Data are now accumulating on the feasibility of various treatment options even in unfit patients and there is an increased awareness that the chronological age by itself sometimes does not reflect patient functional status. Clinical assessment of patients should also take into account the comorbidities and the polypharmacy that are strictly associated with older age. However, the reliability of methods proposed for assessing and measuring patient fitness status still require large and comprehensive validation. This represents a challenging duty for physicians treating CLL patients in the day-to-day practice. What is clear is that any method of measuring fitness in CLL patients must be simple and easy to use in clinical practice.
From a clinical standpoint, the following concepts remain valid for elderly patients with CLL:
Treatment should be given only to symptomatic patients with active disease since there is no clinical evidence that an earlier treatment will improve clinical outcome in terms of OS;
The best initial therapy for elderly patients with chronic CLL has not yet been defined;
Several rituximab-based options of chemoimmunotherapy (e.g., FCR-Lite, R-B, leukeran plus rituximab) are feasible in the front-line setting in elderly patients selected on the basis of performance status, presence of comorbidities and the goals of treatment (Figure 2). The role of new anti-CD20 monoclonal antibodies (i.e., ofatumumab, GA101) is being tested in ongoing clinical trials;
Patients with relevant comorbidities not suitable for chemoimmunotherapy should be treated only with chlorambucil. Alternatives are bendamustine or single-agent fludarabine given as an attenuated dose;
New single agents with reduced toxic effects (i.e., inhibitors of BCR signalling) that have achieved promising results in Phase I/II studies when available will eventually replace chemotherapy.
Schematic representation of the aims of treatment and treatment options in the day-to-day practice for patients with chronic lymphocytic leukemia depending on their level of fitness. B: Bendamustine; BSC: Best supportive care; CLB: Chlorambucil; CR: Complete response; FCR: Fludarabine–cyclophosphamide–rituximab; OS: Overall survival; PFS: Progression-free survival; R: Rituximab.
Expert Rev Hematol. 2013;6(4):441-449. © 2013 Expert Reviews Ltd.