There are currently three agents approved for the frontline treatment of patients with Philadelphia chromosome-positive chronic myelogenous leukemia (CML). As a result, several factors go into the decision of which therapy to utilize, including efficacy and costs.

In general, the second-generation agents, dasatinib and nilotinib, have demonstrated better long-term outcomes, Ruben A. Mesa, MD, states. However, imatinib has similar efficacy at a lower cost, making it an attractive option. Due to these factors, several nuances go into the selection of a frontline therapy, Mesa notes. If patients are at high-risk, the case for second-generation agents is much stronger. The main driver behind the use of upfront imatinib is cost. In patient discussions, the second-generation agents are usually recommended.

As physicians, it is important to be mindful of both economics and outcomes; however, the primary responsibility is to ensure an optimal patient outcome, Harry P. Erba, MD, PhD, says. In general, alterations outside of BCR-ABL do not help select frontline therapies. As a result, genetic sequencing is often reserved for the detection of a possible resistance mutation, which may play a role in the selection of treatments, Rafael Bejar, MD, PhD, states.

In the interest of economics, it is plausible to start with imatinib treatment for 3 months to 6 months and then switch to dasatinib or nilotinib, suggests Elias J. Jabbour, MD. However, some feel it is best to start with the best agent upfront, as an induction therapy, and reserve imatinib as a type of maintenance choice, Jabbour suggests. However, at this point, data on long-term outcomes is limited.