Chronic lymphocytic leukemia in less fit patients: "slow-go"

The management of "slow-go" patients with chronic lymphocytic leukemia (CLL) remains a primary unmet clinical need. This subgroup of patients, underrepresented in clinical trials, represents the burden of patients with CLL that will progressively increase in future years. Diagnostic tools to identify this patient population are emerging: the Cumulative Illness Rating Scale and reproducible geriatric functionality tests should be included, in addition to the traditional performance status assessment, in the work-up of elderly patients prior to treatment, in order to use a common language and better focus the aims of therapy. Quality of life has to be preserved and evaluated with dedicated tests. Evidence-based therapeutic strategies for "slow-go" patients with CLL are still lacking. Therefore, monotherapy with chlorambucil +/- rituximab and possibly fludarabine or bendamustine remains a first-line option outside clinical trials. Bendamustine +/- rituximab, pentostatin +/- rituximab +/- cy clophosphamide, fludarabine +/- cyclophosphamide at reduced doses, and chlorambucil plus new anti-CD20 antibodies can be options to be assessed within clinical trials, as their claimed acceptable toxicity is formally unproven. Clinical trials specifically designed for "slow-go" CLL are strongly needed, and the enrollment of patients in dedicated trials is recommended. New non-chemotherapeutic drugs could be also explored in this setting.