What is remission? What does it mean?

What is remission in chronic lymphocytic leukemia?

In CLL, a remission basically means that when we look for the leukemia, we don't see it. So that can be either in the form of enlarged lymph nodes and enlarged spleen. Rarely, but not never an enlarged liver that those have all gone back to normal and that the bone marrow is clear of involvement with the CLL cells.

And now, in today's age, with some very active agents and CLL, we're also looking at minimal residual disease measurements. And so that's using more sensitive techniques than just having a pathologist look through a microscope to tell you whether or not he thinks he sees any CLL cells.

So you can imagine that that that's great. It's sensitive somewhat. Our pathology colleagues do a great job, but they can only look at so many cells per bone marrow biopsy. So we have additional techniques, something called flow cytometry, which can look at tens of thousands of cells and then something called next generation sequencing, which can look at millions of cells.

And so there are different depths to remission in whole. And so with these newer techniques, we can can really tell a patient what was the depth of their response to their current treatment. And this is really helped us to usher in an era where we have fixed duration therapy treatments. And so for a long time, all we had to offer patients with chemo, chemotherapy with a with an antibody corporate tax grab, and that that era is officially and firmly done.

So I would absolutely make sure that CLL patients, when they are contemplating getting treated, be sure that they're being talked to about the targeted therapies that are available and that the chemotherapies really should be used in only very rare situations. In fact, that the number of situations where it's still appropriate are getting smaller and smaller. So we definitely have them talk to their oncologist about the targeted therapies, and those include bruton's tyrosine kinase inhibitors or BCL two inhibition with a drug called the Nana. And those really are the cornerstone in the front line treatment for CLL.

Remission, unfortunately, even with these newer agents is not the same thing as cure. And that can be really confusing. So when a patient achieves a remission, even though we don't see the leukemia and sometimes we don't even see it with those more sensitive techniques I talked about, unfortunately, leukemia is not gone. And we know that given time off of therapy, eventually it will return.

I think it's really hard and small because I think it's really defined by what treatment pathway you go down. For BTK inhibitors, a patient can be in usually what we call partial remission. They're still taking the drug. This is very much under control. But the way these drugs were designed and currently are approved, you continue taking taking the drug less frequently. Will you get with BTK inhibitors to this point of undetectable mineralized residual disease whereby a very sensitive test, we can't detect any? Well, I don't think that that, you know, we still don't know that that's necessarily the goal for all patients. And so I think it's really hard to compare that. You know, you really can't necessarily compare the treatments on that basis alone.

With the venetoclax pill based treatment and IV infusion, many patients actually do get to this undetectable, minimal residual disease state where we really can't detect this level. And like I had mentioned, these are, you know, can be time limited treatments. And so patients can have come off treatment and have what we call a treatment for remission.

The remission can be defined in many different ways. And a lot of this is still in clinical trial or investigational, but you can have this MRI, undetectable remission where we can't detect any seal cells. But then there's a subgroup of patients where we do still detect some CLL cells. But all the clinical criteria for why they started treatment, such as, you know, the blood counts being abnormal, white cell hemoglobin platelets are all normal. They don't have any detectable lymph nodes, so they're still in a remission there.

So it really depends and this is something just to talk to your doctor about, you know, what you can expect depending on what treatment program you use, you know what you know what the goal of the treatment is and what can be expected in terms of relapse for that's a little bit more unifying.

I'd say relapse. You know, clinical relapse is truly like meeting those criteria again that we're used to determine if you needed treatment. So bigger, bulky lymph node symptoms, fatigue, fever, stretching sweats, weight loss, low hemoglobin, low platelets, all of those things would be really the a relapse.