First-Line management of CML: a state of the art review

With the advent of imatinib, an inhibitor of the fusion Bcl-Abl tyrosine kinase that is responsible for the disease phenotype, first-line treatment of chronic myelogenous leukemia (CML) has undergone rapid changes. As a consequence of the success of imatinib, allogeneic stem cell transplantation (allo-SCT) has moved from the first-line indication to an option that is usually considered for patients without optimal response to imatinib or those for whom treatment with imatinib has failed. First-line use of interferon-alpha (IFN-alpha), with or without cytarabine or hydroxyurea, is now rarely considered. Most patients with newly diagnosed chronic-phase CML experience complete cytogenetic responses during imatinib treatment, but continued treatment is necessary to prevent cytogenetic or molecular relapse. Cumulative evidence with imatinib and IFN-alpha show that experiencing early and deep responses is important in preventing progression to more advanced phases of the disease. These features emphasize the need to carefully monitor patients for residual disease and provide guidance on treatment options in the event of imatinib intolerance or failure. This article reviews the current role of allo-SCT, imatinib, and IFN-alpha in treating newly diagnosed chronic-phase CML, highlighting the benefits and challenges of long-term patient management, and discusses emerging trends.