With three approved first-line tyrosine kinase inhibitors (TKIs) available, the treatment of patients with chronic myeloid leukemia (CML) represents a complex decision-making process. Along with assessing history and disease factors, Stuart L. Goldberg, MD, aims to select a treatment that best serves a patient's lifestyle, comorbidities, and preferences.

With imatinib coming off patent in 2015, the potential frontline treatment of CML could change significantly, if a generic is made available, Neil P. Shah, MD, believes. As lower-cost generic versions of imatinib become available, it is probable that everyone will start on this first-generation TKI. Shah suggests that if response milestones are not met at the 3-month assessment, patients can be switched to one of the second-generation TKIs.

Side effects, which are often less chronic and severe with second-generation TKIs, will also play a role in treatment selection, comments Elias Jabbour, MD. He suggests an alternative approach: induction therapy with a second-generation TKI, then after an optimal response is achieved, making a switch to maintenance therapy with imatinib. Jabbour also speculates as to whether there is still a role for pegylated interferon in CML.