Current perspectives on the role of chemotherapy in chronic lymphocytic leukemia

Chemotherapy has long been integral to the treatment of chronic lymphocytic leukemia (CLL). Fludarabine/cyclophosphamide, chlorambucil and bendamustine are commonly used as a backbone, depending on the patient's age and general health. The advent of the anti-CD20 monoclonal antibodies, such as rituximab and obinutuzumab, altered the face of treatment, and chemoimmunotherapy still forms the current standard first-line approach. However, the landscape is changing following the emergence of novel targeted agents, such as ibrutinib, idelalisib and venetoclax, which offer the chance for improved efficacy over standard therapy alone, with no substantial increase in toxicity. This review focuses on the role of chemotherapy in CLL, discussing the characteristics that define a state-of-the art chemotherapy, the current role of chemotherapy in the treatment of CLL, within the context of guidelines, and its future role in a setting in which chemotherapy-free regimens are being increasingly investigated.