CLL is a disease that mainly affects
older individuals. Therefore, in the treatment of patients with CLL,
consideration must be given to the patients’ age, comorbid medical conditions,
functional status, and ability to tolerate treatment. There have been
significant changes in the treatment of patients with CLL in recent years with
the introduction of several novel targeted agents that have advantages over
traditional chemoimmunotherapy in certain patient populations.
In the SEQUOIA study, 1 previously
untreated CLL/SLL patient was treated with Zanubrutinib. In the study’s
randomized cohort, 50 treatment-naïve CLL/SLL patients without del(17p) were
randomly assigned to receive either Zanubrutinib or BR. With a median follow-up
of 61.2 months, PFS was significantly longer for patients who received Zanubrutinib
(median PFS not reached) than for those who received BR (median PFS of 44.1
months; hazard ratio of 0.29). Estimated 60-month OS rates were 85.8% for Zanubrutinib
and 85.0% for BR. For the 38 patients with both mutated and unmutated IGHV
genes, PFS was significantly longer for patients who received Zanubrutinib than
for those who received BR. No new safety signals for Zanubrutinib were
identified. The rate of atrial fibrillation was 7.1%.
In addition to the reported PFS endpoint,
the SEQUOIA study provides information for the management of older patients
with CLL. Assessing whether Zanubrutinib or other approaches including
chemoimmunotherapy are appropriate for the treatment of patients with CLL considers
the patients’ overall health status, coexisting medical problems and
concomitant medications. An assessment of the patients’ functional status and
ability to take long-term oral medications is also considered.
Most of the older patients with CLL will
have a wide range of physical and mental abilities. They will have many
different co-morbid conditions. They will be on many different medications.
They will have many different physical and mental limitations. We can call
these limitations the patient’s “physical and mental fitness” or their
“biological age” and this is usually different from the patient’s
“chronological age”.
Two patients of the same age can have
vastly different levels of functional status, comorbid disease, renal function,
cardiovascular disease and on medications. So in addition to chronological age,
the biological age or fitness of the patient and their clinical status need to
be taken into consideration when deciding on treatment.
Comorbidities and concomitant medications
are more common with advancing age in CLL patients. These factors must be taken
into consideration when choosing a treatment for CLL patients as well as when
monitoring CLL patients on treatment.
Historically, few studies have included
adequate numbers of older patients with CLL to draw meaningful conclusions
regarding their clinical course and the effects of treatment. More recently,
there is little data regarding the treatment of patients with CLL and
significant comorbidity. Therefore, most studies regarding the treatment of CLL
have been conducted in relatively healthy younger patients. These studies must
be interpreted in the context of the older patient with CLL.
Separate analysis in del(17p) patients
receiving sequoia zanubrutinib, data cut-off of July 2023, median follow-up of 26.1 months,
median PFS not reached. Patients were followed for a median of 26.2 months.
With longer follow-up (61.2 months), the median PFS for patients treated with Zanubrutinib
had not been reached (NR) in comparison with a PFS of 44.1 months for patients
treated with BR (HR = 0.29; 95% CI = 0.22-0.37; estimated 60-month OS rates of
85.8% vs 85.0% for Zanubrutinib vs BR, respectively).
There was no new safety signals
identified with longer follow-up. The incidence of reported atrial fibrillation
(AF) was 7.1% in patients treated with Zanubrutinib and 9.4% in patients
treated with BR.
While the SEQUOIA study provides data on
the use of zanubrutinib in the study population, it is not appropriate or
recommended for the treatment of all older patients with CLL.
For an older patient to be considered for
treatment, there are several factors that need to be assessed before choosing a
treatment.
These can include:
●
Performance status
●
Activities of daily living
●
Frailty
●
Cardiovascular disease
●
Renal and hepatic function
●
Infection history
●
Cognitive status
●
Nutritional status
●
Polypharmacy
●
Previous treatment exposure
●
Patient preferences and treatment
goals
This assessment allows us to
differentiate between a fit older adult and a frail patient with many
co-morbidities competing for attention. The example of a 70-year-old fit
patient with very few co-morbidities would be managed very differently to an 85
year old frail patient with co-existing cardiovascular disease, renal
impairment and on multiple medications.
Cardiac arrhythmias, including serious
and life-threatening cardiac arrhythmias, have been reported in patients with Zanubrutinib
treatment. These events have occurred in patients with cardiac risk factors,
including those with hypertension, and in patients experiencing an acute
infection.
These individuals should have their
concomitant cardiovascular medications identified by complete medication
reconciliation and a bleeding risk assessment for patients on anticoagulants
for conditions such as atrial fibrillation and other indications.
Review of cardiac history, blood pressure
and cardiac rhythm as well as of concomitant antithrombotic treatment before as
well as during Zanubrutinib treatment.
There are cardiovascular medications that
the older patient is likely to be on, including anticoagulants and antiplatelet
agents. The potential interactions with the BTK inhibitor and their
consequences need to be assessed and their impact on the overall treatment of
the patient’s other medical problems considered.
Review of the patient’s prescription and
non-prescription medicines and supplements, as well as any vitamins, are needed
for a complete assessment of medicines to identify any possible drug
interactions and determine if a patient’s current medicines are still needed. In
old patients with many medicines (polypharmacy) the number of drug interactions
increases. These interactions are difficult to detect.
Monitoring blood counts and organ
function is needed for a long-term treatment with Zanubrutinib. It is necessary
to regularly monitor blood counts to look for signs of developing cytopenia and
organ function to search for early warning signs of emerging problems.
The aging process and underlying disease
can lead to decreased renal function and/or decreased hepatic function with
even minor changes having important clinical implications. Monitor the patient
on Zanubrutinib individually based on the patient’s specific disease,
treatment, co-morbidities and clinical situation.
Infections are important in the
management of CLL patients. They are affected by the disease and by therapy.
Zanubrutinib has been associated with infections, including serious ones. A
pooled safety analysis of Zanubrutinib across B-cell malignancies reported
pneumonia, sepsis, and other infections among serious adverse events.
Patients
≥75 years of age reported a higher rate of adverse events of Grade 3 or higher
and serious adverse events compared to younger patients. Consider
the patient’s past history of infections, assess their current vaccination
status, determine the frequency of their infections and assess their overall
immune competence.
Although oral therapy is given outside of
an infusion center, it can be given for a long period of time and therefore
needs to be monitored. Older adults may have difficulty with the scheduling of
their oral medication, due to factors such as cognitive impairment, inability
to read the label, need for transportation to a pharmacy, and need for a
caregiver.
Assess the ability of the older patient
and their family/caregiver to manage oral drugs, with or without help from
others. Medication reconciliation for all oral drugs, including those for CLL,
should be performed for all patients every time they are seen in the clinic. Consideration
of the practical burden of long-term treatment should be considered in the
discussion of the treatment of CLL in the older patient.
SEQUOIA may be considered for individual
patients in a similar fashion to the study population. There are, however,
limitations to how one can apply the results of a single clinical trial to
individual patients with CLL. The SEQUOIA study enrolled treatment-naïve
patients with CLL/SLL without del(17p) and the resulting data assesses the
safety and efficacy of Zanubrutinib in this subgroup of patients. There have
been separate clinical trials assessing the safety and efficacy of Zanubrutinib
in patients with del(17p) and, although there are encouraging results for
certain endpoints (including OS), the results for PFS have not been as strong
as in treatment-naïve patients without del(17p).
Even a clinical trial cannot include all
a patient’s health problems, medicines, degree of frailness, preferences, and
other health problems. Thus, the results of SEQUOIA have to be applied with a
lot of common sense in individual cases.
Older CLL patients with complex problems,
such as CLL and multiple co-morbidities on multiple medications, need a
multidisciplinary approach to their care. This team would consist of members
from the disciplines of hematology, primary care, cardiology, pharmacy, and
nursing, among others. This team of healthcare professionals may be able to manage
the CLL in the older patient with complicated issues such as anticoagulation,
renal impairment, recurrent infections, etc.
The key to managing older CLL patients in
the multidisciplinary team setting is to take account of all their health
problems. Managing the disease in older patients is not just a matter of
discussing treatment with the patient and their family and drawing on the
expertise of several different healthcare professionals including those from
primary care, hematology, cardiology, pharmacy and nursing. Rather, all the
patients’ health problems need to be considered, for example, their
cardiovascular disease, requirement for anticoagulation, renal impairment,
history of recurrent infections, and polypharmacy.
In SEQUOIA, Zanubrutinib demonstrated
higher level of efficacy as compared with bendamustine plus rituximab (BEND +
RIT) in treatment-naïve patients with CLL/SLL without del(17p) mutation.
Follow-up of 5 years or longer from start of study treatment, where available,
continues to show PFS advantage for ZANU with no new safety concerns.
Besides the chronological age of patients
with CLL, their functional status and potential degree of frailty, the
cardiovascular risk, the risk of bleeding as well as of infections need to be considered
in the treatment decision. Furthermore, organ function, the concomitant
medication, the possibility of treatment as well as the treatment goals of
individual patients need to be considered. In summary, consideration of the
SEQUOIA trial results as they relate to the management of older adults with CLL
utilizing Zanubrutinib may be useful in the patient’s overall clinical care.
The results of such trials can serve as very valuable information to aid in
making clinical decisions as it relates to the management of individual
patients.
Disclaimer: The information provided in
this article is intended for educational purposes only and should not be
interpreted as medical advice, a clinical guideline, or a recommendation for
any specific treatment.
Staying socially connected is an important part of healthy aging. Spending time with family, talking with friends, attending community events, and participating in hobbies can help seniors maintain meaningful relationships and enjoy a greater sense of purpose.However, hearing loss can sometimes make social activities more difficult. When conversations become challenging to follow, a senior may begin avoiding restaurants, family gatherings, clubs, religious services, or other activities they once enjoyed.The good news is that addressing hearing loss may make it easier for seniors to communicate, participate, and remain connected with the people and activities that matter most.Hearing Loss Can Make Conversations More DifficultOne of the most noticeable effects of hearing loss is difficulty following conversations. This can be especially challenging when several people are talking at once or when there is background noise.A senior may hear that someone is speaking but has trouble understanding the words. They may frequently ask others to repeat themselves or worry that they are responding incorrectly.Over time, these challenges can make everyday conversations frustrating and exhausting.Social Situations Can Become OverwhelmingMany popular social activities take place in environments where hearing clearly can be difficult. Restaurants, family celebrations, community centers, and sporting events may all have background noise that makes conversation harder to understand.Someone experiencing hearing loss may begin to think: "It's too noisy for me to hear." "I don't want to keep asking people to repeat themselves." "I'm afraid I'll miss something important." "It's easier to stay home." When these feelings lead a senior to participate less often, they can gradually become less socially active.Better Hearing Can Make Family Time More EnjoyableFamily relationships are an important source of connection for many older adults. Being able to comfortably hear conversations can make visits with children, grandchildren, siblings, and other loved ones more enjoyable.Better hearing can help seniors participate in conversations instead of simply listening from the sidelines. It can also make it easier to hear grandchildren's stories, enjoy jokes, discuss family news, and stay involved in everyday conversations.These seemingly small interactions can make a big difference in maintaining close relationships.Hearing Can Help Seniors Stay Involved in Their CommunitiesSocial connection extends beyond family. Seniors may have friendships and relationships through volunteer activities, senior centers, clubs, classes, faith communities, exercise groups, or other organizations.When hearing difficulties interfere with participation, a senior may gradually stop attending.Addressing hearing loss may help make these activities more comfortable. Being able to follow conversations and interact with others can encourage seniors to continue participating in the communities they enjoy.Better Hearing May Increase ConfidenceHearing loss can sometimes affect a person's confidence in social situations. A senior may worry about misunderstanding a question, giving an inappropriate response, or missing an important part of a conversation.These concerns can cause someone to become quieter or withdraw from conversations.Improving hearing may provide greater confidence. When seniors can hear and understand what is being said, they may feel more comfortable speaking up, asking questions, and participating in conversations.Staying Socially Active Is Important as We AgeMaintaining social connections can contribute to overall quality of life. Friends and family can provide companionship, encouragement, emotional support, and opportunities to stay engaged with the world around us.Social activities also give seniors opportunities to laugh, share experiences, learn new things, and maintain a sense of belonging.Hearing well can make it easier to take advantage of these opportunities.Hearing Aids May Help Seniors Participate More FullyFor seniors with hearing loss, hearing aids may be one option for improving communication. Modern hearing aids are designed to amplify sounds and can be selected and adjusted based on an individual's hearing needs and lifestyle.A hearing professional can evaluate a person's hearing and discuss whether hearing aids may be appropriate.It is important to remember that hearing aids are not necessarily an instant solution. Seniors may need time to adjust to hearing sounds differently, and follow-up appointments can help ensure that the devices are working comfortably and effectively.Family Members Can Help, TooFamily and friends can make communication easier for someone experiencing hearing loss.Simple changes can include: Getting the person's attention before speaking Facing them during conversations Speaking clearly and at a comfortable pace Reducing unnecessary background noise Moving to a quieter area when possible Avoiding shouting Being patient when something needs to be repeated These strategies can help make conversations more comfortable for everyone.Don't Let Hearing Loss Lead to IsolationHearing loss does not have to mean giving up the activities and relationships a senior enjoys. If communication has become increasingly difficult, it may be time to have hearing evaluated.Some common signs that a hearing evaluation may be helpful include: Frequently asking others to repeat themselves Turning the television volume higher than others prefer Having difficulty understanding conversations in restaurants or groups Struggling to hear on the telephone Feeling that people are mumbling Avoiding social gatherings because hearing is difficult Relying heavily on watching people's faces or lips when they speak Recognizing these signs and seeking professional guidance can be an important first step toward staying socially engaged.Better Hearing Can Help Seniors Stay ConnectedSocial connection is an important part of enjoying life at any age. For seniors experiencing hearing loss, improving communication may make it easier to participate in conversations, spend time with loved ones, maintain friendships, and continue enjoying favorite activities.If you or someone you love is having difficulty hearing, consider scheduling a professional hearing evaluation. Understanding the cause and degree of hearing loss can help determine what options may be available.Darrell M. Sipe Opticians & Hearing Aids is committed to helping patients with their hearing and vision needs. Better hearing can be about much more than hearing sounds, it can help seniors remain involved, confident, and connected to the people and activities that make life meaningful.
Independence is important at every stage of life. For many seniors, being independent means being able to communicate with others, make their own decisions, participate in social activities, manage everyday responsibilities, and continue doing the things they enjoy.Hearing plays an important role in maintaining that independence. When hearing loss goes untreated, everyday communication can become more difficult and frustrating. Over time, some seniors may begin avoiding situations where they have trouble hearing or relying more heavily on family members for help.The good news is that hearing loss doesn't have to mean giving up your independence. Understanding the signs of hearing loss and seeking appropriate hearing care can help seniors stay connected and confident in their daily lives.How Hearing Loss Can Affect IndependenceHearing loss can affect much more than the ability to hear a conversation. It can influence how a senior interacts with family, friends, healthcare providers, coworkers, and members of the community.For example, a senior with hearing loss may have difficulty: Understanding instructions Communicating with healthcare providers Hearing someone at the front door or on the telephone Following conversations in restaurants or other busy environments Participating in group activities Communicating while shopping or running errands Hearing alarms, doorbells, or other important sounds Staying connected with family and friends When these challenges become frustrating, a person may begin relying on others or avoiding certain activities altogether.Hearing Loss Can Make Communication More DifficultCommunication is a major part of independent living.If you frequently have to ask people to repeat themselves or find yourself guessing what someone said, everyday conversations can become tiring.You may also find yourself depending on family members to repeat information or explain what was said during important conversations.Addressing hearing difficulties can make it easier to communicate directly and confidently with the people around you.Staying Connected Is Part of Staying IndependentIndependence doesn't mean doing everything alone. Maintaining relationships and staying involved in your community are also important parts of a fulfilling life.Hearing loss can sometimes cause seniors to withdraw from social activities because they are embarrassed or frustrated when they cannot follow conversations.A person may stop going to restaurants, attending family gatherings, participating in community activities, or visiting friends.Seeking hearing care may make it easier to participate in these activities and maintain the social connections that contribute to a healthy and active lifestyle.Hearing Loss and Healthcare ConversationsClear communication with healthcare providers is especially important for older adults.During medical appointments, seniors may need to understand instructions, ask questions, discuss symptoms, and make decisions about their care.Having difficulty hearing important information can create unnecessary confusion.If you have hearing loss, let your healthcare provider know. Wearing your hearing aids when appropriate, asking people to speak clearly, and choosing a quieter environment can make important conversations easier.Hearing Aids May HelpFor seniors with hearing loss, hearing aids may help improve access to speech and everyday sounds.Modern hearing aids are available in a variety of styles and technology levels. A hearing professional can evaluate your hearing and help determine what type of device may be appropriate for your individual needs.Hearing aids don't necessarily make hearing the same as it was before hearing loss. However, they can help many people hear speech and environmental sounds more easily.The right hearing solution depends on factors such as hearing loss, lifestyle, communication needs, comfort, and personal preferences.Getting Used to Hearing Aids Takes TimeIf you are new to hearing aids, remember that adjusting to them can take time.Sounds may initially seem different or louder than you remember. Your brain needs time to become accustomed to hearing sounds through devices.Work with your hearing professional and follow their recommendations for wearing and caring for your hearing aids. Follow-up appointments can also help address comfort or sound-quality concerns and allow adjustments when needed.Simple Strategies Can Make Communication EasierWhether or not you use hearing aids, there are ways to make everyday communication more successful.Reduce Background NoiseWhen possible, move to a quiet area before having an important conversation. Turning down the television or radio can make it easier to focus on speech.Face the Person SpeakingBeing able to see the speaker's face provides helpful visual information and can make communication easier.Ask People to Speak ClearlyIf you dont understand something, don't be afraid to ask the person to repeat or rephrase it.Be Open About Your HearingLet friends, family members, and healthcare providers know if you have difficulty hearing. Most people are happy to make small adjustments when they understand what you need.Don't Let Embarrassment Stand in Your WaySome seniors avoid talking about hearing loss because they worry that wearing hearing aids will make them appear older or less independent.In reality, taking action to address hearing loss can be a positive step toward maintaining independence.Seeking professional help doesn't mean you are giving up control. It means you are taking an active role in managing your health and finding ways to make everyday life easier.Family Members Can Offer SupportFamily members can play an important role in helping seniors address hearing loss, but the senior should remain involved in decisions about their hearing care.Instead of making decisions for your loved one, encourage them to have their hearing evaluated and learn about their options.Be patient during conversations and avoid shouting. Face them when speaking, reduce background noise, and give them time to respond.Support and encouragement can make it easier for a senior to take the first step toward better hearing.When Should You Have Your Hearing Checked?If you have noticed changes in your hearing, don't wait until communication becomes extremely difficult before seeking help.Consider scheduling a hearing evaluation if you: Frequently ask people to repeat themselves Turn the television volume up higher than others prefer Have trouble hearing in restaurants or groups Struggle to understand conversations on the telephone Feel that people are mumbling Avoid social activities because hearing is difficult Have difficulty hearing important sounds around your home A professional hearing evaluation can help determine whether hearing loss is present and provide information about your options.Protecting Your Independence Starts With Taking Care of YourselfHearing loss doesn't have to prevent seniors from living active, independent lives. Recognizing hearing difficulties and seeking appropriate care can help make communication easier and support continued participation in the activities and relationships that matter most.If you or someone you love is experiencing hearing difficulties, consider scheduling a professional hearing evaluation. Understanding your hearing is the first step toward finding the right solution for your needs.Darrell M. Sipe Opticians & Hearing Aids provides hearing care services to help seniors understand their hearing needs and explore appropriate solutions.Your independence is worth protecting. Don't let untreated hearing loss keep you from communicating, participating, and enjoying the life you want to live.
Hearing loss can affect many areas of a senior's life, from conversations with family members to enjoying television, attending social events, or communicating with friends. For some older adults, hearing aids can be an important tool for making everyday communication easier.If you or a loved one has recently been told that hearing aids may be beneficial, you may have questions about what happens next. Will they be comfortable? Will you hear normally again? How long will it take to get used to them?Understanding what to expect can make the process less overwhelming and help seniors feel more confident about taking the next step.The First Step Is a Hearing EvaluationBefore recommending hearing aids, a hearing professional will typically evaluate your hearing.A hearing evaluation helps determine whether hearing loss is present and provides information about the type and degree of hearing difficulty. Your hearing professional can also discuss how your hearing affects your everyday activities.Be open about the situations in which you have difficulty hearing. For example, let your provider know if you struggle most with conversations in restaurants, talking on the telephone, watching television, or hearing family members.This information can help guide recommendations based on your individual needs.Your Hearing Aids Should Be Selected for YouThere is no single hearing aid that is right for every senior.Hearing aids come in different styles, sizes, features, and technology levels. Your hearing professional can help you understand your options and choose devices that fit your hearing needs, lifestyle, and preferences.Consider the activities that are important to you. Someone who spends most of their time in quiet surroundings may have different needs from someone who regularly attends family gatherings, restaurants, community events, or other busy environments.Getting Your Hearing Aids Properly FittedOnce you have selected your hearing aids, they need to be properly fitted and adjusted.A hearing professional can make sure the devices fit comfortably and are programmed appropriately for your hearing loss.Don't hesitate to speak up if something doesn't feel or sound right. Hearing aids can often be adjusted to improve comfort and sound quality.The goal is not simply to put hearing aids in your ears. The goal is to help you hear as comfortably and effectively as possible.You May Notice That Sounds Seem DifferentOne of the biggest surprises for first-time hearing aid users is that sounds may seem different when they begin wearing their devices.You may suddenly notice sounds you haven't heard clearly in a long timethe refrigerator running, birds outside, footsteps, or the rustling of clothing.Your own voice may also sound different at first.This doesn't necessarily mean something is wrong. Your brain needs time to become accustomed to receiving sounds differently.Getting Used to Hearing Aids Takes TimeAdjusting to hearing aids is a process.Some seniors become comfortable wearing their devices relatively quickly, while others need more time. Start by wearing them for the amount of time recommended by your hearing professional and gradually become accustomed to using them throughout your day.Try wearing your hearing aids during conversations with one person in a quiet environment before moving into more challenging listening situations.Patience is important. Give yourself time to adjust.Hearing in Noisy Places May Take PracticeMany people expect hearing aids to immediately make every conversation effortless. However, noisy environments can remain challenging.Restaurants, parties, family gatherings, and other busy environments contain many competing sounds. Your hearing professional can help you learn how to use your hearing aids effectively in these situations.Some hearing aids include features designed to help manage background noise, but it is still helpful to position yourself where you can see the person speaking and reduce unnecessary background noise when possible.Family Members Can HelpFamily support can make the adjustment process easier.Encourage family members to face you when speaking, reduce background noise when possible, and give you time to become accustomed to your hearing aids.It is also important for family members to understand that hearing aids don't restore hearing to exactly the way it was before hearing loss. They are designed to help improve access to sound and make communication easier.Learn How to Care for Your Hearing AidsProper care can help keep your hearing aids functioning properly.Your hearing professional can show you how to: Insert and remove your hearing aids Clean them properly Change or recharge batteries Store them safely Keep them away from moisture Recognize when they may need cleaning or servicing If your hearing aids aren't working properly, don't assume that they need to be replaced. Sometimes a simple cleaning, adjustment, or repair can solve the problem.Follow-Up Appointments Are ImportantYour first hearing aid fitting is not necessarily the end of the process.Follow-up appointments give your hearing professional an opportunity to see how you are doing and make adjustments if necessary.Let your provider know about any concerns you have. Perhaps certain sounds seem too loud, the devices feel uncomfortable, or you are still struggling in particular listening environments.Small adjustments can sometimes make a significant difference in your experience.Be Patient With YourselfIt is normal to have questions or frustrations when you first begin wearing hearing aids.Learning how to use the devices, getting comfortable with the fit, adjusting to new sounds, and incorporating hearing aids into your daily routine all take time.Don't become discouraged if everything doesn't feel perfect immediately. Stay in communication with your hearing professional and follow their recommendations.Hearing Aids Can Help You Stay ConnectedFor seniors experiencing hearing loss, the goal of hearing care isn't simply to hear more sounds. It's about making communication easier and helping you stay connected to the people and activities that are important to you.Hearing aids may help make conversations with family easier, improve your ability to participate in social situations, and make everyday sounds more accessible.If you or a loved one is experiencing hearing difficulties, a professional hearing evaluation is a good place to start.Darrell M. Sipe Opticians & Hearing Aids provides hearing care services to help seniors and their families understand hearing loss and explore appropriate hearing solutions.If hearing loss is making conversations or everyday activities more difficult, don't assume you simply have to live with it. Talk with a hearing professional, learn about your options, and take the first step toward better communication.