Chronic lymphocytic leukemia: towards a paradigm shift in disease management

Pablo Andrés Roa Torres,
MD, Mg Health Administration.

Chronic lymphocytic leukemia (CLL) is a cancerous pathology that affects B lymphocytes, generating an uncontrolled proliferation of its population (exceeding 5000 cell counts in hemogram), generating cells morphologically equal to normal lymphocytes, but smaller and immunologically incompetent (that is, they do not fully fulfill their function as defense cells of the body).

It is the most frequent hematological neoplasm in western countries (5 / 100,000 inhabitants-year). It predominantly affects older adults, more men than women (in a 2: 1 ratio). Its incidence increases with age, reaching 30 cases per 100,000 inhabitants-year in people over 70 years of age. About 85% of cases occur in adults older than 65 years, with an estimated duration of the disease ranging between 10 and 12 years for low-risk varieties, and 2 to 3 years for those of more high risk. Death usually occurs as a consequence of infections favored by the immuno-incompetence of the affected cell line, or as a consequence of the comorbidities that the patient presents (between 50% and 80% of patients affected by CLL present comorbidities, the majority cardiovascular type).

A parallel reality makes this cancer particularly relevant, and it is the fact that globally the aging of the population is increasing; something more noticeable in European countries, but also observable in our country. This is evidenced in the most recent report by ECLAC (Economic Commission for Latin America and the Caribbean) where as of June 2020, 9.1% of the Colombian population was 65 years of age or older (an increase of 2 percentage points compared to the 7.1% in 2015, and 4.1 percentage points in relation to the 5% with which the country entered the 21st century (almost doubling it). If it continues at this rate, it is estimated that by 2070 it could reach to be 32% of the total population.

Also relevant is the increase in life expectancy, reaching 77.9 years by 2020, an increase of almost two years in relation to the 76 years estimated between 2010 and 2015. For men it was 74 , 2 years, and for women, 79.8 years.

Another indicator that points in the same direction is the aging index, which measures the number of adults over 60 for every 100 children and young people. This data for Colombia in 2020 was 59.3%, above the average for Latin America (which stands at 54.3%).

In addition to the reality described, a good part of our population of older adults must still continue to form part of the productive force. Based on data from the Great Integrated Household Survey (GEIH, 2017), the employment rate of people aged 60 years or more in Colombia reached 37.3%, being higher for men than for women ( 52.7% vs 24.4%). Likewise, it was observed that the occupancy rate is higher for those 60 years or older with a low socioeconomic level. This population has high rates of labor informality (estimated at 47.8% of the population, according to information released by DANE in November / 2020). All of this is consistent with lower savings and lack of access to social security (and with it, access to a pension), which forces people of retirement age to remain linked to the labor market to maintain their income. Thus, only one in 4 older adults in our country (25%) has access to an old-age pension. 

Far from being irrelevant, all this information allows us to contextualize the present and future of the LLC in our country, given that a “perfect storm” scenario is configured, in terms of economic and social impact, for a pathology that to date present continues to be “off the radar” of the types of cancer considered as a public health problem, and its impact is not calculated given its incidence and prevalence rates, almost at the level of an orphan disease (without for this reason consider it as such). The conjunction of all the mentioned elements, generate an unpleasant panorama, since:

Diagnostic and therapeutic approaches to different types of cancer, including hematological ones, have usually focused on 3 specific aspects:

• Assessment of severity
• Estimation of the possibility of survival
• Choosing the most appropriate treatment regimen considering the two previous ones.

All of which is decided considering the neoplasia to be treated as an isolated entity, that is, directing all efforts to diagnose and treat cancer as a specific disease, sometimes leaving aside the individual being treated, in their social context, familiar and economic.

And this is the paradigm that must be rethought, directing efforts towards a comprehensive approach to the individual affected by the disease, and carrying out a real management of the disease, a term coined since 1993 by the Boston Consulting Group, and defined as “a process of optimization of the provision of care through the coordination of resources throughout the entire health system, throughout the life cycle of the disease, based on scientific evidence and aimed at improving quality and results (clinical, economic, quality of life and satisfaction of users and professionals) at the lowest possible cost ”.

The patient affected by CLL is usually an elderly adult, in whom, before his condition as a cancer patient, must be considered in its integral geriatric dimension (family, economic, social). Before a patient affected by cancer who is an older adult, he should be considered as an older adult – with all that this implies – who happens to be affected by CLL. Your care and treatment should not focus only on the management of CLL, but should address your condition as a geriatric patient suffering from this disease, with its implications in functionality and eventual disability, so that your recovery is comprehensive; or failing that, in terminal states, ensure that their palliative management is as comprehensive as possible, privileging their dignity as a human being at all times.

Comprehensive geriatric assessment (VGI) in these patients, defined as the “diagnostic process, usually interdisciplinary, aimed at determining the medical, functional and psychosocial problems and capacities of the elderly with the aim of developing a general treatment plan and long-term follow-up term ”, has been shown to decrease mortality, hospital stays, the rate of readmissions and institutionalization, less functional and mental decline, and greater access to rehabilitation for patients. Thus, the set of variables evaluated in this type of approach has a greater impact than that of the onco-specific treatment itself.

Now, if we focus on the purely economic aspect, the costs of CLL care are increasingly high, given the complexity of the drugs necessary for its management, with the cost-effectiveness and cost-utility of the treatments becoming especially important. , which is defined not only by economic variables, but also by health results and the quality of life gain as a result (expressed as quality-adjusted life years); this will be the subject of more detailed analysis in another article. So it’s not just about beating cancer and surviving; It is also important that survival and the resulting quality of life be given in decent conditions, and at a reasonable cost; taking into account that this reasonableness should not only be framed in the cost of the treatment itself, but in the costs avoided as a result of that same treatment.

Framed in this same paradigm shift, palliative management, usually considered only in terminal stages of various types of cancer, must also be refocused. Classically, palliative care has been framed in the final stage and close to the death of patients. 

This concept has been modified in recent years, and palliative care offers a multidisciplinary care model focused on the quality of life of patients with advanced diseases and their families, through the early identification and treatment of pain and other physical symptoms. , psychosocial and spiritual. There is evidence of improvement in the control of symptoms derived from the disease or of onco-specific treatments, in the quality of life of the patient, in the benefit in decision-making in situations of advanced disease and in the support to family, as a consequence of well-structured palliative management focused more on “good living” than “good death”.

Everything proposed, in addition to the change of vision in favor of the patient, must be integrated with routes and models of care that guarantee the transit of the patient through the system and its actors, guaranteeing accessibility, opportunity, continuity, security and technical-scientific rationality in all its lines of action and levels of care. 

The great conclusion will be that, to the extent that we consider our seniors affected by LLC as important members of our society in all its dimensions (including economic, being part of the productive force, even exceeding retirement age), Likewise, comprehensive approaches and treatments are designed that guarantee, within a harmonious articulation between providers and insurers, framed in comprehensive health care models and routes, the proper quality of care, and a dignified quality of life as a result of all these efforts. And likewise, to make it visible to the health system in its real scope and impact, so that it is considered within the pathologies susceptible to specific monitoring.

Until next time.