Consensus Recommendations for the Management of Chronic Lymphocytic Leukemia: Primary Care Guideline

Transcription

1 Practice Guideline: Clinical Guide Cnsensus Recmmendatins fr the Management f Chrnic Lymphcytic Leukemia: Primary Care Guideline CCMB Practice Guideline Clinical Guide Develped by: Lymphprliferative Disrders Disease Site Grup

2 CancerCare Manitba Practice Guideline: Clinical Guide: Primary Care Guideline fr CLL 2 Preface At CancerCare Manitba (CCMB) the Clinical Practice Guidelines Initiative (CPGI) seeks t imprve patient utcmes in terms f survival and quality f life thrugh the develpment, disseminatin, implementatin, and evaluatin f guidelines fr the management f cmmn clinical scenaris encuntered by cancer patients thrughut the prvince. This clinical guide was apprved by the Lymphprliferative Disrders Disease Site Grup. Purpse This dcument is intended as a guide t facilitate an evidence-infrmed, shared apprach fr primary care prviders in the diagnsis and management f patients with CLL/SLL. This dcument is intended t supplement the Cnsensus Recmmendatins fr the Management f Chrnic Lymphcytic Leukemia. Fr this purpse, it may be used by qualified and licensed healthcare practitiners invlved with the care f nclgy patients, which may include (but is nt limited t): physicians, surgens, nurses, radiatin therapists, pharmacists, psychscial nclgy caregivers, and dieticians at CCMB, CCPN sites, Uniting Primary Care Onclgy Netwrk (UPCON) clinics, and WRHA Cmmunity Onclgy Prgram sites. Disclaimer Use f this clinical guide in any setting shuld nt preclude use f the practitiner s independent clinical judgment; nr shuld it replace cnsultatin with the apprpriate nclgy specialty when indicated (example: medical r radiatin nclgy, pharmacy, nursing, etc.). Clinicians are expected t apply the recmmendatins within bundaries f prfessinal standards and scpe f practice, and accrding t level f training and experience. It is the respnsibility f the practitiner t develp an individualized disease r symptm management plan fr each patient under his/her care, and ideally this shuld take place within the cntext f an inter-prfessinal team. The needs and preferences f the patient and the family shuld always be reflected in the plan f care. This clinical guide shuld be viewed as an evidence-infrmed practice tl, and as such, it des nt represent an exhaustive text n the diagnsis and management f patients with CLL/SLL in a primary care setting. Clinicians are advised t use it in their practice cncmitantly with infrmatin frm ther evidence-infrmed surces. CCMB, Cnsensus Recmmendatins fr the Management f Chrnic Lymphcytic Leukemia: Primary Care Guideline p. 2

3 CancerCare Manitba Practice Guideline: Clinical Guide: Primary Care Guideline fr CLL 3 Primary Care Guideline Tests The fllwing is a list f essential and useful tests t rder befre referral t CancerCare Manitba when a patient has a high lymphcyte cunt (greater than 5 x 10 9 /L). Essential diagnstic tests: CBC with differential Review f peripheral smear t lk fr smudge cells Flw cytmetry CLL patients have greater than 5 x 10 9 B cells with typical mlecular markers (psitive fr CD19, CD5 and CD23) Testing fr ZAP-70 and CD38, which are assciated with wrse prgnsis if psitive, can nly be perfrmed n a fresh bld sample Useful tests: Reticulcyte cunt Immunglbulin levels (IgA, IgM, IgG) Serum prtein electrphresis (SPEP) bichemistry (electrlytes, creatinine, glucse, LDH, LFT) Viral hepatitis screen HIV screen Direct antiglbulin test (DAT) β2-micrglbulin CT scan, lymph nde bipsy, r bne marrw aspirate/bipsy are nt rutinely required fr CLL hwever, may be necessary fr MBL and SLL. CCMB, Cnsensus Recmmendatins fr the Management f Chrnic Lymphcytic Leukemia: Primary Care Guideline p. 3

4 CancerCare Manitba Practice Guideline: Clinical Guide: Primary Care Guideline fr CLL 4 C-Management f Patients with the Hematlgist r the CCMB CLL Clinic Annual testing (perfrmed by the CLL clinic at the first appintment f the calendar year): CBC Cmplete bichemistry Immunglbulin levels Cmbs (direct antiglbulin) test Serum electrphresis β2-micrglbulin Cmmn cmplicatins f CLL t be aware f: 1. Autimmune cytpenias Especially autimmune hemlytic anemia (AIHA) if suspected, check LDH, bilirubin, haptglbin and Cmbs (direct antiglbulin) test Patients may als develp immune thrmbcytpenia (ITP), immune neutrpenia and/r red cell aplasia 2. Immundeficiency Watch fr recurrent sinus/respiratry infectins Administer pneumcccal vaccine at diagnsis (a single re-immunizatin is recmmended after 5 years) Administer annual influenza vaccine D nt administer live virus vaccines (e.g. shingles vaccine) 3. Develpment f secnd malignancies Tw-fld increase in CLL patients; especially skin, lung, breast, cln, prstate and lymphma Patients need: Aggressive screening (e.g. regular full skin exam; strict adherence t usual breast, prstate and clrectal cancer screening guidelines) Educatin regarding cancer risk reductin (e.g. smking cessatin, sun prtectin, eating healthy and staying active) Early detectin and interventin f suspicius findings (e.g. endscpy if irn-deficiency anemia discvered; referral t dermatlgy fr suspicius skin lesins) CCMB, Cnsensus Recmmendatins fr the Management f Chrnic Lymphcytic Leukemia: Primary Care Guideline p. 4

5 CancerCare Manitba Practice Guideline: Clinical Guide: Primary Care Guideline fr CLL 5 Indicatins t call the CCMB Hematlgist: 1. Significant interval prgressin f CLL: Dubling f lymphcyte cunt and/r lymph nde/spleen size within a 6 mnth perid Prgressive anemia, neutrpenia and/r thrmbcytpenia Uncmfrtable lymphadenpathy and/r splenmegaly Significant symptms, such as night sweats, weight lss r fatigue 2. Significant delays in treatment 3. Suspected develpment f an immune cytpenia 4. Suspected transfrmatin t mre aggressive disease (e.g. prlymphcytic leukemia, diffuse large B cell lymphma, multiple myelma, Hdgkin s disease r acute leukemia). Patients in transfrmatin are usually symptmatic with rapidly enlarging lymph ndes, fevers, weight lss and an elevated LDH 5. Multiple recurrent bacterial infectins. Patients may be a candidate fr replacement immunglbulin therapy (IVIG r SCIG) References 1. Chrnic Lymphcytic Leukemia Clinic. Cnsensus recmmendatins fr the management f chrnic lymphcytic leukemia. CancerCare Manitba, Full guideline available at: b_cancer_management_guidelines/clinical_practice_guidelines/ CCMB, Cnsensus Recmmendatins fr the Management f Chrnic Lymphcytic Leukemia: Primary Care Guideline p. 5

6 CancerCare Manitba Practice Guideline: Clinical Guide: Primary Care Guideline fr CLL 6 CancerCare Manitba 675 McDermt Avenue Winnipeg, Manitba, Canada R3E 0V9 Clinical Practice Guideline: Clinical Guide Chrnic Lymphcytic Leukemia Primary Care Guideline March 2016 CancerCare Manitba, March All rights reserved. This material may be freely reprduced fr educatinal and nt-fr-prfit purpses. N reprductin by r fr cmmercial rganizatin, r fr cmmercial purpses is allwed withut written permissin f CancerCare Manitba. CCMB, Cnsensus Recmmendatins fr the Management f Chrnic Lymphcytic Leukemia: Primary Care Guideline p. 6