There is therefore a clinical need to design specific treatments for older patients who often have multiple co morbidities.32,33 It  together with patients AMG 900 and their families. Apart from prolonging life to the predicted life expectancy of an individual, treatment of elderly patients with cancer should aim to improve or maintain quality of life. Although age is a helpful indicator of what the treatment goal should be, there is a considerable grey area in patients between 55 and 70 years of age. A patient,s performance status rather than their chronological age can be more informative. Scoring systems such as the Cumulative Illness Rating Scale to establish and quantify co morbidities have been validated in the elderly and are being used as part of clinical trials.
34 Their value in day to day clinical practice is less clear. The GCLLSG utilises this scoring system to stratify patients based on CIRS score,Go Go, patients have a low co morbidity score and a normal creatinine clearance, and,Slow Go, patients have relevant comorbidities. On the other hand, in young patients without comorbidities, curative options should at least be considered. Intimately linked to these considerations is the desired depth of response. There is clear evidence that minimal residual disease eradication is associated with a better overall survival as well as progression free survival providing a clear rationale for using the most effective treatment available up front.
18,35 This is also corroborated by emerging long term follow up data suggesting that sequential treatment with chlorambucil followed by fludarabine shortens OS compared to fludarabine treatment up front,36 and therefore implying that the most effective treatment should be given preference. However, whether eradication of MRD should become a treatment goal and obtained with maintenance treatment remains an area of active research.37 The treatment algorithm proposed in this review is summarized in Figure 1. A summary of pivotal clinical trials defining treatment for patients with CLL is given in Table 1. Go Go 1st line treatment Over the last decade, considerable progress has been made in the treatment of physically fit patients with CLL. Purine analogue combinations have improved treatment outcomes.38,39 Importantly, we have witnessed a paradigm shift in the management of CLL changing for the first time the natural history of the disease.
The German CLL8 study compared FC versus FCR and demonstrated that therapeutic intervention in CLL led to an improved overall survival in patients with CIRS scores of,6.40 There was no upper age limit for this study, but the median age was 61 years. Only 10% of patients were /70 years old. Overall response rates were 80% vs 90% for FC and FCR, respectively. At 3 years after randomisation, 65% of patients in the chemoimmunotherapy group were free of progression compared with 45% in the chemotherapy group, 87% were alive versus 83%, respectively.40 Patients with del11q benefitted particularly from the addition of rituximab. On the other hand, neither FC nor FCR were effective at treating patients with del17p. Following the publication of this study, FCR is considered the new standard of care for fit patients with CLL in first line treatment.