Choosing First Line Therapy to Optimise Patient Care

It is just over 20 years since imatinib was introduced into clinical practice and heralded a remarkable change in the outcome of patients with chronic myeloid leukemia (CML). Since then we have witnessed the development of second, third and fourth generation tyrosine kinase inhibitors (TKI)  and by their judicious use, can give the majority of patients a life expectancy unaffected by the diagnosis of CML. The dilemmas that face physicians and patients today are no longer only those concerned with delaying inevitable progression to the terminal blastic phase, or selecting the individual most likely to benefit from allogeneic stem cell transplantation, but are now focussed also on the choice of TKI, the management of co-morbidities and side effects, strategies to improve quality of life and the appropriateness of a trial of discontinuation. Interestingly, with four TKI approved for frontline use, the choice of initial therapy continues to cause controversy, a situation made more complicated by the tantalising prospect of treatment free remission (TFR).