There is no evidence that early treatment improves survival in CLL compared to watching and waiting until symptoms arrive. Because the potential side effects of the treatment are so worrying many patients are quite pleased when their doctor tells them that there is not treatment necessary at the present time. However, because treatment is so scary there is a great temptation to prolong the watching and waiting beyond the time when NCI guidelines suggest that treatment should begin. This can be dangerous.
The NCI guidelines should be interpreted sensibly. Fatigue, for example must be the sort of fatigue that disables; that prevents a patient from carrying out normal activities like going to work or managing the house work. It shouldn't be just the 'tired all the time' symptom that is the commonest reason for doing a blood test. Similarly night sweats should be out of the ordinary, not just what most of us get on a hot summer night. Similarly, one platelet count of 95 should not trigger a rush to treatment. Patients with enlarged spleens often have a slightly low platelet count and it doesn't necessarily mean treatment needs to start there and then. The platelet count needs to be falling progressively.
On the other hand patients are apt to let their spleens enlarge and their lymph nodes grow bigger and still put off treatment. The reason that this is dangerous is that it is much more difficult to treat bulky disease than less bulky disease. It is all a question of bone marrow reserve. The drugs used in CLL tend to cause pancytopenia. If they are given late in the disease they cause worse pancytopenia because more of the marrow has been replaced by CLL cells.
As with all things the right course in the treatment of CLL is a moderate one - between the two extremes.