Establish intent of treatment

• Curative
• Anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
• Symptom palliation.

Targeted therapies and immunotherapy

TKI therapy is the mainstay of therapy for chronic phase CML. The choice of TKI will depend on the CML risk score (using the EUTOS Long-Term Survival (ELTS) score to assess), comorbidities, the patient’s motivation to achieve treatment-free remission and, importantly, patient preference.

Supportive therapies

Comprehensive side effect management is essential since lifelong treatment may be required. Treatment with TKIs can affect physical, psychological, nutritional and general wellbeing. Patients should be offered appropriate psychosocial and supportive care and symptom-related interventions as part of routine care from the time of diagnosis.

Treatment-free remission

Patients who achieve deep molecular response that is maintained for at least 12 months have the option to consider ceasing treatment. It’s important to discuss what this entails including the chance of success, the frequency of molecular monitoring required, the risk of TKI-withdrawal syndrome and the impact of restarting therapy if required.

Palliative care for blast phase CML

Timely referral to palliative care can improve quality of life and in some cases survival. Referral should be based on need, not prognosis. For more information, visit the Palliative Care Australia website <www.palliativecare.org.au>.

Communication

The lead clinician and team’s responsibilities include:

• discussing treatment options with the patient and/or carer including the intent of treatment as well as risks and benefits
• discussing advance care planning with the patient and/or carer where appropriate
• communicating the treatment plan to the patient’s GP
• helping patients to find appropriate support for exercise programs where appropriate to improve treatment outcomes.

Checklist

• Intent, risk and benefits of treatment discussed with the patient and/or carer
• Treatment plan discussed with the patient and/or carer and provided to GP
• Supportive care needs assessed and referrals to allied health services actioned as required
• Advance care planning discussed where appropriate with the patient and/or carer

Timeframe

Ideally TKI therapy should begin within 4 weeks, unless there is a specific indication to delay.

Initiating therapy is urgent in blast phase CML. Ideally chemotherapy and/or TKI therapy should be started within 1 week of diagnosis.