Is there a best frontline therapy in chronic myeloid leukemia?

The management of chronic myeloid leukemia in chronic phase (CML-CP) was transfigured with the introduction of imatinib in 2001. Since then, four other tyrosine kinase inhibitors (TKI), dasatinib, nilotinib, bosutinib and most recently asciminib, have garnered approval for frontline management of CML-CP. The second generation TKI (2G-TKI) and asciminib have all been shown to be significantly superior to imatinib in attaining molecular responses, and asciminib possibly superior to 2G-TKI. With limited prospective comparisons between the 2G-TKI and similar survival outcomes with imatinib compared to 2G-TKI, the selection of a TKI for patients with newly diagnosed CML-CP must be individualized to the needs of that specific patient. Important factors to consider when choosing a drug include patient-related factors (age, co-morbidities, lifestyle considerations, quality of life, patient preferences, shared-decision making and whether treatment-free remission is a goal), disease-related factors (risk stratification, transcript type, presence of high-risk gene mutations such as ASXL1) and drug-related factors (major molecular response rates with each TKI, adverse events, rates of treatment discontinuation and treatment-free remission rates).