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Ángeles-Velázquez JL, Hurtado-Monroy R, Vargas-Viveros P, Carrillo-Muñoz S, Candelaria-Hernández M. Imatinib Intolerance Is Associated With Blastic Phase Development in Philadelphia Chromosome-Positive Chronic Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 16 Suppl:S82-5. [PMID: 27521331 DOI: 10.1016/j.clml.2016.02.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/09/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Over the past years, the survival of patients with Philadelphia-positive chronic myeloid leukemia (CML Ph(+)) has increased as a result of therapy with tyrosin kinase inhibitors (TKIs). Intolerance to TKIs has been described in approximately 20% of patients receiving treatment. We studied the incidence of imatinib intolerance in patients with CML Ph(+) and their outcome in our CML reference site, as there is no information about the evolution of patients intolerant to TKIs. PATIENTS AND METHODS A group of 86 patients with CML Ph(+) receiving imatinib monotherapy who abandoned treatment were the basis for this study. We present the trends of their disease evolution. RESULTS The median of age at diagnosis was 42 years. Within a year, 19 (22%) of 86 patients developed imatinib intolerance, all of them with grade III or IV disease that required imatinib dose reduction or discontinuation. Of these patients, 16 (84%) of 19 developed transformation to blastic phase. The cumulative incidences of blastic phase development were 47% in the nonintolerant group and 84% in the intolerant group. There was a relative risk for those with imatinib intolerance to develop blastic phase of 1.78 (95% confidence interval, 1.28 to 2.42) (P < .05). CONCLUSION Most imatinib-intolerant patients develop blastic phase transformation, with a poor survival of 3 to 6 months; no effective rescue treatment is available. Future research should to determine whether the origin of this evolution is really due to the intolerance itself or whether it is due to a more aggressive form of the disease, perhaps related to genetic transformation.
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Affiliation(s)
- Jorge Luis Ángeles-Velázquez
- Resident of Internal Medicine, Mexican Faculty of Medicine, La Salle University, Hospital Angeles del Pedregal, Mexico City, Mexico
| | - Rafael Hurtado-Monroy
- Head of the Department of Hematology, Hospital Angeles del Pedregal, Mexico City, Mexico.
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Vivot A, Boutron I, Béraud-Chaulet G, Zeitoun JD, Ravaud P, Porcher R. Evidence for Treatment-by-Biomarker interaction for FDA-approved Oncology Drugs with Required Pharmacogenomic Biomarker Testing. Sci Rep 2017; 7:6882. [PMID: 28761069 PMCID: PMC5537292 DOI: 10.1038/s41598-017-07358-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 06/22/2017] [Indexed: 01/21/2023] Open
Abstract
For oncology drugs that were approved by the US Food and Drug Administration (FDA) and required pharmacogenomic biomarker testing, we describe 1) the use of enrichment (biomarker-positive patients) and a randomized controlled design by pre-approval trials and 2) the treatment-by-biomarker interaction. From the 137 drugs included in the FDA table, we selected the 22 oncology drugs with required genetic testing in their labels. These drugs corresponded to 35 approvals supported by 80 clinical studies included in the FDA medical officer reviews of efficacy. For two thirds of approvals (24/35, 69%), all clinical studies were restricted to biomarker-positive patients (enriched). Among the 11 remaining approvals with at least one non-enriched trial, for five approvals, the non-enriched studies were non-randomized. The treatment-by-biomarker interaction was statistically significant for three approvals and missing for two. Among the six approvals with a non-enriched randomized controlled trial, three featured a statistically significant treatment-by-biomarker interaction (p < 0.10), for an enhanced treatment effect in the biomarker-positive subgroup. For two thirds of FDA approvals of anticancer agents, the requirement for predictive biomarker testing was based on clinical development restricted to biomarker-positive patients. We found only few cases with clinical evidence that biomarker-negative patients would not benefit from treatment.
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Affiliation(s)
- Alexandre Vivot
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Greater Paris University Hospital (AP-HP), Paris, France.
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France.
| | - Isabelle Boutron
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Greater Paris University Hospital (AP-HP), Paris, France
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France
- School of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Geoffroy Béraud-Chaulet
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Greater Paris University Hospital (AP-HP), Paris, France
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France
| | - Jean-David Zeitoun
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France
- Gastroenterology and Nutrition Department, Saint-Antoine Hospital, Greater Paris University Hospital (AP-HP), Paris, France
- Proctology Department, Croix Saint-Simon Hospital, Paris, France
| | - Philippe Ravaud
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Greater Paris University Hospital (AP-HP), Paris, France
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France
- School of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Raphaël Porcher
- Clinical Epidemiology Unit, Hôtel-Dieu Hospital, Greater Paris University Hospital (AP-HP), Paris, France
- Epidemiology and Statistics Sorbonne Paris Cité Research Center (CRESS), INSERM, Paris Descartes University, Paris, UMR1153, France
- School of Medicine, Paris Descartes University, Sorbonne Paris Cité, Paris, France
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Zhang Y, Somtakoune SD, Cheung C, Listiawan M, Feng X. Therapeutic Application of Pharmacogenomics in Oncology. AAPS JOURNAL 2016; 18:819-29. [DOI: 10.1208/s12248-016-9926-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/26/2016] [Indexed: 12/18/2022]
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Hamerschlak N, de Souza C, Cornacchioni AL, Pasquini R, Tabak D, Spector N, Steagall M. Quality of life of chronic myeloid leukemia patients in Brazil: ability to work as a key factor. Support Care Cancer 2014; 22:2113-8. [PMID: 24647489 DOI: 10.1007/s00520-014-2196-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 03/02/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the quality of life (QOL) of patients receiving treatment by the public health system in Brazil for chronic myeloid leukemia (CML), a disease requiring daily and strict compliance to oral medication and regular blood and bone marrow controls, which are invasive exams. METHODS Between 2008 and 2010, patients with CML were surveyed by telephone. Quality of life was evaluated by the functional assessment of chronic illness therapy (FACIT) tool. RESULTS The mean QOL among CML patients was 92.53 (out of 124 total points) in the trial outcome index, 78.50 (out of 108) in the general total score, and 130.43 (out of 176) in the leukemia total score. Patients who had the prescriptions recently changed anyway had better QOL general score (p = 0.012) and leukemia-specific score (p = 0.043) than those who remained with the same treatment. Imatinib was not associated with this change in QOL (p > 0.797). The more the patient felt able to work, the higher the scores in all three FACIT scales (p < 0.001, Spearman's correlation). The use of imatinib (p = 0.012) was associated with a better ability to work, while chemotherapy (p = 0.017) and the use of hydroxyurea (p = 0.001) were inversely associated with work capability. CONCLUSIONS A recent change in medication can improve quality of life. The ability to work is an important component of quality of life of patients with CML. Ability to work should be specifically considered in CML treatment.
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Affiliation(s)
- Nelson Hamerschlak
- Hospital Israelita Albert Einstein. Associação Brasileira de Linfoma e Leucemia, Av. Albert Einstein, 627/520, São Paulo, SP, Brazil, 05651-901,
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Jabbour EJ, Cortes JE, Kantarjian HM. Resistance to tyrosine kinase inhibition therapy for chronic myelogenous leukemia: a clinical perspective and emerging treatment options. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2013; 13:515-29. [PMID: 23890944 PMCID: PMC4160831 DOI: 10.1016/j.clml.2013.03.018] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 03/06/2013] [Indexed: 01/12/2023]
Abstract
The development of tyrosine kinase inhibitors (TKIs) has led to extended lifespans for many patients with chronic myelogenous leukemia (CML). However, 20% to 30% of patients fail to respond, respond suboptimally, or experience disease relapse after treatment with imatinib. A key factor is drug resistance. The molecular mechanisms implicated in this resistance include those that involve upregulation or mutation of BCR-ABL kinase and those that are BCR-ABL independent. The clinical consequences of these molecular mechanisms of resistance for disease pathogenesis remain open for debate. This review summarizes the molecular mechanisms and clinical consequences of TKI resistance and addresses the current and future treatment approaches for patients with TKI-resistant CML.
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Affiliation(s)
- Elias J Jabbour
- The University of Texas, MD Anderson Cancer Center, Houston, TX.
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Wild C, Nachtnebel A. [HTA-Perspective: Challenges in the early assessment of new oncological drugs]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2013; 107:129-135. [PMID: 23663907 DOI: 10.1016/j.zefq.2013.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Oncologic drug therapies have gained wide attention in the context of health policy priority setting for serious and socially significant diseases with high human and monetary costs. Due to uncertainties and scepticism about the actual therapeutic importance of newly approved oncology products, an early assessment programme was already established in Austria in 2007. The assessment of new oncology products is thereby faced with special challenges, since study populations are frequently not representative or the study design is laid out in such a manner that a definitive assessment of patient-relevant endpoints is not possible (cross-overs after interim assessments, surrogate parameters as primary endpoints, uncontrolled studies or those with unrealistic comparators, invalidated post-hoc identified biomarkers). On account of these major uncertainties, even the European Medicines Agency (EMA) is already contemplating multi-stage, "adaptive" approvals, and national reimbursement institutions are increasingly working with outcome-oriented, conditional reimbursement. (As supplied by publisher).
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Affiliation(s)
- Claudia Wild
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria.
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Recommendations from the EGAPP Working Group: can testing of tumor tissue for mutations in EGFR pathway downstream effector genes in patients with metastatic colorectal cancer improve health outcomes by guiding decisions regarding anti-EGFR therapy? Genet Med 2013; 15:517-27. [PMID: 23429431 DOI: 10.1038/gim.2012.184] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 12/21/2012] [Indexed: 12/31/2022] Open
Abstract
SUMMARY OF RECOMMENDATIONS The Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working Group (EWG) found that, for patients with metastatic colorectal cancer (mCRC) who are being considered for treatment with cetuximab or panitumumab, there is convincing evidence to recommend clinical use of KRAS mutation analysis to determine which patients are KRAS mutation positive and therefore unlikely to benefit from these agents before initiation of therapy. The level of certainty of the evidence was deemed high, and the magnitude of net health benefit from avoiding potentially ineffective and harmful treatment, along with promoting more immediate access to what could be the next most effective treatment, is at least moderate.The EWG found insufficient evidence to recommend for or against BRAF V600E testing for the same clinical scenario. The level of certainty for BRAF V600E testing to guide antiepidermal growth factor receptor (EGFR) therapy was deemed low. The EWG encourages further studies of the potential value of testing in patients with mCRC who were found to have tumors that are wild type (mutation negative) for KRAS to predict responsiveness to therapy.The EWG found insufficient evidence to recommend for or against testing for mutations in NRAS, or PIK3CA, and/or loss of expression of PTEN or AKT proteins. The level of certainty for this evidence was low. In the absence of supporting evidence, and with consideration of other contextual issues, the EWG discourages the use of these tests in guiding decisions on initiating anti-EGFR therapy with cetuximab or panitumumab unless further evidence supports improved clinical outcomes. RATIONALE It has been suggested that patients with mCRC whose tumors harbor certain mutations affecting EGFR pathway signaling are typically unresponsive to therapy with anti-EGFR antibodies (cetuximab and panitumumab). The EWG identified recent evidence reviews that have addressed this topic, and this recommendation statement is based on results of these reviews. In developing these recommendations the EWG considered evidence in the areas described below. ANALYTIC VALIDITY Although no research syntheses that have formally evaluated analytic validity of these tests were found, the EWG was able to draw the following conclusions from assessments included in the evidence reviews under consideration. There is adequate evidence that KRAS mutation analysis reliably and accurately detects common mutations (codons 12 and 13), whereas evidence was inadequate for less frequent KRAS mutations (e.g., codon 61). There is also adequate evidence that testing for BRAF V600E accurately and reliably detects the mutation. For common mutations in NRAS, PIK3CA, and expression of PTEN AKT, there is adequate evidence of accurate and reliable detection. However, much less data exist in support. Furthermore, in the specific context of mCRC, no evidence was found on the analytic validity of immunohistochemistry (IHC) assays for PTEN or AKT expression. CLINICAL VALIDITY For KRAS mutation analysis, the EWG found convincing evidence for association with treatment response to anti-EGFR therapy, independent of prognostic association. For BRAF V600E mutation testing, the EWG found insufficient evidence for association with treatment response to anti-EGFR therapy independent of prognostic association. The EWG found insufficient evidence for association of results of testing for mutations in NRAS or PIK3CA, and loss of expression of PTEN or ATK proteins, with treatment response to anti-EGFR therapy. CLINICAL UTILITY For KRAS mutation analysis, the EWG found adequate evidence that improved health outcomes are achieved by avoiding ineffective chemotherapy and potential side effects and expediting access to the next most effective treatment. Inadequate evidence was found regarding association of BRAF V600E mutation testing or loss of PTEN expression with improved health outcomes among patients with mCRC undergoing anti-EGFR therapy as compared with patients with tumors bearing wild-type BRAF sequence and PTEN expression levels, respectively. No evidence was found to support improved health outcomes associated with testing results for NRAS or PIK3CA variants, or AKT protein expression levels in this clinical scenario. CONTEXTUAL ISSUES CRC is an important and highly prevalent health problem. Improvements in mCRC outcomes associated with pharmacogenetic testing could have important clinical, and potentially public health, impacts. Adverse events related to cancer chemotherapy can be common and severe. Therefore, successfully optimizing treatment to maximize efficacy and minimize side effects is important for reducing mCRC-related morbidity and mortality.
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Goddard KAB, Knaus WA, Whitlock E, Lyman GH, Feigelson HS, Schully SD, Ramsey S, Tunis S, Freedman AN, Khoury MJ, Veenstra DL. Building the evidence base for decision making in cancer genomic medicine using comparative effectiveness research. Genet Med 2012; 14:633-42. [PMID: 22516979 PMCID: PMC3632438 DOI: 10.1038/gim.2012.16] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The clinical utility is uncertain for many cancer genomic applications. Comparative effectiveness research (CER) can provide evidence to clarify this uncertainty. The aim of this study was to identify approaches to help stakeholders make evidence-based decisions and to describe potential challenges and opportunities in using CER to produce evidence-based guidance. We identified general CER approaches for genomic applications through literature review, the authors' experiences, and lessons learned from a recent, seven-site CER initiative in cancer genomic medicine. Case studies illustrate the use of CER approaches. Evidence generation and synthesis approaches used in CER include comparative observational and randomized trials, patient-reported outcomes, decision modeling, and economic analysis. Significant challenges to conducting CER in cancer genomics include the rapid pace of innovation, lack of regulation, and variable definitions and evidence thresholds for clinical and personal utility. Opportunities to capitalize on CER methods in cancer genomics include improvements in the conduct of evidence synthesis, stakeholder engagement, increasing the number of comparative studies, and developing approaches to inform clinical guidelines and research prioritization. CER offers a variety of methodological approaches that can address stakeholders' needs and help ensure an effective translation of genomic discoveries.
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Pinilla-Ibarz J, Flinn I. The expanding options for front-line treatment in patients with newly diagnosed CML. Crit Rev Oncol Hematol 2012; 84:287-99. [PMID: 22487423 DOI: 10.1016/j.critrevonc.2012.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Revised: 03/12/2012] [Accepted: 03/16/2012] [Indexed: 11/17/2022] Open
Abstract
The past decade has seen remarkable advances in the treatment of chronic myeloid leukemia (CML). The discovery of the underlying cause of CML, a chromosomal translocation resulting in the expression of an aberrant tyrosine kinase, has enabled the rational development of targeted therapy with tyrosine kinase inhibitors (TKIs). The first available TKI, imatinib, dramatically improved survival rates and demonstrated the potential for long-term treatment. A number of additional strategies have been tested to further maximize outcomes in patients with newly diagnosed CML, including newer TKIs, imatinib dose escalation, and combination therapy. The advanced, more potent TKIs, nilotinib and dasatinib, have proven effective for newly diagnosed patients and for those who experience inadequate response or intolerance to imatinib. Randomized phase 3 studies have shown that nilotinib and dasatinib are more efficacious than imatinib in achieving primary study endpoints. Nilotinib was superior to imatinib in the rate of major molecular response at 12 months; dasatinib was superior to imatinib in the rate of complete cytogenetic response by 12 months. These phase 3 studies are ongoing to further define longer-term efficacy and safety. Research on additional contributing signaling pathways in CML, T315I mutations, and other causes of treatment resistance has identified additional potential treatments that are now in early stages of clinical development, with encouraging preliminary results. With continued advances, it is conceivable that the ultimate goal - a cure for CML - is in our sights.
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Affiliation(s)
- Javier Pinilla-Ibarz
- H. Lee Moffitt Cancer Center and Research Institute, 13131 Magnolia Drive, 3 East, Rm 3056H, Tampa, FL 33612, USA.
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Trikalinos TA, Moorthy D, Chung M, Yu WW, Lee J, Lichtenstein AH, Lau J. Concordance of randomized and nonrandomized studies was unrelated to translational patterns of two nutrient-disease associations. J Clin Epidemiol 2011; 65:16-29. [PMID: 22047889 DOI: 10.1016/j.jclinepi.2011.07.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 07/09/2011] [Indexed: 02/07/2023]
Abstract
OBJECTIVE There are several examples in nutrition of discordance between the results of observational studies and randomized controlled trials (RCTs). We hypothesized that this discordance is attributable to differences in the translational paths of nutrient-disease associations. Translational paths can be assessed using citation analysis. STUDY DESIGN AND SETTING We compared the characteristics of citation networks using examples, where RCTs and observational studies agreed (long-chain n-3 polyunsaturated fatty acids [n-3 PUFA]) or disagreed (vitamin E). We performed systematic reviews in each example, constructed citation networks, and compared them with respect to the number of articles and citation relationships between them, as well as the distribution of articles' hub and authority scores. RESULTS For n-3 PUFA, meta-analyses of 14 RCTs and 10 observational studies both suggested that higher intake was associated with lower cardiovascular mortality. For vitamin E, the meta-analysis of 14 RCTs excluded a clinically significant effect, whereas 14 observational studies reported a significant inverse association. The respective citation networks consisted of 392 (n-3 PUFA) and 351 (vitamin E) articles. No differences between the characteristics of the two networks were identified. There was no evidence that the observational studies predated RCTs in the translational process in either example. CONCLUSION In the two examples, citation network characteristics do not predict concordance in the results of observational studies and RCTs.
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Affiliation(s)
- Thomas A Trikalinos
- Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Box #63, 800 Washington Street, Boston, MA 02111, USA.
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Abstract
Advances in our understanding of the intricate molecular mechanisms for transformation of a normal cell to a cancer cell, and the aberrant control of complementary pathways, have presented a much more complex set of challenges for the diagnostic and therapeutic disciplines than originally appreciated. The oncology field has entered an era of personalized medicine where treatment selection for each cancer patient is becoming individualized or customized. This advance reflects the molecular and genetic composition of the tumors and progress in biomarker technology, which allow us to align the most appropriate treatment according to the patient's disease. There is a worldwide acceptance that advances in our ability to identify predictive biomarkers and provide them as companion diagnostics for stratifying and subgrouping patients represents the next leap forward in improving the quality of clinical care in oncology. As such, we are progressing from a population-based empirical 'one drug fits all' treatment model, to a focused personalized approach where rational companion diagnostic tests support the drug's clinical utility by identifying the most responsive patient subgroup.
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Shieh MP, Mitsuhashi M, Lilly M. Moving on up: Second-Line Agents as Initial Treatment for Newly-Diagnosed Patients with Chronic Phase CML. Clin Med Insights Oncol 2011; 5:185-99. [PMID: 21792346 PMCID: PMC3140277 DOI: 10.4137/cmo.s6416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The treatment of chronic myelogenous leukemia (CML) was revolutionized by the development of imatinib mesylate, a small molecule inhibitor of several protein tyrosine kinases, including the ABL1 protein tyrosine kinase. The current second generation of FDA-approved ABL tyrosine kinase inhibitors, dasatinib and nilotinib, are more potent inhibitors of BCR-ABL1 kinase in vitro. Originally approved for the treatment of patients who were refractory to or intolerant of imatinib, dasatinib and nilotinib are now also FDA approved in the first-line setting. The choice of tyrosine kinase inhibitor (ie, standard or high dose imatinib, dasatinib, nilotinib) to use for initial therapy in chronic-phase CML (CML-CP) will not always be obvious. Therapy selection will depend on both clinical and molecular factors, which we will discuss in this review.
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Affiliation(s)
- Marie P Shieh
- Division of Hematology-Oncology, Department of Medicine, and Chao Family Comprehensive Cancer Center, University of California, Irvine, CA, USA
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