HJNO Sep/Oct 2023

HEALTHCARE JOURNAL OF NEW ORLEANS I  SEP / OCT 2023 55 Janeiro Goffin, MD Medical Oncologist Terrebonne General | Mary Bird Perkins Cancer Center determine your correct treatment, we need to calculate the risk score of your CML, and for that, we need to know the size of your spleen. For all my patients, I order an abdo- men ultrasound to calculate the size of your spleen and liver. Phases of chronic myeloid leukemia Chronic phase: 85% of people are in the chronic phase of CML when initially diag- nosed. In chronic phase CML, there are less than 15% immature leukemic blast cells (the abnormal white blood cells) in the periph- eral blood or bone marrow. Chronic phase CML is well controlled with oral medications in nearly all cases. Acelerated phase: 15-30% leukemic blast cells in peripheral blood. Accelerated phase CML is more difficult to control with medi- cations because of new mutations that de- velop in the CML cells. Blast phase: In the blast phase of CML (also called “blast crisis”), there are more than 30% blast cells in the blood or bone marrow. CML can progress to the blast phase from the chronic or accelerated phase, or in some cases, a person is already in the blast phase at the time of diagnosis. Treatment of chronicmyeloid leukemia: tyrosine kinase inhibitor (TKI) This medication is a pill you take by mouth that blocks the effects of BCR::ABL1, the abnormal protein found in people with CML. First-line TKI includes imatinib me- sylate, dasatinib, nilotinib, and bosutinib. If the patient does not respond to the first TKI eight months), but resuming a TKI immedi- ately is usually successful. Conversely, about half of people who stop TKI treatment have not had a recurrence of their CML five years later. People whose treatment is stopped should have BCR-ABL quantitative PCR monitoring every four to six weeks for six months and then every three months indefinitely. Stem cell transplantation Stem cell transplantation (also called bone marrow transplantation or hemato- poietic cell transplantation) is usually used after the disease stops responding or re- lapses during treatment with a TKI, usually in CML accelerated/blast phase. Chemotherapy Certain chemotherapy medications (hy- droxyurea, busulfan, omacetaxine, or inter- feron alfa) may be used to reduce symptoms of CML in special circumstances, although they do not cure the disease. Interferon is usually used if a patient is pregnant and has CML. Clinical trials Many people with CML will be asked about enrolling in a clinical or research trial. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. More information can be found at clinical- trials.gov. n used, I switch to another TKI from this list and do a mutation analysis of the BCR::ABL1 gene. If the patient’s BCR-ABL has not been reduced after the second TKI from the previ- ous list, then I switch them to a third line of TKIs called ponatinib or asciminib, which usually act against a mutation called T315I. TKIs are used to treat chronic and acceler- ated/blast phase CML. While on an oral TKI (every couple of months), I usually do BCR-ABL quantita- tive PCR to calculate howmuch of this pro- tein has been reduced to ensure the patient achieves what is called major molecular re- sponse (MMR). In addition, I do blood work to ensure the white blood cell count, red blood cell count, and platelets are respond- ing to the TKI, going back to normal values; this is called hematological response. I see the patient in the clinic, take a history, and do labs and a physical exam to make sure the patient is responding clinically with im- provement of their symptoms. Discontinuing a TKI is a consideration only in people who have had very low or undetectable levels of BCR::ABL1 for at least two to three consecutive years. The terms “very low” and “undetectable” have specific meaning in this context and refer to at least a “4-log” reduction of CML cells. To explain this terminology, only 1 out of every 10,000 CML cells remains; another way of describ- ing this effect is 0.01% (because 99.99% of CML cells were killed). In people who do stop TKI treatment in this setting, molecular relapses occur about half the time (usually within the first six to