Advanced CML Treatment Options

The National Comprehensive Cancer Network (2011) recommends clinical trial participation for all patients in accelerated or blast phase CML.

• High-dose combination chemotherapy (chemotherapy plus imatinib, dasatinib, or nilotinib) has demonstrated responses in patients with accelerated phase CML.
• Chemotherapy plus dasatinib or nilotinib should be considered for patients with Philadelphia chromosome-positive blast phase CML.
• Dasatinib or nilotinib alone is an option for patients who progress to accelerated phase following initial TKI therapy.
• The use of allogeneic hematopoietic stem cell transplant (allo-HSCT) has decreased because of the results of imatinib and other TKIs. Advancements in allo-HSCT technology are improving, which in turn is improving outcomes, but survival remains poor for those in advanced CML stages. Studies have also demonstrated that the use of pretransplant imatinib does not have a deleterious effect on transplant outcomes. However, because of the TKIs, allo-HSCT is no longer recommended as first-line treatment for chronic phase CML. It is recommended for patients with T315I mutation and for those who progress to accelerated or blast phases.
• Patients who enter cytogenetic relapse, or increasing molecular relapse following allo-HSCT, may consider imatinib, dasatinib, donor leukocyte infusions, interferon, or PEG-interferon as treatment options.
• Long- term data confirm that 10%–20% of patients treated with interferon alpha have a complete cytogenetic response; however, maintenance on interferon can be difficult because of its side effect profile, causing discontinuation of treatment (National Cancer Institute, 2011a).