Treatment options for chronic myeloid leukaemia (CML)
A team of health professionals decides what treatment options you have. The main treatment for chronic myeloid leukaemia (CML) are targeted cancer drugs. These drugs are called tyrosine kinase inhibitors (TKIs).
Deciding which treatment you need
A team of doctors and other professionals discuss the best treatment and care for you. They are the multidisciplinary team (MDT). Your MDT might include:
- a blood cancer specialist called consultant haematologist
- doctors specialising in reporting
bone marrow 
or lymph node biopsies. They are called haemato-pathologists - a radiologist – a doctor specialising in reporting x-rays and scans
- a specialist haematology nurse – also called a clinical nurse specialist (CNS)
- symptom control specialists called palliative care doctors and nurses
- pharmacists
- social workers
The MDT look at a number of different factors including:
- the phase of your CML
- whether you have other health conditions
- your age, general health and level of fitness
- the side effects of the different medicines
- the results of
genetic tests on your CML cells - your personal situation and preference
Your doctor will talk to you about your treatment options. They will discuss the benefits and the possible side effects with you.
The aim of treatment is to put your CML into remission. Remission means there are no signs of CML in your blood. The doctors refer to remission as ‘response to treatment’.
The main treatment for CML
Targeted cancer drugs are the main treatment for CML. They can change the way that cells work and help the body control the growth of cancer. There are different types of targeted cancer drugs. The main type for CML is tyrosine kinase inhibitors (TKIs).
Examples of TKI drugs for CML include:
- imatinib
- bosutinib
- dasatinib
- nilotinib
Other treatments for CML
Chemotherapy and a are other possible treatments for CML. It is uncommon to have these as targeted cancer drugs work well at controlling most people's CML.
Chemotherapy
Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate throughout the body in your bloodstream.
The chemotherapy drugs you have depends on the type of leukaemia your CML develops into. CML most commonly transforms into acute myeloid leukaemia (AML). So the chemotherapy treatment you have is the same chemotherapy treatment as AML.
Fludarabine, cytarabine, G-CSF and idarubicin (FLAG-Ida) is an example of chemotherapy drug combination you might have for AML. You might also have a TKI drug alongside the chemotherapy.
You might have chemotherapy if you have more advanced stages of CML or before a stem cell transplant.
Stem cell transplant
Having a transplant means destroying as many leukaemia cells as possible and replacing these with healthy .
You first have chemotherapy and other treatments such as radiotherapy. This prepares your body for the healthy stem cells.
After the chemotherapy you have the new stem cells into your bloodstream through a drip. These stem cells make their way to the bone marrow. Here they make the you need to recover.
You have a stem cell transplant using stem cells from someone else. This is called a donor transplant.
Treatment by phase
There are 3 phases (stages) of CML:
- chronic phase
- accelerated phase
- blast phase
Chronic phase
Most people are diagnosed in the chronic phase. The main aim of treatment is to control your CML and get you into remission. Remission means there's no sign of active leukaemia in your body. And you don’t have any symptoms. This remission can last for years.
The most common treatment is a type of targeted cancer drug called a tyrosine kinase inhibitor (TKI).
There are several different TKIs. The most common drug for CML is imatinib. But your doctor might suggest a different TKI such as dasatanib, nilotinib or asciminib.
Most people respond well to this treatment. CML can stay under control for many years.
Your doctor might suggest you try a different TKI if:
- tests to look for signs of CML show that your CML hasn’t gone away
- tests detect signs of CML again after a period of time
- you have severe side effects from your current treatment
Occasionally TKI treatment does not work. In this situation your doctor might offer you chemotherapy and a stem cell transplant.
Accelerated and blast phase
You might:
- progress to the accelerated or blast phase after having treatment for chronic phase CML
- be diagnosed in the accelerated or blast phase, although this is less common
Treatment for the accelerated or blast phase depends on whether you have already had treatment. And if so, what treatment you had.
Accelerated phase
Treatment aims to get you back into remission.
The first choice of medicine depends on several factors including if you have already had a TKI medicine.
There are several available including:
- nilotinib
- dasatinib
- bosutinib
- ponatinib
Your doctor might recommend a stem cell transplant if the TKI treatment doesn’t work. This is more likely if you:
- have progressed to accelerated phase from chronic phase
- are younger and fairly fit and well
Blast phase
Blast phase CML is where your CML transforms to an . The drugs you have for the blast phase CML depends on the type of leukaemia your CML develops into.
CML most commonly transforms into acute myeloid leukaemia (AML). So the treatment you have is the same treatment as AML.
The second most common transformation is acute lymphoblastic leukaemia (ALL). So if you have this type you have the same treatment as ALL.
There are other types of acute leukaemia and treatments are similar to AML and ALL. Transformation to these types of leukaemia are rarer.
Your doctor might suggest:
- a combination of chemotherapy drugs such as FLAG-Ida. You have this on its own, or together with a TKI
- a TKI on its own
Your doctor usually recommends you have a stem cell transplant if you are well enough and have a stem cell donor.
You might have also treatment to relieve symptoms.
First and second line treatments
You might hear your doctor refer to your treatment as first line or second line.
First line treatment
This is the first treatment you have when you are diagnosed with CML. The most common first line treatment for CML is a TKI drug.
Second and third line treatments
Some people have to change on to a different treatment. The second treatment you have is called second line treatment. And then the next treatment is called third line treatment, and so on.
The aim of second line treatment is to put your CML back into remission. Remission means there are no signs of CML in your blood.
Supportive treatments
You might have symptoms or problems caused by the leukaemia. Supportive treatments can help to either prevent or control these problems.
Some of the supportive treatments for CML include:
- a chemotherapy drug called hydroxycarbamide. This is to lower your white blood cell or platelet levels. You might have this whilst you wait for your diagnosis
- fluids through a drip into your vein. This is to prevent complications caused from a condition called
tumour lysis syndrome - medicines to protect your kidneys from tumour lysis syndrome
- antibiotics, antifungals and antivirals to help prevent or treat infections
blood transfusions platelet transfusions
Monitoring your response to treatment
To begin with, you need to see your doctor regularly, maybe weekly or monthly. You usually have a blood test at each visit. Your doctor might examine you and asks you how you are. This is to see whether you have any problems with the treatment.
The time between check ups will gradually get longer if everything is going well.
The aim of treatment is to put your CML into remission. There are different tests that look for signs of CML. The test results provide information about how well the treatment is working to control your leukaemia. To monitor your response to treatment, you have blood tests every 3 to 6 months depending on your situation. You might also have bone marrow tests.
Having a break in treatment
Doctors know that it is safe for some people to stop treatment if their CML is under control. This is called a treatment break. Or your doctor might call it treatment free remission.
Your doctor can talk with you about whether a treatment break might be an option for you.
Clinical trials
Your doctor might ask if you’d like to take part in a clinical trial. Doctors and researchers do trials to make existing treatments better and develop new treatments.
