Chronic myeloid leukemia. Drug selection in first-line therapy and beyond

The current guidelines for chronic myeloid leukemia (CML) endorse the tyrosine kinase inhibitors (TKIs) imatinib, nilotinib and dasatinib for front-line therapy of CML in chronic phase (CP) and, consequently, physicians and patients face a difficult choice. There is no difference in overall survival between these TKIs. Choice of front-line treatment should be based on additional considerations: age, prognostic category, safety of the drug, the possibility of a deep and sustained response (treatment free remission, TFR). Whatever TKI is used first, current guidelines include milestones of optimal response (and failure) earlier than before, and a timely monitoring and treatment optimization, as early as after three months from starting front-line treatment, drives the treatment strategy. If the most important end point of treatment is overall survival, and the definitive cure of CML remains elusive for most patients, a survival free of treatment, a “treatment free remission”, may be achievable and may be particularly attractive for younger patients.