Q: My 75 years old father was diagnosed with chronic lymphocytic leukaemia (CLL) three years back. Two years back he was given pulse therapy with Chlorambucil (clokaran) –10 mg/day for two weeks every month for 8 months. All parameters were within limits (haemoglobin - 11.8 g/dl, WBC - 4,500/mcl, lymphocytes - 36%, neutrophils - 60%, platelet - 2.45 lakhs/mcl). Hence the therapy was stopped and the doctor put him under observation. After 10 months, again the parameters increased (WBC - 250,000/mcl and lymphocytes - 90%). Then the doctor advised that Chlorambucil will not benefit the second time, so he used Rituximab and Fludarabine six cycles each, but the toxicity and the cost is very high. We consulted another oncologist who preferred to continue the treatment with Chlorambucil. He also told us that a 75-year-old patient couldn’t sustain the treatment with Rituximab. He prescribed Chlorambucil 10 mg/day for 2 weeks every month for 12 months and again all parameters came within the normal limits - haemoglobin - 12 g/dl, lymphocytes - 34%, nutrophils - 58%, WBC - 3,500/mcl. He stopped the treatment and put him under 6 weeks observation. After 4.5 months of stopping treatment, again his counts have increased - WBC - 16,700/mcl, lymphocytes - 83%, nutrophils - 14%, Hb - 11.7 g/dl, platelets - 2.44 lakhs/mcl). Now the second doctor also wants to shift to the regime of chemotherapy with Rituximab and Fludarabine. My father is physically very fit and walks around 3-4 km per day. He doesn't get sick frequently (once a year upper respiratory tract infection /gastrointestinal problem). Can we continue the treatment with Chlorambucil rather than switching over to Rituximab and Fludarabine? What are the side effects? What are the chances of success (life + disease cure)? Please advise.

A:Treatment plan for CLL - First thing required is whether the patient of CLL needs treatment or not. Generally patients with stage 3 and 4 of CLL (depended on level of Hb and Platelets) require treatment. Controlling total white cell counts and lymphocyte counts is never the aim of therapy in CLL.

1st line therapy - Standard of care for newly diagnosed CLL is Fludarabine + Cyclophosphamide (FC) with or without Rituximab (R).

Overall response rate with FC is ~ 88% and with FCR is 90-95%.

The side effects of FR + C is mainly because of their myelotoxocity and somewhat increased risk of infection.