Blood cancers

New CML guidance provides more info on managing risks

Updated advice on selecting TKI therapy, managing side effects and vascular risk and stopping treatment in patients with chronic myeloid leukaemia (CML) has been published by the British Society for Haematology.

It updates the previous  guidance from 2007 and covers several aspects not really addressed by other recommendations, said guideline author Dr Graeme Smith in a BSH podcast.

This includes detailed information on patient factors that influence the choice of tyrosine kinase inhibitor (TKI) including co-morbidities as well as how to deal with side effects, how to assess and treat a patient’s vascular risk and when and how to go about discontinuing therapy, he added.

It also includes advice on specific clinical scenarios such as managing the disease in pregnant women or women who wish to have children, which has not been covered in detail in other recommendations.

“With regards primary therapy the majority of patients diagnosed in 2020 have a realistic prospect of a life expectancy similar to that of the normal population,” said Dr Smith who has recently retired from his role as consultant haematologist at Leeds Teaching Hospitals NHS Trust.

And while there are some patients for whom a more potent second generation TKI may be a better choice, this needs to be balanced against the risk of inducing and/or exacerbating co-morbidity, the guidelines state.

“For many patients there is no reason to choose a second generation tyrosine kinase inhibitor over imatinib which has a well established safety profile with no life threatening long term side effects identified to date,” said Dr Smith.

The recommendations call for all patients to have their cardiovascular disease risk assessed using the QRisk3 algorithm as well as baseline cholesterol and blood glucose levels done with preventive therapy offered where appropriate.

Most side effects of treatment can be managed with dose interruption or reduction or switching TKI if needed, but breathlessness should be investigated thoroughly.

In addition to detail on choice of second line therapy in resistant disease, Dr Smith pointed out that there is important information for clinicians on when and how to discontinue therapy following trials of several thousand patients.

The guidelines note that new data from the UK DESTINY trial suggest initial dose reduction may be important and, “in the absence of any reason not to, it is reasonable that initial dose reduction, as per the DESTINY protocol, is undertaken”, the guidelines advise.

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