Twenty-Five Years of CML Therapy in India: A Model for Precision Oncology in a Resource-Constrained Setting

Chronic myeloid leukemia (CML) is the classic example in oncology of a single molecular lesion turned into a manageable, and increasingly curable, disease. This review focuses specifically on what is distinctive about CML in India and is organized so that the features that most clearly set Indian practice apart from the West are presented within their essential clinical context. The disease presents in India roughly 2 decades earlier than in Western registries, more often symptomatically and at a higher risk score, yet almost always still in chronic phase, and it is treated, overwhelmingly, with generic imatinib. We collate the national evidence across epidemiology; humanitarian access; the generic imatinib revolution; real-world outcomes; second-generation TKIs; resistance and transplantation; treatment-free remission; pregnancy and other special situations; and health economics, adherence, and quality of life. Several Indian contributions are highlighted: generic imatinib reproduces the innovator's response, survival and treatment-free-remission outcomes at a fraction of the cost, sustained BCR::ABL1 below 1% is a legitimate goal, and deeper responses, while desirable, are not mandatory, low-dose (50 mg) dasatinib achieves deep responses while sparing the pleural and pericardial toxicity seen at standard doses, allogeneic transplantation remains a one-time, cost-effective cure for T315I and multi-TKI-failure disease, far cheaper than ponatinib or asciminib and a young patient population has generated some of the world's largest CML-in-pregnancy series, with reassuring outcomes. We assert that the residual India-West survival gap is driven by access and adherence rather than by disease biology, and that several Indian lessons apply to high-income countries too.