Chronic/ Small Lymphocytic Lymphoma Survey

Question Title

* 1. Please complete the following questionnaire in case you match a study!

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

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* 2. Are you at least 18 years old

Yes

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* 3. Have you been diagnosed with CLL (Chronic Lymphocytic Leukemia)

Yes

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* 4. Have you been diagnosed with SLL (small lymphocytic lymphoma)?

Yes

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* 5. Do you have CLL or SLL that is considered active with at least one of the following:

Worsening of anemia and/or thrombocytopenia?

Enlarged spleen ( > 6 cm)?

Enlarged lymph nodes?

Worsening of lymphocytosis due to CLL or SL?

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* 6. Do you have CLL or SLL unintentional weight loss of greater then 10% within the past 6 months?

Yes

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* 7. Do you have CLL or SLL and experience significant fatigue?

Yes

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* 8. Do you have CLL or SLL and experience night sweats greater then 1 month without evidence of any other infection?

Yes

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* 9. Have you been diagnosed with CLL or SLL and experienced fevers warmer then 100.5 degrees (F) for 2 weeks without any evidence of any other infections?

Yes

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* 10. Have you relapsed or been resistant to at least 1 systemic therapy (2 cycles of treatment) for CLL or SLL?

Yes

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* 11. Is your current neutrophil count greater or equal to 750 cells/microliter and CLL involved in bone marrow?

Yes

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* 12. Is your Hemoglobin greater or equal to 10 g/dL?

Yes

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* 13. Is your platelet count greater or equal too 50,000 cells/ microliter or greater or equal too 25,000 cells/ microliter with CLL bone marrow involvement?

Yes

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* 14. Are liver function tests (AST or ALT) equal or greater then 2.5 times upper normal limit?

Yes

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* 15. Is your bilirubin equal or less then 2 times upper normal limit?

Yes

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* 16. Is your creatinine clearance greater or equal to 50mL/min?

Yes

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* 17. If you are childbearing, are you on effective contraceptive?

Yes

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* 18. Are you able to swallow pills without difficulty?

Yes

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* 19. If you have been on a BTK inhibitor, have you been without evidence of disease progression?

Yes

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* 20. Are you tolerant to acalabrutinib or venetoclax?

Yes

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* 21. If you have had prior malignancy, have you been disease free for at least 2 years and currently not on active treatment?

Yes

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* 22. Are you free of malabsorption diseases or previous surgeries that affect absorption in the GI tract?

Yes

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* 23. Are you free of bleeding abnormalities (hemophilia or von Willebrand disease?

Yes

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* 24. Are you currently not taking anticoagulation medications (ex: warfarin)?

Yes

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* 25. Are you free of a gastrointestinal ulcer for at least 3 months?

Yes

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* 26. If you are on a proton pump inhibitor (omeprazole, esomeprazole, lansoprazole, pantoprazole ETC), would you be willing to switch to an H2-receptor antagonist or antacid?

Yes

Chronic/ Small Lymphocytic Lymphoma

Question Title

* 1. Please complete the following questionnaire in case you match a study!

Question Title

* 2. Are you at least 18 years old

Question Title

* 3. Have you been diagnosed with CLL (Chronic Lymphocytic Leukemia)

Question Title

* 4. Have you been diagnosed with SLL (small lymphocytic lymphoma)?

Question Title

* 5. Do you have CLL or SLL that is considered active with at least one of the following:

Question Title

* 6. Do you have CLL or SLL unintentional weight loss of greater then 10% within the past 6 months?

Question Title

* 7. Do you have CLL or SLL and experience significant fatigue?

Question Title

* 8. Do you have CLL or SLL and experience night sweats greater then 1 month without evidence of any other infection?

Question Title

* 9. Have you been diagnosed with CLL or SLL and experienced fevers warmer then 100.5 degrees (F) for 2 weeks without any evidence of any other infections?

Question Title

* 10. Have you relapsed or been resistant to at least 1 systemic therapy (2 cycles of treatment) for CLL or SLL?

Question Title

* 11. Is your current neutrophil count greater or equal to 750 cells/microliter and CLL involved in bone marrow?

Question Title

* 12. Is your Hemoglobin greater or equal to 10 g/dL?

Question Title

* 13. Is your platelet count greater or equal too 50,000 cells/ microliter or greater or equal too 25,000 cells/ microliter with CLL bone marrow involvement?

Question Title

* 14. Are liver function tests (AST or ALT) equal or greater then 2.5 times upper normal limit?

Question Title

* 15. Is your bilirubin equal or less then 2 times upper normal limit?

Question Title

* 16. Is your creatinine clearance greater or equal to 50mL/min?

Question Title

* 17. If you are childbearing, are you on effective contraceptive?

Question Title

* 18. Are you able to swallow pills without difficulty?

Question Title

* 19. If you have been on a BTK inhibitor, have you been without evidence of disease progression?

Question Title

* 20. Are you tolerant to acalabrutinib or venetoclax?

Question Title

* 21. If you have had prior malignancy, have you been disease free for at least 2 years and currently not on active treatment?

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* 22. Are you free of malabsorption diseases or previous surgeries that affect absorption in the GI tract?

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* 23. Are you free of bleeding abnormalities (hemophilia or von Willebrand disease?

Question Title

* 24. Are you currently not taking anticoagulation medications (ex: warfarin)?

Question Title

* 25. Are you free of a gastrointestinal ulcer for at least 3 months?

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* 26. If you are on a proton pump inhibitor (omeprazole, esomeprazole, lansoprazole, pantoprazole ETC), would you be willing to switch to an H2-receptor antagonist or antacid?

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* 27. If you have had a stroke, has it been greater than 6 months since the event?

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* 28. Has any recent surgery been greater than 7 days?

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* 29. Are you without active fungal, bacterial, or viral infection?

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* 30. Are you HIV negative?

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* 31. If you have Hepatitis B, are you PCR negative?

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* 32. If you have Hepatitis C, are you PCR negative?