Clinical Journal of Oncology Nursing Volume 12, Number 3 Caring for Patients With Chronic Lymphocytic Leukemia 417
Erin E. Elphee, RN, BN
Chronic lymphocytic leukemia (CLL) is the most commonly diagnosed form of leukemia in the Western world, accounting for approximately 20%30% of all cases of leukemia. Despite recent medical and scientic advances, the literature on the subjective experience and nursing care of patients diagnosed with CLL remains scarce and sporadic. This article pro- vides a brief overview on the pathophysiology, clinical characteristics, and treatment options of CLL with focus placed on implications for nursing care. Fatigue, the most common symptom reported by patients, and infection, the leading cause of disease-related deaths, also will be addressed. Emerging data examining quality of life and the incidence of anxiety and depression in this patient population will be reviewed, and strategies aimed at addressing the educational needs of patients and family members will be discussed. Caring for Patients With Chronic Lymphocytic Leukemia At a Glance F Chronic lymphocytic leukemia (CLL) is a common and often chronic hematologic malignancy that has undergone major medical and scientic advances since the late 1990s. A deeper understanding of the pathology, diagnosing, staging, and treatment of CLL is necessary to provide com- prehensive and holistic care. Nursing interventions aimed at patient education, symptom management, and quality of life can have a positive effect on the lives of patients and their families. Erin E. Elphee, RN, BN, is a primary clinic nurse at CancerCare Manitoba in Winnipeg, Canada. No nancial relationships to disclose. (Submitted July 2007. Accepted for publication September 1, 2007.) Digital Object Identier: 10.1188/08.CJON.417-423 H earing the words cancer or leukemia for the rst time can be frightening and conjure feelings of uncertainty (Hays & McCartney, 1998). Advances have been made across healthcare disciplines in recent years to gain a greater understanding of how best to diagnose, treat, and predict the prognosis of patients diagnosed with chronic lymphocytic leukemia (CLL). However, despite a plethora of information, the literature does not provide nurses with an adequate guide on how to best care for patients with CLL (Breed, 2003; Hays & McCartney). Knowledge and support from oncology nurses are crucial for patients and their family members as they work through the disease trajectory and transition into a stage of living with an often chronic and incurable illness. Approximately one-third of patients with CLL are asymp- tomatic at the time of diagnosisoften found during a routine blood countand another one-third may not require immediate intervention but, instead, adopt a watchful waiting approach (Dighiero & Binet, 2000). All patients with CLL, regardless of their risk classication, should receive care tailored to meet their specic needs as both patients with cancer and patients living with a chronic illness. Incidence and Epidemiology CLL remains the most widely diagnosed type of leukemia in the Western world, accounting for about 20%30% of all leukemia diagnoses (Redaelli, Laskin, Stephens, Botteman, & Pashos, 2004). The true incidence remains unknown, but recent epidemiology and population studies are shedding new light on the subject. The annual age-adjusted incidence of CLL in the United States is reported as 3 cases per 100,000, whereas a Canadian population- based study, which accounted for cancer registry data as well as centralized ow cytometry data, reported an incidence rate as high as 10.5 cases per 100,000 (Banerji et al., 2006; Yee & OBrien, 2006). Exact occurrence rates may be difcult to deter- mine because asymptomatic patients with low-risk disease who are diagnosed by family practitioners may not require treatment, negating the need for referral to a specialist and possibly keeping them off of cancer registry databases. CLL has been referred to as a disease of older adults, and re- cent statistics continue to conrm this characterization; the me- dian age at diagnosis is approximately 6068 years in the United States and slightly higher in Canada (72 years) (Banerji et al., 2006; Shanafelt & Call, 2004). Eighty-one percent of patients are This material is protected by U.S. copyright law. Unauthorized reproduction is prohibited. To purchase quantity reprints, please e-mail reprints@ons.org or to request permission to reproduce multiple copies, please e-mail pubpermissions@ons.org. 418 June 2008 Volume 12, Number 3 Clinical Journal of Oncology Nursing diagnosed at age 60 or older (Yee & OBrien, 2006) and men are more likely at a ratio of 1.8:1, but the gap has narrowed in recent years (Shanafelt & Call). Combined efforts in science and medicine to better understand the action mechanism of CLL and the clinical course of the disease will lead to the development of new treatments and the renement of existing ones. Access to specialized care, new and expensive drug treatments, and enrolment in clinical trials will become the impetus for patients to be transferred from general practitioner care to regional oncology centers. Consequently, oncology nurses will come into contact with more patients with CLL and their families, necessitating the need for further education. Etiology The cause of CLL is unknown. No convincing evidence links the diagnosis to previous chemotherapy or radiation expo- sure, as seen with acute leukemias, and no clear link to viral exposure, past or current nicotine use, or diet has been noted (Faguet, 1994). Although no clear hereditary pattern has been determined in patients with CLL, it is estimated that 10% of patients also have a family history of CLL or another lympho- proliferative disorder (Houlston, Catovsky, & Yuille, 2002). For those patients, the term anticipation is used to refer to a CLL diagnosis that often appears earlier and in a more severe form in successive generations (Yuille, Houlston, & Catovsky, 1998). Nurses should reassure patients and their families of the vari- able and typically chronic nature of CLL and provide emotional support aimed at minimizing uncertainty. Current practice guidelines do not support routine screening for CLL in family members (Oscier et al., 2004). Pathophysiology CLL is a disease characterized by the accumulation of a clonal population of small, morphologically mature but immunologi- cally immature B lymphocytes. Small lymphocytic lymphoma, once classied separately from CLL, is now considered to be the same entity and is treated in a similar manner despite the absence of lymphocytosis (Harris et al., 1999). Both small lym- phocytic lymphoma and CLL are marked by an accumulation of lymphocytes within the peripheral blood, bone marrow, lymph nodes or tissue, and spleen. The cells have escaped apoptosis, or programmed cell death, and continue to accumulate at variable rates depending on disease severity (see Figure 1). On the surface, malignant lymphocytes possess specic antigens that can be detected and identied by ow cytometry. When surface antigens are present in a specic combination, they become characteristic of CLL and help to distinguish CLL from other indolent lymphomas, such as marginal zone or fol- licular lymphomas, which may present clinically in a similar manner and make an accurate diagnosis difcult. The charac- teristics surface antigens of the CLL phenotype express include CD5, CD19, CD23, and CD20 (expressed at lower levels). The use of ow cytometry has allowed for accurate classication and treatment of leukemias and lymphomas and has contributed to improved patient outcomes. Clinical Features Approximately 70%80% of patients are diagnosed during a routine blood count (Oscier et al., 2004) and are asymptomatic at the time of diagnosis. One-third of those diagnosed will never require treatment and will die of causes unrelated to CLL; one- third will require treatment at some point in the disease trajec- tory; and the nal one-third will require immediate intervention at the time of diagnosis (Dighiero & Binet, 2000). The hallmark sign of CLL is lymphocytosis with an absolute lymphocyte count greater than 5 x 10 9 /L. All patients with an elevated lymphocyte count should have ow cytometry to con- rm the presence of characteristic surface antigens and further rule out other lymphocytosis causes. Patients should be periodi- cally monitored with repeat blood counts if their lymphocyte count is 3 x 10 9 /L5 x 10 9 /L, as they may develop CLL in the future (Binet et al., 2006). Classic signs of CLL include enlarged lymph nodes, he- patomegaly, splenomegaly, anemia, and thrombocytopenia. Cytopenias often occur in more advanced disease stages. Ap- proximately 15% of patients will present with B symptoms, including weight loss of more than 10% total body weight, drenching night sweats, fatigue, and fever (the least likely of systemic symptoms). Fatigue is the most commonly reported symptom and its incidence does not differ between treated and untreated patient groups (Levin, Li, Riskind, & Rai, 2007; Molica, 2005). Patient age does not appear to inuence the pres- ence of symptoms, with no difference in clinical ndings found between younger (55 years or less) and older patient populations (de Lima, OBrien, Lerner, & Keating, 1998). Disease-related complications may be present in advanced cases at the time of diagnosis but can occur at any point in the disease trajectory. Complications include the presence of Figure 1. Scanning Electron Micrograph of Blood Cells on a Filter, From a Patient With Chronic Lymphocytic Leukemia Note. Copyright 2008 by SPL/Photo Researchers, Inc. All rights reserved Used with permission. Clinical Journal of Oncology Nursing Volume 12, Number 3 Caring for Patients With Chronic Lymphocytic Leukemia 419 autoimmune hemolytic anemia, idiopathic thrombocytopenia purpura, red cell aplasia, infection, and transformation into a more aggressive form of disease (either prolymphocytic leuke- mia or large cell lymphoma (Richters transformation). Approxi- mately 10%20% of patients with CLL will develop autoimmune complications, and patients treated with purine analogues, such as udarabine, are at greater risk of developing hemolysis. It is important that nurses are aware of the complications and moni- tor for symptoms, possibly allowing for early identication and intervention (Palma et al., 2006). Patients undergoing Richters transformation often will present with rapidly enlarging nodes in one area, weight loss, fatigue, elevated lactate dehydrogenase levels, and symptoms of a more aggressive disease. The risk of Richters transformation does not increase with time, affecting only 5%10% of patients; however, when it does occur, the median survival is only ve months (Oscier et al., 2004). Staging Two clinic-based staging systemsthe Rai and the Binet systemsare widely used to classify patients with CLL. Both are useful in estimating disease prognosis and stratifying treatment populations, with the Rai system more widely used in North America (see Table 1). In addition, both systems correlate pa- tient survival and use the presence or absence of organ inltra- tion and cytopenias (see Table 2). The Rai system classies ve stages (0 through IV) of CLL but notes that there are only three patterns of survival: low, intermediate, and high. This helps clinicians determine the most appropriate time to commence treatment (Rai et al., 1975). In addition to these clinical ndings, prognostic markers are useful to assess the extent of disease and determine the likeli- hood of treatment response. Key markers are highlighted in Table 3, along with the clinical signicance of each. Surrogate clinical markers also have been identied that are more ac- cessible, less costly, and can assist clinicians in assessing the extent and severity of the disease. Characteristics of aggressive or advanced CLL are outlined in Table 4 and include a lympho- cyte doubling time of less than one year; diffuse bone marrow involvement; elevated b-2 microglobulin; an elevated lactate dehydrogenase level; and the presence of surface antigens CD23 and CD38, with CD38 being used for prognostic rather than diagnostic purposes (Palma et al., 2006). Survival times have increased with the addition of effective therapeutic options. Survival times range from less than 2 years in advanced cases to 10 years for patients with low-risk disease. Younger patients often die from disease-related complications, whereas older patients die from causes unrelated to CLL (Oscier et al., 2004). Treatment Options All treatment options for CLL represent an effort to slow disease progression and manage symptoms rather than provide curative therapy. It is crucial that a collaborative approach is carried out, one that includes a discussion of patient values and wishes regarding treatment. Treatments can be complex, and considerable patient counseling by nurses will help to allevi- ate fears of possible side effects, answer questions about how treatment will impact patients lives, reinforce the rationale for initiating treatment, and serve as emotional support along patients journies. A broad range of treatment options are available today, and it is important that a step-wise progression is implemented to en- sure maximum benet and minimal toxicity. The least invasive management strategy involves careful monitoring of bloodwork and symptoms at regular intervals with the intent to treat when specic clinical parameters have been met. This approach often is labeled watchful waiting, and some patients may feel that noth- ing is being done. On the contrary, watchful waiting is a dynamic 0 III IIIIV Table 1. Rai System for Classifying Chronic Lymphocytic Leukemia RAI STAGE CLINICAL MEDIAN SURVIVAL RISK FEATURES (YEARS) Lymphocytosis greater than 5 x 10 9 /L Lymphocytosis plus splenomegaly with or without hepato- megaly and with or without lymphade- nopathy Anemia (hemoglobulin less than 110 g/l) Thrombocytopenia (platelet count less than 100 x 10 9 /L) Low Intermediate High > 10 79 1.55 A B C Table 2. Binet System for Classifying Chronic Lymphocytic Leukemia BINET STAGE CLINICAL MEDIAN SURVIVAL RISK FEATURES (YEARS) Hemoglobulin greater than 100 g/l and platelet count great- er than 100 x 10 9 /L Less than three lym- phoid areas Hemoglobulin greater than 100 g/l and platelet count great- er than 100 x 10 9 /L More than three lym- phoid areas Hemoglobulin less than 100 g/l, platelet count less than 100 x 10 9 /L, or both Low Intermediate High > 10 7 5 420 June 2008 Volume 12, Number 3 Clinical Journal of Oncology Nursing process with considerable dialogue between patients and nurses. Patients often feel anxious and uncertain about the future because this approach dees their instinct to immediately ght the cancer. Patient education about the nature of the disease and the develop- ment of a trusting relationship between patients and nurses will facilitate discussion about patients priorities and life goals. This helps them adjust to their diagnosis in a healthy manner. Alkylating agents, such as chlorambucil, were the CLL treat- ment of choice for decades, but nucleoside analog-based regi- mens (with udarabine being the most commonly used) have now become the standard of care (Keating et al., 1991; Rai et al., 2000). Oral preparations of both chlorambucil and udarabine are convenient, inexpensive, and well-tolerated treatment op- tions that contain minimal side effects of mild nausea, abdomi- nal discomfort, diarrhea, joint discomfort, and cytopenias. The risk of myelosuppression is higher with udarabine and can persist over time, which can affect future treatment options if not closely monitored (Yee & OBrien, 2006). Fludarabine and cyclophosphamide used in combination have shown longer progression-free and treatment-free survival versus single-agent udarabine and has become the standard rst-line therapy despite no difference in overall survival (Palma et al., 2006). Combination regimens with rituximab and/or cy- clophosphamide also have been shown to have better response rates (measured by blood counts, lymph nodes, and spleen sizes) than udarabine alone, with overall response rates of 90% and 73%, respectively (Oscier et al., 2004), but single-agent treat- ments in either oral or IV form may be more appropriate for older adult patients and patients with multiple comorbidities. IV regimens require greater time spent receiving chemotherapy but generally are well-tolerated. Alemtuzumab is a monoclonal antibody that may be an ap- propriate treatment option for patients who are refractory to udarabine-based regimens (Lynn, Williams, Sickler, & Burgess, 2003). Careful patient selection and close monitoring are im- perative because of dose-related side effects, the increased risk of developing a life-threatening infection because of both B- and T-cell depletion, and risk of marrow suppression and associated complications (Lynn et al.). The treatment can be supervised and symptoms managed by knowledgeable nurse clinicians. Allogeneic stem cell transplantation in patients with CLL is an option that offers patients a possible cure or prolonged disease-free survival (Esteve et al., 2001). However, it comes with considerable risk of mortality and is not an appropriate alternative for all patients. Patients younger than 65 who have not had success with conventional treatments and otherwise have a poor prognosis may be the best candidates for trans- plantation. Khouri et al. (2002) studied 28 patients with CLL and reported an improved ve-year progression-free survival rate in previously untreated patients (78%) compared with che- motherapy-refractory patients (31%), suggesting that treatment with stem cell transplantation should be a consideration earlier than previously thought in the trajectory. Reduced intensity or nonmyeloablative transplantations showed good response rates with less patient toxicity (Abbott, 2006). Clinical trials also are ongoing to evaluate the efcacy of new agents such as avopiridol, a synthetic avone with antiprolif- eration and apoptosis-inducing abilities, and lenalidomide, a thalidomide analog in CLL treatment (Wierda, 2006). In addition to the new agents, drugs such as pentostatin and cladribine also are being studied as possible treatment options (Wierda). The decision to initiate treatment should be guided by the disease stage, symptom presence, and disease activity. No clear indication shows that early treatment initiation prolongs overall survival, therefore, patients with limited-stage disease should not be treated unless symptomatic. The International Workshop on Chronic Lymphocytic Leukemia composed of an international panel of experts in CLL met and developed guidelines for the initiation of treatment, including Rai stage III or IV disease; early- stage disease with the presence of bothersome symptoms; rapid lymphocyte doubling time; declining bone marrow function as evidenced by progressive anemia and thrombocytopenia; and rapidly enlarging lymph nodes (Binet et al., 2006). IgV H mutational status Deletion 17p Trisomy 12 Deletion 11q Deletion 13q P53 mutation Zap 70 Table 3. Key Prognostic Markers and Clinical Implications in Chronic Lymphocytic Leukemia CHROMOSOMAL ABNORMALITY IMPLICATION FOR DISEASE Unmutated status suggests poor outcome. Aggressive disease progression; drug resistenace Shorter treatment-free survival Aggressive disease progression; presence of bulky lymphadenopathy Indolent disease progression; good prognosis Poor response to conventional che- motherapy Correlates with unmutated IgV H
and associated with poor prognosis Lymphocyte doubling time Bone marrow b-2 microglobulin Lactate dehydrogenase Surface antigens CD38 and CD23 Serum thymidine kinase Table 4. Surrogate Markers in the Prognosis of Chronic Lymphocytic Leukemia SURROGATE MARKER INDICATION OF ADVANCED OR AGGRESSIVE DISEASE Less than one year Diffuse involvement with chronic lymphocytic leukemia Elevated Elevated Present Elevated IgV H immunoglobulin heavy chain variable gene Clinical Journal of Oncology Nursing Volume 12, Number 3 Caring for Patients With Chronic Lymphocytic Leukemia 421 Surgical intervention, such as the removal of lymph nodes, currently is not an option in CLL treatment outside of the initial disease diagnosis or to rule out Richters transformation. Sple- nectomy may serve as a treatment for steroid resistant idiopathic thrombocytopenic purpura or persistent splenomegaly. Nursing Care The earliest case report found in the research literature dates back to 1951 when a nursing student published a report in the American Journal of Nursing detailing the case of a woman diagnosed with CLL who was admitted to a hospital with recur- rent infection, ecchymosis, mouth sores, massive splenomegaly, and extensive lymphadenopathy (Yura, 1951). Yura stressed the importance of patient education, frequent bloodwork to monitor disease progression, the importance of guarding against infection, and tailoring nursing care to ensure that the patient was as com- fortable and happy as possible. Little has changed in the nursing focus for the past 55 years, but it is important that nursing manage- ment strategies are revisited to ensure practice remains current. Nursing Assessment Nursing assessment of patients with CLL should start with a head-to-toe physical assessment, with particular attention paid to B symptoms typical of the patient population. Family history of cancer and blood cancers should be determined to rule out any familial patterns. In addition, patients should be asked about their own history of cancer, as there appears to be an increased risk of second malignancy in both treated and untreated patients, and an increased incidence of melanoma and nonmelanomatous skin cancers, cancer of the larynx, lung, brain, stomach, and bladder in the patient group (Oscier et al., 2004; Shanafelt & Call, 2004). Counseling about sun protection, regular skin examinations, and routine cancer screening according to regional and national guidelines should be encouraged and conducted in all CLL pa- tients regardless of the disease extent. Complete blood counts should be reviewed and interpreted as pieces of a larger puzzle. Elevated blood counts examined alone can cause confusion and frustration, but when connected and viewed as a whole, they may illustrate a very different picture. For example, a lymphocyte count of 20 x 10 9 /L may cause alarm and panic for nurses and patients if considered in isolation. But when the lymphocyte count is trended over time and found to be stable over the past year, coupled with normal platelet and hemoglobin values in asymptomatic patients, there is less cause for concern as little has changed in the patients disease status. A focused assessment should address patients energy levels or their degree of fatigue; appetite and current weight; the presence of fever, chills, or recent infection; palpable lymph nodes; and the presence of drenching night sweats (see Table 5). The assessment of fatigue and infection, the most frequently reported physical symptom and most common complication of CLL, will be discussed further. Fatigue Fatigue is the most commonly reported symptom, and its ac- tion mechanism is poorly understood (Mandrell, 2004). Patients with CLL report more fatigue and lower role performance func- tion than age-matched healthy controls; however, no signicant difference was found between previously treated and untreated patients (Holzner, Koppe, Nguyen-Van-Tam, Sperner, & Greil, 2004). Advanced disease and age also are risk factors for fatigue development. Assessment and intervention can help patients better manage their symptoms and improve overall quality of life. Sources of underlying fatigue, including stress, anemia as a result of the disease, treatment or autoimmune complications, infection, dehydration, the presence of comorbid conditions such as diabetes, and insomnia resulting from treatment with corticosteroids should be assessed and addressed. Patients should plan activities for times when they are rested and attend to one activity at a time. When educating patients, ensure that they are rested and provide information in smaller amounts rather than all at once. Patients also should be encour- aged to engage in regular physical activity, eat a well-balanced diet, take naps if necessary, and talk to their healthcare team about management strategies (Graydon, Bubela, Irvine, & Vin- cent, 1995). For patients interested in more information on diet and exercise, referrals within the multidisciplinary team, such as physiotherapy and nutrition services, can be valuable sources of information. Cancer risk Psychosocial Integumentary Respiratory Gastrointestinal Genitourinary Complete blood count Table 5. Focused Nursing Assessment in Chronic Lymphocytic Leukemia SYSTEM ASSESSMENT Personal cancer history Family history of cancer and chronic lym- phocytic leukemia Previous cancer experiences or contacts Presence of anxiety, depression, and over- all well-being Presence of uncertainty related to their condition Presence of skin rashes, lesions, or moles Abnormal bruising or bleeding Drenching night sweats Fever Enlarged lymph nodes in neck, axilla, and groin Persistent or productive cough Signs of sinusitis Adventitia or crackles on auscultation Chest pain Mouth sores Weight loss Appetite Presence of abdominal bloating or discom- fort (splenomegaly) Dysphagia Urinary frequency or dysuria Symptoms of infection White blood count, lymphocyte count, hemoglobin, platelets, reticulocyte count 422 June 2008 Volume 12, Number 3 Clinical Journal of Oncology Nursing Infection Recurrent infections are another hallmark symptom of CLL. Infection is the leading cause of disease-related deaths, with an estimated 80% of patients developing moderate to life-threaten- ing complications at some point in the course of their illness, and up to 60% of deaths attributed to infection (Morrison, 1998). Mucosal tissue, particularly upper and lower respiratory tract infections, are the most commonly affected sites and patho- gens. Staphylococcus aureus, Streptococcus pneumonia, and Hemophilus inuenza are the most common culprits (Chapel & Bunch, 1987; Morrison). Patients also are at risk of developing life-threatening viral and fungal infections as a result of their compromised immunity, which is characteristic of the disease and treatment (Chapel & Bunch, 1987). Humoral and cellular immunity defects, T-cell dysfunction, and hypogammaglobulinemia make patients with CLL more suscep- tible to infection. Patients who have received multiple chemother- apy regimens in the past or who have advanced disease are at higher risk of developing severe infectious complications than pa- tients with more indolent disease (Hensel, Kornacker, Yammeni, Egerer, & Ho, 2003). Hypogammaglobulinemia often is a late com- plication, with 70% of patients developing this condition seven years after diagnosis (Rozman, Montserrat, & Vinolas, 1988). Low dose IV immunoglobulin therapy minimizes the frequency and severity of infections for these patients (Morrison, 1998). Early symptom recognition and reporting is vital. Patients should be taught to monitor for fevers, persistent cough, and urinary symptoms from the time of diagnosis and report these symptoms. Patients on active treatment with purine analogs and alemtuzumab should have their blood checked regularly for cytomegalovirus reactivation and should receive leukocyte- depleted and irradiated blood products to reduce the incidence of graft-versus-host disease and blood-borne viral infections. Cy- tomegalovirus reactivation can be life threatening and should be immediately checked if patients become febrile. Pneumocystis carinii pneumonia from steroid therapy and herpes infection can occur if medication compliance to prophylactic antibiotics and antivirals for patients with a past history of recurrent infec- tions or on active treatment is not followed. Quality of Life Despite the frequency of diagnosis and the chronic nature of CLL, little attention has been paid in the literature to the experience of patients living with CLL (Bertero & Erikkson, 1997; Holzner et al., 2004; Montgomery, Popcock, Titley, & Lloyd, 2002). Clinicians believed for decades that patients on watchful waiting were more anxious than those receiving ac- tive treatment, but no research supported this belief. Levin et al. (2007) published results of a cross-sectional study examining depression, anxiety, and quality of life in treated and untreated patients with CLL (N = 105), and no difference was found be- tween the two groups in depression level, anxiety, and mental or physical function. The study supported Holzners (2004) ndings that watchful waiting patients reported similar quality of life and psychosocial morbidity to those who had received chemotherapy in the past. However, patients younger than 60 reported lower levels of emotional and social quality of life and higher levels of anxiety. Older patients with CLL generally do better emotionally than younger patients (Levin et al., 2007), and women generally report lower emotional and social function scores; noteworthy because the prognosis for male patients with CLL is worse than female patients. Nurses can use this information to identify patients at risk for psychological distress and poor diagnosis adaptation. All patient assessments should be individualized and address domains beyond physical characteristics to provide the most comprehensive and holistic nursing care. Studies examining quality of life, depression, and anxiety in both treated and untreated patients with CLL will change patient care as they validate the importance of nursing assessment and psychosocial interventions on patient outcomes. More attention should be given to the psychosocial needs and coping strate- gies specic to these patients. Social worker referrals can help patients transition through times of relapse and progression and prevent the development of severe psychological distress. Nurses should use research ndings to identify patients at high risk for psychological distress and poor coping with a chronic ill- ness. Uncertainty, unlike anxiety, is not a medical diagnosis and the presence of uncertainty in patients with cancer can affect psychological adaptation and be a signicant source of stress that leads to less optimism and creates adjustment issues for patients and family members (Mishel, Hostetter, King, & Graham, 1984). Patient Education Nursing assessment and education should start early in the nurse-patient relationship, enabling them to take control and manage their own health. The provision of information (both one-on-one and in larger group settings) about the natural course of CLL, symptom progression, and treatment side effects is important when addressing patient uncertainties and when bringing patients together to talk with and nd support from others in similar situations. Helping patients identify which aspects of their lives are important allows nurses to encourage and facilitate realistic appraisal and adaptation to the illness (Montgomery et al., 2002). Patients should be encouraged to involve their family and friends in their care rather than isolate themselves or keep their diagnosis private. Social support provides patients with an emotional and social network as they cope and make lifestyle changes. Patients who express interest should be encouraged to join support groups and share stories with other patients with CLL. Conclusion As new information becomes available on the incidence, diag- nosis, treatment, and outcomes of patients with CLL, it is impor- tant that oncology nurses review the information and integrate relevant ndings into their daily practice. New diagnostic tools and the often indolent nature of the disease mean that more pa- tients will be living with CLL, requiring nursing assessment and intervention at some point in the disease trajectory. Nursing care should be individualized to meet each patients unique needs and address their specic questions and concerns. Attention should be paid to disease and treatment side effects, disease complica- tions, symptom management, infection risk, and patient educa- tion to help patients adjust and adapt to their diagnosis. Clinical Journal of Oncology Nursing Volume 12, Number 3 Caring for Patients With Chronic Lymphocytic Leukemia 423 Author Contact: Erin E. 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C. J. Mieny, U. Mennen: Principles of Surgical Patient Care - Volume II Chapter 11: Vascular Trauma Chapter 11.1: Principles and Management J. V. Robbs