Chronic Myelogenic Leukemia Management in the TKI Era: Patient Compliance is Still Critical

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Tyrosine kinase inhibitors have revolutionized chronic myeloid leukemia treatment and changed the role of transplantation in CML management.
Tyrosine kinase inhibitors have revolutionized chronic myeloid leukemia treatment and changed the role of transplantation in CML management.

Tyrosine kinase inhibitors (TKIs) have revolutionized chronic myeloid leukemia (CML) treatment and changed the role of transplantation in CML management, but patient compliance remains a challenge, experts told Cancer Therapy Advisor.

“Nowadays, allogeneic stem cell transplant is limited to young patients with advanced disease and those refractory or intolerant to multiple TKIs,” said Bruno Medeiros, MD, a professor of hematology at the Stanford University Medical Center in California.

Elderly patients are also faring better. If patients are treated before advanced stages of CML, older individuals “seem to do just as well” as younger ones with TKI therapies, said Jeffrey Lipton, MD, PhD, FRCPC, professor of medicine at the University of Toronto in Ontario, Canada, and head of the CML Group at Princess Margaret Hospital.

“The demographics aren't really changing; what's changed is that the treatments in the past were just not tolerable to older patients,” said Dr Lipton. “Now, with newer TKIs, I'm treating people well into their 70s and 80s.”

Early diagnosis and treatment are critical for successful CML management, Dr Lipton told Cancer Therapy Advisor. “Blast-phase CML is a challenge for any patient, but especially because if you have to add cell transplant to TKI, it's a challenge for older individuals. You couldn't give older individuals very intensive chemotherapy that you can give younger patients, and older patients aren't often eligible for bone marrow transplantation, primarily because of comorbidities.”

At a molecular level, CML “doesn't look any different by age,” Dr Lipton noted. But even elderly patients who seem “completely well” may have unidentified comorbidities, he said. “They have less tissue reserve, and there may be effects of aging that we don't identify.”

According to Dr Lipton, more patients are being diagnosed and treated for CML earlier in their disease. “We used to wait for patients to develop symptoms to diagnose them, but now the majority are picked up in the chronic phase, and because of that, it's very uncommon for them to go on to more advanced disease.”

RELATED: First-line Dasatinib Safe, Effective for Long-term Treatment of CML-CP

Age has long been considered a component of intermediate- to high-risk CML, but those scoring systems were developed prior to the current TKI era of CML management. New risk-stratification systems are in development, but “nothing is perfected yet,” cautioned Dr Lipton.

“Risk stratification in CML can be performed by 1 of 3 strategies: Sokal, Hasford, or EUTOS,” explained Dr Medeiros. “But only the EUTOS classification derives prognostic features in newly diagnosed patients with CML treated with imatinib.”

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