The Unmet Need in Chronic Lymphocytic Leukemia: Impact of Comorbidity Burden on Treatment Patterns and Outcomes in Elderly Patients


Introduction: Chronic lymphocytic leukemia (CLL) is a disease of the elderly. Elderly patients often have increased comorbidity burden and loss of organ reserve that may impact their ability to tolerate cancer therapy. We described realworld characteristics of typical CLL patients and identified factors predictive of receiving treatment. Methods: A retrospective cohort analysis of 8343 first primary CLL patients was performed using the linked Surveillance, Epidemiology, and End Results-Medicare database. Patients were diagnosed from 1/1/1998 to 12/31/2007, >66 years, and continuously enrolled in Medicare Parts A and B in the year prior to diagnosis. Comorbidity was examined using the National Cancer Institute comorbidity index and the Cumulative Illness Rating Scale. Cox and Logistic regression modeling assessed patient characteristics predictive of receiving treatment within the first year after diagnosis. Results: Median follow-up time from diagnosis was 782 days. During the study time period, there were 3366 (40%) treated patients and 4977 (60%) untreated. Even among those diagnosed with advanced stage (n = 4213), 57% were not treated. Treated patients were younger at diagnosis compared to untreated (76 vs. 79; p < 0.0001). In general, as age increased, the incidence and severity of comorbidities increased. In multivariate regression analyses, the treatment rate was significantly lower among patients >80 years, females, and with early stage disease; and significantly decreased with increasing comorbidity burden. Conclusions: Age, gender, comorbidity and stage were predictive of receiving treatment. Among patients with advanced stage, 57% were not being treated possibly due to older age and/or higher comorbidity burden.

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S. Satram-Hoang, C. Reyes, K. Hoang, F. Momin and S. Skettino, "The Unmet Need in Chronic Lymphocytic Leukemia: Impact of Comorbidity Burden on Treatment Patterns and Outcomes in Elderly Patients," Journal of Cancer Therapy, Vol. 4 No. 8, 2013, pp. 1321-1329. doi: 10.4236/jct.2013.48156.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] G. M. Dores, W. F. Anderson, R. E. Curtis, et al., “Chronic Lymphocytic Leukaemia and Small Lymphocytic Lymphoma: Overview of the Descriptive Epidemiology,” British Journal of Haematology, Vol. 139, No. 5, 2007, pp. 809-819.
[2] J. G. Gribben, “Chronic Lymphocytic Leukemia: Planning for an Aging Population,” Expert Review of Anticancer Therapy, Vol. 10, No. 9, 2010, pp. 1389-1394.
[3] N. A. Howlader, M. Krapcho, et al., “SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations),” National Cancer Institute, Bethesda, 2011.
[4] R. Siegel, C. DeSantis, K. Virgo, et al., “Cancer Treatment and Survivorship Statistics, 2012,” CA: A Cancer Journal for Clinicians, Vol. 62, No. 4, 2012, pp. 220-241. caac.21149
[5] C. Zent, “Chronic Lymphocytic Leukemia in the Elderly: Who Should Be Treated?” 2010 Educational Book, 2010. detail_view&confI D=74&abstractID=60
[6] L. Smolej, “How I Treat Elderly or Comorbid Patients with Chronic Lymphocytic Leukemia,” Acta Medica (Hradec Kralove), Vol. 53, 2010, pp. 213-220.
[7] B. Eichhorst, V. Goede and M. Hallek, “Treatment of Elderly Patients with Chronic Lymphocytic Leukemia,” Leukemia & Lymphoma, Vol. 50, No. 2, 2009, pp. 171-178. 10428190802688517
[8] J. C. Byrd, K. Rai, B. L. Peterson, et al., “Addition of Rituximab to Fludarabine May Prolong Progression-Free Survival and Overall Survival in Patients with Previously Untreated Chronic Lymphocytic Leukemia: An Updated Retrospective Comparative Analysis of CALGB 9712 and CALGB 9011,” Blood, Vol. 105, No. 1, 2005, pp 49-53.
[9] M. Hallek, K. Fischer, G. Fingerle-Rowson, et al., “Addition of Rituximab to Fludarabine and Cyclophosphamide in Patients with Chronic Lymphocytic Leukaemia: A Randomised, Open-Label, Phase 3 Trial,” Lancet, Vol. 376, No. 9747, 2010, pp. 1164-1174.
[10] P. Thurmes, T. Call, S. Slager, et al., “Comorbid Conditions and Survival in Unselected, Newly Diagnosed Patients with Chronic Lymphocytic Leukemia,” Leukemia & Lymphoma, Vol. 49, No. 1, 2008, pp. 49-56.
[11] L. Smolej, “Therapy of Elderly/Comorbid Patients with Chronic Lymphocytic Leukemia,” Current Pharmaceutical Design, Vol. 18, No. 23, 2012, pp. 3399-3405. 12801227096
[12] K. A. Foon, M. Boyiadzis, S. R. Land, et al., “Chemoimmunotherapy with Low-Dose Fludarabine and Cyclophosphamide and High Dose Rituximab in Previously Untreated Patients with Chronic Lymphocytic Leukemia,” Journal of Clinical Oncology, Vol. 27, No. 4, 2009, pp. 498-503.
[13] F. Forconi, A. Fabbri, M. Lenoci, et al., “Low-Dose Oral Fludarabine Plus Cyclophosphamide in Elderly Patients with Untreated and Relapsed or Refractory Chronic Lymphocytic Leukaemia,” Hematological Oncology, Vol. 26, No. 4, 2008, pp. 247-251.
[14] National Comprehensive Cancer Network, NCCN Clinical Practice Guidelines in Oncology, Non-Hodgkin’s Lymphomas, Vol. 3, 2012.
[15] J. L. Warren, C. N. Klabunde, D. Schrag, et al., “Overview of the SEER-Medicare Data: Content, Research Applications, and Generalizability to the United States Elderly Population,” Medical Care, Vol. 40, No. 8, 2002, pp. IV-3-IV-18.
[16] A. L. Potosky, G. F. Riley, J. D. Lubitz, et al., “Potential for Cancer Related Health Services Research Using a Linked Medicare-Tumor Registry Database,” Medical Care, Vol. 31, No. 8, 1993, pp. 732-748.
[17] N. C. Institute, “SEER-Medicare: How the SEER and Medicare Data Are Linked,” 2007.
[18] J. L. Binet, A. Auquier, G. Dighiero, et al., “A New Prognostic Classification of Chronic Lymphocytic Leukemia Derived from a Multivariate Survival Analysis,” Cancer, Vol. 48, No. 1, 1981, pp. 198-206.<198::AID-CNCR2820480131>3.0.CO;2-V
[19] K. R. Rai, A. Sawitsky, E. P. Cronkite, et al., “Clinical Staging of Chronic Lymphocytic Leukemia,” Blood, Vol. 46, No. 2, 1975, pp. 219-234.
[20] M. D. Danese, R. I. Griffiths, M. Gleeson, et al., “An Observational Study of Outcomes after Initial Infused Therapy in Medicare Patients Diagnosed with Chronic Lymphocytic Leukemia,” Blood, Vol. 117, No. 13, 2011, pp. 3505-3513.
[21] J. L. Warren, L. C. Harlan, A. Fahey, et al., “Utility of the SEER-Medicare Data to Identify Chemotherapy Use,” Medical Care, Vol. 40, No. 8, 2002, pp. IV-55-IV-61. 00005650-200208001-00008
[22] C. N. Klabunde, J. M. Legler, J. L. Warren, et al., “A Refined Comorbidity Measurement Algorithm for Claims-Based Studies of Breast, Prostate, Colorectal, and Lung Cancer Patients,” Annals of Epidemiology, Vol. 17, No. 8, 2007, pp. 584-590.
[23] M. E. Charlson, P. Pompei, K. L. Ales, et al., “A New Method of Classifying Prognostic Comorbidity in Longitudinal Studies: Development and Validation,” Journal of Chronic Diseases, Vol. 40, No. 5, 1987, pp. 373-383.
[24] B. S. Linn, M. W. Linn and L. Gurel, “Cumulative illness rating scale. Journal of the American Geriatrics Society, Vol. 16, 1968, pp. 622-626.
[25] P. A. Parmelee, P. D. Thuras, I. R. Katz, et al., “Validation of the Cumulative Illness Rating Scale in a Geriatric Residential Population,” Journal of the American Geriatrics Society, Vol. 43, 1995, pp. 130-137.
[26] V. de Groot, H. Beckerman, G. J. Lankhorst, et al., “How to Measure Comorbidity: A Critical Review of Available Methods,” Journal of Clinical Epidemiology, Vol. 56, No. 3, 2003, pp. 221-229.
[27] T. M. Johnson, “Treatment and Management of Chronic Lymphocytic Leukemia in the Elderly: What the Pharmacist Clinician Should Know,” The Consultant Pharmacist, Vol. 27, No. 4, 2012, pp. 274-285.
[28] B. R. V. Goede, S. Stilgenbauer, et al., “Cumulative Illness Rating Scale (CIRS) Is a Valuable Tool to Assess and Weigh Comorbidity in Patients with Chronic Lymphocytic Leukemia (CLL): Results from the CLL8 Trial of the German CLL Study Group (GCLLSG),” European Hematolgy Association.
[29] D. C. Dale, “Poor Prognosis in Elderly Patients with Cancer: The Role of Bias and Undertreatment,” The Journal of Supportive Oncology, Vol. 1, No. 1, 2003, pp. 11-7.
[30] J. L. Lund, T. Sturmer, L. C. Harlan, et al., “Identifying Specific Chemotherapeutic Agents in Medicare Data: A Validation Study,” Medical Care, Vol. 51, No. 5, 2013, pp. e27-e34.
[31] “Number of Part D Enrollees,” National Cancer Institute, Bethesda, 2012.

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