Potential risk model, definitions, and suggested treatment algorithms in CLL
| Risk group . | Definition . | Treatment . |
|---|---|---|
| Highest-risk | F-refractory CLL Early relapse (≤ 24 mo) after FCR (or FCR-like) treatment TP53 deletion/mutation and indication for treatment | Alternative induction with novel agent in clinical trial/alemtuzumab in general practice Consolidation with allogeneic SCT Maintenance (in clinical trial) |
| High-risk | Unmutated IGHV, 11q deletion, high β2-MG, no highest-risk traits | FCR + investigational agent (in induction/maintenance) |
| Low-risk | None of the above, no prior treatment | FCR, consider de-escalation, potentially MRD-based |
| Risk group . | Definition . | Treatment . |
|---|---|---|
| Highest-risk | F-refractory CLL Early relapse (≤ 24 mo) after FCR (or FCR-like) treatment TP53 deletion/mutation and indication for treatment | Alternative induction with novel agent in clinical trial/alemtuzumab in general practice Consolidation with allogeneic SCT Maintenance (in clinical trial) |
| High-risk | Unmutated IGHV, 11q deletion, high β2-MG, no highest-risk traits | FCR + investigational agent (in induction/maintenance) |
| Low-risk | None of the above, no prior treatment | FCR, consider de-escalation, potentially MRD-based |
The risk model takes into account 3 groups of patients. The “highest-risk” group may be defined based on predicted failure to respond to FCR (TP53 loss/mutation; short or no response to FCR). There are a number of exciting substances in clinical development (eg, CAL-101; PCI 32765), which make inclusion into trials an attractive option. The high-risk category is expected to benefit from FCR (or similar), but relapse risk is high and there remains room for improvement in efficacy by investigational approaches. At relapse, these patients are still expected to respond to FCR or similar regimens. The low-risk group includes all other patients. In these, FCR (or similar) is of high efficacy, and the aim of future trials may be to achieve similar outcomes with less treatment toxicity.