Treatment

The first decision to be made in CLL is whether the patient requires treatment at the time of initial diagnosis. This cautionary approach is based on the older age of the patient, the heterogeneity of the disease course, and lack of evidence that early treatment affects long-term survival. Given these vagaries, the NCIWG has devised guidelines for the initiation of treatment for CLL.77,78 These include constitutional symptoms, progressive bone marrow failure, AIHA and ITP poorly responsive to corticosteroid therapy, massive or progressive lymphadenopa-thy or splenomegaly; progressive lymphocytosis, or a doubling time less than 6 months. Hypogammaglobulinemia or the development of a monoclonal protein alone are not sufficient criteria to initiate therapy. Response criteria guidelines have also been established by this group (Table 7-3).

Chemotherapy

For several decades, the backbone of chemotherapy in CLL has been either of two alkylating agents, chlorambucil (CLB) and cyclophosphamide (CTX), with or without the addition of cor-ticosteroids. Both agents are rapidly absorbed from the gastrointestinal tract and can be administered orally.79,80 Doses

Table 7-3. National Cancer Institute Working Group

Response Criteria for Chronic Lymphocytic Leukemia

Parameter

CRa

PRa

Lymphocytes

< 4.0 x 109/L

> 50 percent 4

Lymph nodes

No palpable disease

> 50 percent 4

(liver, spleen)

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