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Treatments for relapsed or refractory chronic myelogenous leukemia
The following are treatment options for relapsed or refractory chronic myelogenous leukemia (CML). Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.
Relapsed, or recurrent, CML means that the number of leukemia cells has increased after treatment and reaching remission. Remission means that the blood cell counts have returned to normal and stay at or near normal levels for long periods of time.
Refractory CML means that the leukemia is not responding to treatment.
The goal of treatment for relapsed or refractory CML is to return to the chronic phase. Your healthcare team will check your blood and bone marrow to closely monitor the response to treatment.
Targeted therapy with a tyrosine kinase inhibitor may be offered for relapsed or refractory CML. If you are already taking targeted therapy, your doctors may increase the dose or try a different drug. The following targeted therapy drugs are used for relapsed or refractory CML.
Imatinib (Gleevec) is the standard first-line therapy.
Dasatinib (Sprycel) or nilotinib (Tasigna) may be given as a first-line therapy. They may also be given if someone cannot cope with the side effects of imatinib or if CML is resistant to imatinib.
Bosutinib (Bosulif) may be given if someone cannot cope with the side effects of imatinib, dasatinib or nilotinib. Bosutinib may also be used if the CML is resistant to these drugs.
Pontatinib (Iclusig) may be given if the CML is resistant to other targeted therapies or because the leukemia cells have a certain gene mutation.
Stem cell transplant
An allogeneic stem cell transplant may be offered for relapsed or refractory CML. Doctors will usually try to get CML to return to the chronic phase or improve the blood counts before the transplant.
A reduced-intensity transplant may be an option for older people who are not healthy enough to cope with the side effects that happen with a standard transplant. A reduced-intensity transplant uses less intense chemotherapy or radiation therapy to prepare for the stem cell transplant.
Before a stem cell transplant, lymphocytes are removed from the donor’s blood and frozen for storage. If relapse occurs after a stem cell transplant, the lymphocytes are thawed and given to the person through one or more infusions. This is called a donor lymphocyte infusion (DLI). It may boost the immune system and bring on a stronger immune reaction against the CML cells.
Biological therapy may be offered for relapsed or refractory CML. It may be offered to people who cannot cope with the side effects from, or if the CML is resistant to, targeted therapy. Biological therapy can be used alone or in combination with chemotherapy.
The most common biological therapy used is interferon alfa (Intron A, Wellferon).
Chemotherapy may be offered for relapsed or refractory CML. It is used if someone cannot cope with the side effects from targeted therapy or if the CML is resistant to targeted therapy. Chemotherapy is also used in preparation for a stem cell transplant.
The chemotherapy drugs used to treat relapsed or refractory CML include:
- cytarabine (Cytosar, Ara-C)
- high-dose cytarabine (HDAC)
- hydroxyurea (Hydrea)
- busulfan (Myleran [oral], Busulfex [intravenous])
- vincristine (Oncovin)
Supportive therapy is important during treatment for every phase of CML. It is used to treat the complications that usually happen with treatments for CML and the disease itself.
Supportive therapies given during treatment for relapsed or refractory CML include:
- antibiotics, antivirals or antifungals to prevent or fight infections
- growth factors to help the bone marrow recover from chemotherapy (chemotherapy can affect the bone marrow so it doesn’t make enough healthy blood cells, which can increase the risk for infection)
- transfusions of red blood cells, platelets, fresh frozen plasma and cryoprecipitate (a product that replaces clotting factors) as needed
- drugs to bring down high levels of some chemicals in the blood that increase when many cancer cells die at the beginning of treatment (called tumour lysis syndrome)
- leukapheresisleukapheresisA procedure that uses a special machine (pheresis machine) to separate and collect specific white blood cells from withdrawn blood. The remaining blood is then returned to the body. to remove large numbers of white blood cells from the blood
You may be asked if you want to join a clinical trial for CML. Find out more about clinical trials.
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Establishing a national caregivers strategy
The Canadian Cancer Society is actively lobbying the federal government to establish a national caregivers strategy to ensure there is more financial support for this important group of people.