The "Hit Hard and Hit Early" Approach to the Treatment of Chronic Myeloid Leukemia: Implications of the Updated National Comprehensive Cancer Network Clinical Practice Guidelines for Routine Practice

Abstract: In July 2012, the National Comprehensive Cancer Network (NCCN) updated its clinical practice guidelines in chronic myeloid leukemia (CML) with perhaps the most sweeping changes in a decade. These changes are expected to affect routine practice in CML, particularly with respect to criteria for early molecular response at 3 months and minimum specifications for molecular monitoring assays. Viewed as a whole, these updates signal an important shift in the recommendations for managing patients with CML. These updates support the wider use of standardized molecular monitoring assays, which should improve data consistency, reliability, and reproducibility. They also implicitly recommend that treating physicians strive for deeper levels of response early in the treatment course, in recognition of the effectiveness of current standard therapy. Most importantly, these updates reinforce the increasingly common perception that CML in its early chronic phase can be managed as a chronic disease in the majority of newly diagnosed patients. In this review, we outline the major updates to the guidelines, discuss the rationale behind these updates, and provide our perspectives on how they affect patient management in CML, including a preference for the use of newer tyrosine kinase inhibitors in the first-line setting