‘The HemOnc Pulse’ Live 2024: Unanswered Questions in CML Treatment

Recorded at the first “HemOnc Pulse” Live meeting in Chicago, this podcast episode features a panel discussion on unanswered questions in chronic myeloid leukemia (CML) with Elias Jabbour, MD, a Professor of Medicine in the Department of Leukemia at the University of Texas MD Anderson Cancer Center; Mikkael Sekeres, MD, MS, a Professor of Medicine and Chief of the Division of Hematology at the University of Miami Sylvester Comprehensive Cancer Center; and Sangeetha Venugopal, MD, MS, an Assistant Professor of Medicine at the Sylvester Comprehensive Cancer Center.

The panel first discussed frontline tyrosine kinase inhibitors (TKIs) for the treatment of chronic phase CML.

“We’re approaching chronic phase CML the way we’re approaching some pediatric malignancies that we’ve done so well,” Dr. Sekeres began. “It’s time to start questioning the amount that we’re giving. Our approach is to increasingly turn to drugs that are potentially more potent but also more toxic.”

While Dr. Sekeres typically administers imatinib due to cost reasons, a lot of patients are also started on dasatinib or nilotinib. Bosutinib is also increasingly being administered in the clinic, while ponatinib is reserved for later lines of therapy. Dr. Venugopal also starts patients on low dose imatinib.

Dr. Sekeres asked the following unanswered questions regarding relapse after treatment discontinuation:

• Where do you think we are with the data to allow discontinuation safely?
• Do we have enough data to know if patients are not going to relapse?
• If they do relapse, are we going to be able to recapture deep remission?

Patients should be on a TKI for five years before discontinuation, according to Dr. Jabbour.

“At this cutoff, the success rate is 87%. Of those 13% who are relapsing, 90% will go back to the same stage,” he explained. “The concern patients have is insurance. They have to submit paperwork for insurance to approve the drug. It’s more of a financial and logistical issue than a medical issue. A minority of patients today are still anxious about second therapy, but it’s becoming more and more routine.”

The panel then shifted to blast phase and accelerated phase CML, which represent under-researched areas of the disease.

“We don’t have a standard of care for CML blast phase,” Dr. Venugopal said. “That’s the area that needs more research. For the subset of patients who transplant, we do not know when they transform or if there are any particular factors. Additional cytogenetic abnormalities are a harbinger for transformation, but some patients have random cytogenetic abnormalities and still transform.”