Answer is A (Treatment should be initiated as soon as diagnosis is established) It is not essential to initiate treatment as soon as a diagnosis of CLL is established. 'An unusual feature of CLL compared to other leukemias is that making the diagnosis is not necessarily an indication to initiate treatment' - DeVita Treatment need not be initiated as soon as diagnosis of CLL is established Early stage asymptomatic disease requires no treatment. CLL may be diagnosed in an asymptomatic patient and have a prolonged course. Meta-analysis has shown no survival advantage of initiating treatment in early stage disease. Active monitoring should however be pursued and treatment initiated only if and when the patient meets established 'criteria for treatment'. Criteria for treatment Progressive marrow failure Massive(>10cm)/progressive lymphadenopathy Massive (>6cm)/progressive splenomegaly Progressive lymphocytosis (doubling time <6 months) Systemic symptoms; Weight loss >10%in 6 months fever>38deg C for >2 weeks extreme fatigue or night sweats Autoimmune cytopenias (this may only require treatment of the autoimmune component not necessarily the leukaemia) Chlorambucil and Fludarabine are the most commonly used agents. The most common treatment for CLL are Chlorambucil or Fludarabine alone or in combination. Chlorambucil Can be administered orally and has few side effects Less active than Fludarabine and usually unsuccessful in achieving remission Most common agent chosen for treatment of elderly patients requiring therapy. (Majority of elderly patients have significant comorbid conditions associated with aging and may have an indolent disease) Fludarabine Administered intravenously and has significant side effects (Significant immune suppression) More active agent and by far the only drug associatedwith a significant incidence of complete remission Preferred agent for treatment of young patientsrequiring therapy Fludarabine is often used incombination with Cyclophosphamide (FC).Following theresults of LRF CC4 Trial many now consider FC to be thegold standard first Line treatment of CLL in the young Young patients are candidates for Bone marrow transplanatation Bendamustine is an alkylating agent structurally related to nitrogen mustards that is highly effective and is vying with fludarabine as the primary treatment of choice. Rituximab (AntiCD20) and Alemtuzumab (anti CD52) may also be used. `Young patients with CLL can be candidates for Allogenic bone marrow transplantation. Allogenic bone marrow transplantation can be urative but is associated with a significant treatment related moality rate' - Harrison