STEP 4: Treatment

Step 4 describes the optimal treatments for CML, the training and experience required of the treating clinicians and the health service characteristics required for optimal cancer care.

All health services must have clinical governance systems that meet the following integral requirements:

  • identifying safety and quality measures
  • monitoring and reporting on performance and outcomes
  • identifying areas for improvement in safety and quality (ACSQHC 2020).

Step 4 outlines the treatment options for CML. For detailed clinical information on treatment options refer to the European LeukemiaNet 2020 recommendations for treating CML (Hochhaus et al. 2020).

The intent of treatment can be defined as one of the following:

  • curative
  • anti-cancer therapy to improve quality of life and/or longevity without expectation of cure
  • symptom palliation.

The treatment intent should be established in a multidisciplinary setting, documented in the patient’s medical record and conveyed to the patient and carer as appropriate.

The potential benefits need to be balanced against the morbidity and risks of treatment.

The lead clinician should discuss the advantages and disadvantages of each treatment and associated potential side effects with the patient and their carer or family before treatment consent is obtained and begins so the patient can make an informed decision. Supportive care services should also be considered during this decision-making process. Patients should be asked about their use of (current or intended) complementary therapies (see Appendix D).

Timeframes for starting treatment should be informed by evidence-based guidelines where they exist. The treatment team should recognise that shorter timeframes for appropriate consultations and treatment can promote a better experience for patients.

Initiate advance care planning discussions with patients before treatment begins (this could include appointing a substitute decision-maker and completing an advance care directive). Formally involving a palliative care team/service may benefit any patient, so it is important to know and respect each person’s preference (Australian Government Department of Health 2021a).

Initial treatment for patients diagnosed with CML will depend on several factors.

For patients in the chronic phase with a WBC under 100 and platelets below 800, there is no urgency to start therapy.

Prior to choosing a TKI, patients with chronic phase CML should be assessed for comorbidities and CML risk category using an accepted scoring system. ELTS is the preferred CML scoring system currently. This should be recorded in the notes and in correspondence with their general practitioner.

Hydroxyurea/hydroxycarbamide is frequently used in the first few weeks to reduce the WBC count and/or the platelet count to safer levels. Hydroxyurea should be switched to a TKI as soon as the patient has decided which TKI to take.

In cases with markedly elevated platelet counts it may be necessary to use anagrelide for the first few days or weeks before an appropriate TKI is selected.

The mainstay of therapy for chronic phase CML is TKI therapy. There are currently three TKIs approved and reimbursed for first-line therapy in Australia: imatinib, nilotinib and dasatinib. All three represent excellent choices, but the preferred TKI for each patient will depend on a combination of CML risk score (ELTS), comorbidity assessment (including Framingham risk score or equivalent) and the patient’s motivation to achieve treatment-free remission. Ideally, the choice of TKI should be a shared decision between the clinician and patient after an in-depth discussion of the advantages and disadvantages of each drug and to consider any available clinical trials that may be available.

It’s important not to rush this decision to give the patient time to consider the advantages and disadvantages of each option.

Ideally TKI therapy should start within the first four weeks, unless there is a specific indication to delay.

Blast phase may be present at diagnosis of CML, or it may develop after a period of chronic and/or accelerated phase CML.

Once diagnosed, the treatment approach for blast phase CML should be similar to that taken for acute myeloid leukaemia if in myeloid blast phase, or acute lymphoblastic leukaemia if in lymphoid blast phase, except that TKI therapy will generally be used alongside chemotherapy.

An allogeneic stem cell transplant is almost always indicated for patients with good performance status who achieve a second chronic phase.

The treatment pathway is complex for patients who are potential candidates for an allogeneic stem cell transplant. They should be admitted to a hospital with expertise in managing acute leukaemia that is accredited to undertake allogeneic stem cell transplants, or has close links to a hospital with this capability.

TKI-related side effects can significantly affect quality of life and have the potential to be life-threatening.

Comprehensive side effect management is essential since lifelong treatment may be required, and treatment with TKIs can impact physical, psychological, nutritional and general wellbeing.

From the time of diagnosis, the treating team should offer patients appropriate psychosocial and supportive care and symptom-related interventions as part of routine care. The approach should be personalised to meet each patient’s needs, values and preferences.

Managing side effects may be complex and requires optimal communication between the treating clinician, patient, general practitioner and appropriate specialties in the multidisciplinary team.

Patients who achieve deep molecular response that is maintained for at least 24 months have the option to consider ceasing treatment. It’s important to have a frank discussion about what discontinuing TKI therapy 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 that becomes necessary. Before ceasing treatment, strict processes need to be in place to ensure that molecular monitoring is timely and results are acted on promptly.

For more information, see Table 8 in the European LeukemiaNet 2020 recommendations for treating CML

Systemic therapy (cytotoxic agents) is only indicated in cases of blast phase CML.

Timeframes for starting treatment

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

Training and experience required of the appropriate specialists

Haematologists must have training and experience of this standard:

  • Fellow of the Royal Australian College of Physicians (or equivalent)
  • adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

  • anti-cancer treatment administration
  • specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
  • the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

  • adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

In a setting where no haematologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having systemic therapy, health services should have these features:

  • a clearly defined path to emergency care and advice after hours
  • access to diagnostic pathology including basic haematology and biochemistry, and imaging
  • cytotoxic drugs prepared in a pharmacy with appropriate facilities
  • occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
  • guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
  • coordination for combined therapy with radiation therapy, especially where facilities are not co-located
  • appropriate molecular pathology access.

Palliative care is a multidisciplinary approach to symptom management, psychosocial support and assistance in identifying care goals for patients with serious illness and their families.

For patients in blast phase, early referral to palliative care can improve the quality of life and in some cases may have survival benefits.

The lead clinician should ensure patients receive timely and appropriate referral to palliative care services. Referral should be based on need rather than prognosis. Emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers.

The ‘Dying to Talk’ resource may help health professionals when initiating discussions with patients about future care needs (see ‘More information’). Ensure that carers and families receive information, support and guidance about their role in palliative care (Palliative Care Australia 2018).

Patients, with support from their family or carer and treating team, should be encouraged to consider appointing a substitute decision-maker and to complete an advance care directive.

Refer to step 6 for a more detailed description of managing patients with refractory or relapsed disease.

More information

These online resources are useful:

Participation in clinical trials, patient registries and tissue banking, where available, is encouraged for patients with CML. Cross-referral between clinical trials centres should be encouraged to facilitate participation. Many emerging treatments are only available on clinical trials that may require referral to certain trial centres.

For more information visit:

See validated screening tools mentioned in Principle 4 ‘Supportive care’.

A number of specific challenges and needs may arise for patients at this time:

  • assistance for dealing with emotional and psychological issues, including body image concerns, fatigue, quitting smoking, traumatic experiences, existential anxiety, treatment phobias, anxiety/ depression, interpersonal problems and sexuality concerns
  • potential isolation from normal support networks, particularly for rural patients who are staying away from home for treatment
  • management of physical symptoms including musculoskeletal pain
  • decline in mobility, functional or nutritional status as a result of treatment
  • assistance with beginning or resuming regular exercise with referral to an exercise physiologist or physiotherapist (COSA 2018; Hayes et al. 2019).

Early involvement of general practitioners may lead to improved cancer survivorship care following acute treatment. General practitioners can address many supportive care needs through good communication and clear guidance from the specialist team (Emery 2014).

Patients, carers and families may have these additional issues and needs:

  • financial issues related to loss of income (through reduced capacity to work or loss of work) and additional expenses as a result of illness or treatment
  • advance care planning, which may involve appointing a substitute decision-maker and completing an advance care directive
  • legal issues (completing a will, care of dependent children) or making an insurance, superannuation or social security claim on the basis of terminal illness or permanent disability.

Cancer Council 13 11 20 and Leukaemia Foundation 1800 953 081 information and support lines can assist with information and referral to local support services.

For more information on supportive care and needs that may arise for different population groups, see Appendices A, B and C.

Rehabilitation may be required at any point of the care pathway. If it is required before treatment, it is referred to as prehabilitation (see section 3.5.1).

All members of the multidisciplinary team have an important role in promoting rehabilitation. Team members may include occupational therapists, speech pathologists, dietitians, social workers, psychologists, physiotherapists, exercise physiologists and rehabilitation specialists.

To maximise the safety and therapeutic effect of exercise for people with cancer, all team members should recommend that people with cancer work towards achieving, and then maintaining, recommended levels of exercise and physical activity as per relevant guidelines. Exercise should be prescribed and delivered under the direction of an accredited exercise physiologist or physiotherapist with experience in cancer care (Vardy et al. 2019). The focus of intervention from these health professionals is tailoring evidence-based exercise recommendations to the individual patient’s needs and abilities, with a focus on the patient transitioning to ongoing self-managed exercise.

Other issues that may need to be dealt with include managing cancer-related fatigue, improving physical endurance, achieving independence in daily tasks, optimising nutritional intake, returning to work and ongoing adjustment to cancer and its consequences. Referrals to dietitians, psychosocial support, return-to-work programs and community support organisations can help in managing these issues.

The lead or nominated clinician should take responsibility for these tasks:

  • discussing treatment options with patients and carers, including the treatment intent and expected outcomes, and providing a written version of the plan and any referrals
  • providing patients and carers with information about the possible type and duration of side effects of treatment, what side effects require urgent attention and what to do if they occur
  • informing patients about how to access urgent and non-urgent care
  • providing patients and carers with information about managing symptoms between active treatments, how to access care, self-management strategies (e.g. diet modification, gentle exercise) and emergency contacts
  • encouraging patients to use question prompt lists and audio recordings, and to have a support person present to aid informed decision making
  • initiating a discussion about advance care planning and involving carers or family if the patient wishes.
  1. Communication with the general practitioner

The general practitioner plays an important role in coordinating care for patients, including helping to manage side effects and other comorbidities, and offering support when patients have questions or worries. For most patients, simultaneous care provided by their general practitioner is very important.

The lead clinician, in discussion with the patient’s general practitioner, should consider these points:

  • the general practitioner’s role in symptom management, supportive care and referral to local services
  • using a chronic disease management plan and mental health care management plan
  • how to ensure regular and timely two-way communication about:
  • the treatment plan, including intent and potential side effects
  • information about potential interactions of medications, including what signs to watch out for and what to do if they occur
  • supportive and palliative care requirements
  • the patient’s prognosis and their understanding of this
  • enrolment in research or clinical trials
  • changes in treatment or medications
  • the presence of an advance care directive or appointment of a substitute decision-maker
  • recommendations from the multidisciplinary team.

More information

Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.