2 replies to this topic

[jjg]

With second-generation tyrosine kinase inhibitors available, should imatinib still be first-line treatment for patients with chronic myelogenous leukemia (CML)? Two experts debated the question here at the International Congress on Hematological Malignancies.

http://journals.lww....aspx?PostID=710

Mauro said the real questions in the debate are about early, meaningful response and overcoming resistance.

He offered three axioms for CML:

• This is not like treating an infection with antibiotics, where you 'save the big guns' for resistance if you need them";
• "You have one chance to do it right for chronic-phase CML"; and
• "Treating resistant CML is like a chess match, with sequential and now compound mutations coming like a sequence of moves -- blast crisis is the check mate."

[Trey]

The statement by Dr Mauro that "You have one chance to do it right for chronic-phase CML" does not match with patient experience.  How many here have switched from Gleevec to another drug and done well?  Quite a few.  How many lost the battle simply because they started Gleevec instead of starting with another TKI?  I don't know of anyone in that category (some Oncs can wait too long to switch drugs, however that is a second issue which is an Onc  error).  So the "one chance" statement seems way overblown to me.

There are 2 main reasons why Gleevec remains useful as frontline therapy:

1) Overall survival and progression-free survival are equivalent among the three main CML TKI drugs. 

2) Gleevec will cost a lot less than the others in 2 years (2015), so cost will become a major reason for starting with Gleevec, and a reasonable factor to consider.  So trying to throw out Gleevec as a useful drug is a bit short-sighted.  In 2015 most of the world will need Gleevec to continue to be a frontline drug.

From my perspective, a patient can start on any of the drugs if in Chronic Phase CML.  Otherwise a second line drug would usually be a better choice. 

[CMLSurvivor]

I have to agree. I started on Gleevec and have stayed with it for 5 years and it has kept me in CMR for 4 1/2 years so, for some, it works really well. I would hate to see a drug taken off market because someone thinks something else is better. I cannot wait for the patient to end so I can get the Gleevec cheaper.