Health Maintenance in Chronic Lymphocytic Leukemia

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Transcript: 

Dr. Alessandra Ferrajoli: Good afternoon and thank you for the invitation to present. My focus will be a little bit different from the one of the esteemed speakers that presented before me, because I will not focus on the disease itself. I will more focus on the health measure for the patients, for the individual with CLL, in terms of what we call preventative care, and focus on cancer screening, immunizations, and lifestyle modifications.

So, why is health maintenance so important for individuals with CLL? It’s because the individuals with CLL have a long life expectancy, and also because CLL does not come as an isolated condition in the sense that individuals with CLL are diagnosed, and they often have other health condition, and then they also developed health conditions after the diagnosis of CLL, and those all contribute to the risk for infection complication, and also for the risk of developing other cancer.

And then, for not many people in the room, but at least for myself and probably many individuals with CLL, we know that maintaining fitness and maintaining muscle mass is challenging after age 40. So, this is what support my statement, that individuals with CLL have a long life expectancy. Those are sure data that shows out the life expectancy has changed. The five-year relative survival is now in the order of 88.5 percent. Actually, those are data that we are evaluated for year 2020 and year 2022 in terms of the relative and the estimated, and now, we are in year 2025. So, it’s probably more close to 90 percent, and if we go back to 1975, this was much lower in the order of 68 percent. So, great progress, and this great progress is due to the improvement in drug development, but also in the improvement in what we call supportive care.

As I stated, when somebody’s diagnosed with CLL, they often are in the later part of life, age more than 65, and often have many comorbid conditions. The most common are rheumatological conditions, but also cardiovascular conditions, and they may have had the diagnosis for another cancer. So, when we look at what is that takes the life of the individual with CLL, we see that CLL is only responsible for about less than half of the causes of that, and the comorbidity, particularly cancer and infection, are actually the leading cause of death. And this is why we focus on health maintenance and prevention.

So, we are at MD Anderson, a survivorship clinic for chronic lymphocytic leukemia, and we try to have the patient of CLL to be seen in this clinic, where we focus on all their preventive measures. And I want to specify that the condition of the patients, of the individual with CLL, is a little bit different, because normally, let’s say you are diagnosed with colon cancer, you will be in the colon cancer clinic for a number of years, and then usually, after year three or year five, you are transitioned into survivorship. For CLL, this doesn’t happen, because this is a condition that the patients live with.

So, we use the definition of the National Cancer Institute that says that a patient is considered a cancer survival from the time of diagnosis until the end of life. So, for CLL, if you have CLL, there is not this net separation between the active treatment phase and then the survivorship. The two are really happening concomitantly at the same time, and they are both very important. So, when we conducted a program sponsored by the CLL Global, that is a quality improvement project to optimize the health maintenance in patient with CLL.

So, we conducted some surveys, and this is a prospective program, and then we capture it. Vaccination, cancer screening, primary care visit, and we also knew how the administration of the repetitive surveys helped the team and helped the patients to stay current and to be really up to date on both immunizations and cancer screening. So, our first focus on cancer screening, and cancer screening for certain cancer is really very important for people that have already a diagnosis of cancer. And we were able to conduct a survey in over 1,000 individuals with CLL, follow at our institution, and what we saw is that the cancer screening decline post, during the COVID pandemic, because as we know, there was a dramatic change on what was the approach to being seen in a healthcare institution, but then recovered very well.

Right now in our population, we have a compliance with mammography that is as high as 80 percent. Almost all our patients undergo a colonoscopy, and also, we have pretty good gains in terms of prostate and Pap smear. We have about two-thirds of the patients that regularly have skin exam, this is very important, and we learn from this project that the older you are, the more likely you are having a cancer screening for a skin cancer screening, and we also know that there are some difference based on race with people of white ethnicity having more often cancer screening. And we’re very happy, because this project was selected for representation at the ASH meeting that is going to happen in less than a month in Orlando.

So, they’re going to be more upgrade of this cancer quality improvement project. We are now taking it to the next step in terms of cancer screening, and this is a project that is actually sponsored by the National Cancer Center Institute, where we will be offer as part of a clinical trial, what is – basically, what is often called a lipid biopsy. That is a cancer screening for various types of cancers that is done through a blood draw, and we feel that, Dr. Wierda and I strongly feel that this is a really important initiative, because we hope to demonstrate that we can diagnose other cancer early when they are more curable in a population like the individual with CLL that have a high risk for other cancer.

So, many of the patients follow at our institution will be contacted and encouraged to participate in this program. We’re just waiting to finalize the last bureaucratic step for the project to open. Now, I’ll switch to vaccination. This is my motto. Vaccinate early, vaccinate before the treatment, and also vaccinate family members, because we all live in a community. So, we conducted the same kind of study for the vaccination. This will also be updated at ASH.

Those data were presented at the iwCLL meeting in Krakow in September, and what we have found is that, actually, the vaccination rate was pretty high pre-COVID pandemic, but that’s declined since COVID pandemic, and we really have not been able to regain back the same rate of vaccination, even if the vaccination rate is slowly improving, but we are not back at the pre-pandemic rate. But we did find that individuals that are older tend to have a higher uptake for vaccination, and that our strategy of giving a repetitive survey once a year really work for the vaccination that need to be repeated every year, because we know there’s a very high uptake for influenza that is a vaccine that we need to do every year, and a fairly good rate for COVID.

So, the last topic I would like to discuss is the lifestyle modification. We, again, with the support of CLL Global, we conducted a pilot study called Health for CLL that was a study where we focus on a healthy diet and exercise to encourage our patients to be more active, and also to encourage them to be able to reach and maintain an optimal weight. We have published two reports on these patients, and here, I’m showing, for example, the improvement in weight, the improve in the fatigue score during the study, and very important is that we did the correlational studies where we look at the T-cell function, and particularly the patient that had a high level of comorbidities, as I explained at the beginning of this discussion.

There were significant changes with improvement in T-cell function, so, exercise has been shown in many, many populations, including healthy individual, to be very beneficial for our immune system. And so, this is the case for the individuals with the CLL. So, we conclude from our first experience of health for CLL that the individuals with CLL are able to increase their activity even if they tend to have, at times, an older age and experience fatigue. We optimize the methods to do the coaching and to optimize the strategy to be more active, and the interventions were effective with improvement in fatigue, decrease in weight, and potential benefit from the immune system.

Many patients gave us feedback, and they said that they kept those good habits even after the time of the study. So, this was so positive, now we are conducting Health for CLL Two. That is a study where we are doing – we’re using the type of intervention that was optimal. It’s all remote intervention.

There is a resistant exercise that we found very useful, together with a dietary coaching, and we also are associating not only study on the immune cells’ function, that they’re done in collaboration with the University of Houston, but also study on the intestinal microbiome to see how it changes during this project. So, those are some of the initiatives that we have to take a more global approach to the disease, not only focus on the disease and on its treatment, and this is my mail if you have any questions, and this is always the dog that waits for me to be done with the slides.