Controversies in the front-line management of chronic lymphocytic leukemia

Once considered a simple homogeneous disease, chronic lymphocytic leukemia (CLL) is now recognized to be a heterogeneous lymphoid malignancy with patients classified into low, intermediate, and high-risk categories based on traditional and novel prognostic factors. Purine nucleoside analogues have been the standard first-line approach for over a decade. The recognition of synergistic activity between purine analogues, alkylating agents, and monoclonal antibodies has allowed the introduction of many new active combination therapies for treatment of this disease. The paucity of randomized studies determining the efficacy and tolerability of these new regimens, however, has made therapy selection for individual patients complex and cumbersome. At the present time, it remains unclear whether patients with aggressive disease based on molecular features should receive early or alternative treatment strategies. In this review, we summarize the data on combination chemotherapy and chemoimmunotherapy in CLL and propose several key factors that should be taken into consideration when deciding on an initial treatment strategy. The review is intended to discuss and simplify first-line therapy selection for patients with CLL in the era of new prognostic indicators and the better understanding of disease biology.