Chronic lymphocytic leukemia management in India: balancing evidence, access, and affordability in clinical practice.

Management of Chronic lymphocytic leukemia (CLL) has undergone a paradigm shift, moving from chemoimmunotherapy (CIT) to precision, biology-driven treatment with targeted agents. While these advances have rapidly reshaped practice in high-resource nations, their integration into routine care in India is limited by differences in epidemiology, healthcare infrastructure, drug access, and economic constraints. CLL remains relatively uncommon in India, with patients presenting at a younger age and historically at more advanced stages of disease. Nevertheless, there is a temporal shift towards earlier diagnosis with the wider use of hematological testing. Risk stratification has also evolved from clinical staging to molecular profiling incorporating TP53 mutation testing, IGHV mutation status, and cytogenetic abnormalities. However, access to molecular profiling remains limited across India, directly influencing therapeutic decision-making. Bruton tyrosine kinase inhibitors (BTKi) and BCL-2 inhibitors have demonstrated superior efficacy and tolerability compared to CIT across biological subgroups and are endorsed by international guidelines. In India, treatment selection continues to balance biological risk with access and affordability. The introduction of generic ibrutinib has been important, especially for TP53 mutated CLL, while uptake of venetoclax-based fixed-duration regimens has been limited by cost and monitoring requirements. CIT retains a limited role in selected young, IGHV-mutated patients with durable responses. This review examines contemporary CLL management through an Indian lens, emphasizing how global advances intersect with real-world constraints and influence local practice. Improving access to molecular diagnostics and targeted agents along with health-policy reforms is essential to narrow the outcome gap between Indian and Western patients with CLL.