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First-Line Treatment for CML: Imatinib or Not?

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#1 jjg


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Posted 26 April 2013 - 12:29 AM

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.


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."

Dx Dec 2010 @37

2x IVF egg collection

Glivec 600 & 800mg

PCRU March 2012

Unsuccessful pregnancy attempt - relapsed, 3 months interferon (intron A), bad side effects from interferon

Nilotinib 600mg Oct 2012

PCRU April 2013, 2 years MR4.5 mostly PCRU with a few blips

April 2015 stopped again for pregnancy attempt (donor egg), pregnant first transfer, 0.110 at 10wks, 2.1 at 14wks, 4.2 at 16wks, started interferon, slow dose increase to 25MIU per wk, at full dose PCR< 1 for remainder of pregnancy

Healthy baby girl Jan 2016, breastfed one month

Nilotinib 600mg Feb 2016

MMR May 2016

PCRU Feb 2017

#2 Trey


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Posted 26 April 2013 - 09:37 AM

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. 

#3 CMLSurvivor


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Posted 26 April 2013 - 12:03 PM

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.

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