: Yes.
Troy Trygstad, PharmD, MBA, PhD: And as we age, the risk of diagnosis goes up?
Michael Reff, RPh, MBA: It increases, but it’s still considered a very rare diagnosis.