Chronic Myeloid Leukemia (CML): Staging and Treatment
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What is staging for cancer?
Staging is the process of learning how much cancer is in your body and where it is. While most cancers form tumors, CML does not. It is found in the blood and bone marrow but also can be found in organs of the body. Tests like blood counts, flow cytometry to look for markers on cancer cells, bone marrow biopsy, and blood tests to look at chromosomal changes are done to help stage your cancer. Your providers need to know about your cancer and your health so that they can plan the best treatment for you.
How is CML staged?
Staging for CML is broken down into three phases. The phases are defined by the number of immature white blood cells (called blasts) in your bloodstream.
- Chronic: There are less than 10% (10 out of 100) blast cells in the blood. This is the least aggressive of the phases.
- Accelerated: There are between 10-19% (10 to 19 out of 100) blast cells in the blood.
- Blast: There are 20% or more (20 or more out of 100) blast cells in the blood. This is the most aggressive phase of the disease.
How is CML treated?
Treatment for CML depends on the stage/phase of your disease, your overall health, and your goals. You and your provider will work together to decide the best plan for you. Some treatments used in CML may be:
Targeted Therapy
Targeted therapies are medications that target a specific pathway in how cancer cells grow and divide. The targets themselves are often a certain molecule (or small particle) in the body that is known or thought to play a role in cancer formation. The type of targeted therapy medications used in the treatment of CML are tyrosine kinase inhibitors (TKI). Kinase inhibitors block growth signals within cancer cells, slowing or stopping the growth of new cancer cells.
TKIs used in the treatment of CML include asciminib, imatinib, dasatinib, nilotinib, bosutinib, and ponatinib. These medications do not cure CML but can keep the disease from turning into acute leukemia. You will have regular blood tests to check your response to TKI therapy.
Bone Marrow Transplant
There are two types of transplants that can be used. An allogeneic transplant uses bone marrow or stem cells from a donor. An autologous transplant uses your own bone marrow or stem cells (autologous). Allogeneic transplants are more often used in patients with CML. You will be given very strong chemotherapy (marrow-ablating) before the transplant. The donor's marrow will "rescue" your body with the new, healthy bone marrow. One effect of all allogeneic transplants is called the "graft versus tumor effect.” This is the effect that the donor's immune system (which is part of the marrow that the donor donated) has on your cancer cells. The hope is that the healthy donor's immune system can attack any cancer cells that survived the chemotherapy treatment before the transplant. Bone marrow transplants are not a first-line therapy for CML, but may be used in patients who are no longer responding to TKI therapy.
Other Treatments
Other types of treatments may be used in cases where TKIs are no longer working. These may be:
- Omacetaxine mepesuccinate (Synribo™) is a manmade form of homoharringtonine, a compound from a Chinese evergreen tree. It can be used in patients who have not responded to 2 or more TKI medications.
- Interferon alfa may be used in pregnant women and others who cannot have a transplant.
- Chemotherapy: May be used in combination with TKI before transplant.
- Radiation: May be used to palliate (relieve but not cure) symptoms related to bone pain or an enlarged spleen. It also may be used before transplant.
- Surgery: In some people with CML, the spleen can become enlarged and press against other organs. A splenectomy (removal of the spleen) may be needed.
Clinical Trials
You may be offered a clinical trial as part of your treatment plan. To find out more about current clinical trials, visit the OncoLink Clinical Trials Matching Service.
Making Treatment Decisions
Your provider will make sure you are included in choosing your treatment plan. This can be overwhelming as you may be given a few options to choose from. You can take a few weeks to meet with different providers and think about your options and what is best for you. This is a personal decision. Friends and family can help you talk through the options and the pros and cons of each, but they cannot make the decision for you. You need to be comfortable with your decision – this will help you move on to the next steps. If you ever have any questions or concerns, be sure to call your provider.
You can learn more about CML at OncoLink.org.