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Leukemia - Chronic Myeloid - CML - Introduction

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Chronic Myeloid Leukemia. To see other pages, use the menu. Think of that menu as a roadmap to this full guide.

About leukemia

Leukemia is a cancer of the blood. Leukemia begins when healthy blood cells change and grow out of control. Chronic myeloid leukemia (CML) is a cancer of the blood-forming cells, called myeloid cells, found in the bone marrow. Bone marrow is the spongy, red tissue in the inner part of large bones. CML most often causes an increase in the number of white blood cells, such as neutrophils or granulocytes, that normally fight infection. It is also sometimes called chronic granulocytic, chronic myelocytic, or chronic myelogenous leukemia.

About the Philadelphia chromosome

People with CML have a genetic mutation or change in their bone marrow cells. It is called a translocation. A translocation is when part of a long strand of genes called a chromosome breaks off and reattaches to another chromosome. In CML, part of chromosome 9 breaks off and bonds to a section of chromosome 22, forming the Philadelphia chromosome or Ph chromosome. The Ph chromosome is made up of 2 genes called BCR and ABL that join together into a single fusion gene called BCR-ABL. It is found only in the blood-forming cells, not in other organs of the body. The BCR-ABL gene causes myeloid cells to make an abnormally activated enzyme. Specifically, it is a tyrosine kinase enzyme. This abnormally activated enzyme is called a fusion protein and allows white blood cells to grow out of control.

This genetic change develops from damage that occurs by chance after a person is born. There is no risk that a person will pass on this gene to their children.

About CML

Ordinarily, the number of white blood cells is tightly controlled by the body—more white blood cells are produced during infections or times of stress, but then the numbers return to normal when the infection is cured. In CML, the abnormal BCR-ABL enzyme is like a switch that is stuck in the “on” position—it keeps stimulating the white blood cells to grow and multiply. In addition to increased white blood cells, the number of blood platelets that help the blood to clot often increase. And, the number of red blood cells, which carry oxygen, may decrease.

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The next section in this guide is Statistics. It helps explain how many people are diagnosed with this disease and general survival rates. Or, use the menu to choose another section to continue reading this guide.

Leukemia - Chronic Myeloid - CML - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

ON THIS PAGE: You will find information about how many people are diagnosed with CML each year. You will also learn some general information on surviving the disease. Remember, survival rates depend on several factors. To see other pages, use the menu.

About 10% of all leukemia is CML. This year, an estimated 8,950 people (5,230 men and 3,720 women) in the United States will be diagnosed with CML. Most of these will be adults, with an average age of diagnosis at 64 years. CML is rare in children.

It is estimated that 1,080 deaths (610 men and 470 women) will occur this year.

The 5-year survival rate tells you what percent of people live at least 5 years after the cancer is found. Percent means how many out of 100. The 5-year survival rate of people with CML depends on the phase of the disease, other biologic characteristics of the CML, and the disease’s response to treatment. The pace of CML treatment research is rapid, with several drug approvals in the past 2 decades. It is important to note that many of the new drugs for CML work very well, and survival rates are continually being measured based on these newer drugs.

Due in large part to recent scientific advances in the area of targeted treatments like imatinib (Gleevec), the 5-year survival rate for CML has nearly doubled from 31% for people diagnosed in the early 1990s to 66% for those diagnosed between 2006 and 2012, which are the most recent data available. And, a study of patients consistently taking the drug imatinib found that 90% lived at least 5 years.

It is important to remember that statistics on the survival rates for people with CML are an estimate. The estimate comes from annual data based on the number of people with this cancer in the United States. Also, experts measure the survival statistics every 5 years. So the estimate may not show the results of better diagnosis or treatment available for less than 5 years. People should talk with their doctor if they have questions about this information. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's (ACS) publication, Cancer Facts and Figures 2017, and the ACS website.

The next section in this guide is Medical Illustrations. It offers drawings of body parts often affected by this disease. Or, use the menu to choose another section to continue reading this guide.

Leukemia - Chronic Myeloid - CML - Medical Illustrations

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

ON THIS PAGE: You will find basic drawings of the main body parts affected by this disease. To see other pages, use the menu.

This illustration shows a detail of the human skeleton. A section cut out of the outer edge of the hip bone, called the iliac crest, shows a thin outer layer of bone surrounding the bone marrow, a spongy, red tissue. Copyright 2004 American Society of Clinical Oncology. Robert Morreale/Visual Explanations, LLC.

This illustration of an artery shows various types of blood cells, including the flattened red blood cells, multiple types of white blood cells, and the much smaller platelets. Copyright 2004 American Society of Clinical Oncology. Robert Morreale/Visual Explanations, LLC.

The next section in this guide is Risk Factors. It explains what factors may increase the chance of developing this disease. Or, use the menu to choose another section to continue reading this guide.  

Leukemia - Chronic Myeloid - CML - Risk Factors

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

ON THIS PAGE: You will find out more about the factors that increase the chance of developing this type of leukemia. To see other pages, use the menu.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do develop cancer. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The cause of CML is not known, though researchers now understand how the disease develops from genetic changes in the myeloid cells. Environmental factors account for only a small number of CML diagnoses. And, family history does not appear to play a role in the development of CML.

The following factors may raise a person’s risk of developing CML:

  • Age. The average age of people diagnosed with CML is around 64. CML is uncommon in children and teens.

  • Radiation exposure. More people who were long-term survivors of the 1945 atomic bombings in Japan were diagnosed with CML. In addition, radiation therapy for a condition called ankylosing spondylitis has been linked to CML. However, there is no proven link between CML and radiation therapy or chemotherapy given for other types of cancer or other diseases.

  • Gender. Men are somewhat more likely to develop CML than women.

The next section in this guide is Symptoms and Signs. It explains what body changes or medical problems this disease can cause. Or, use the menu to choose another section to continue reading this guide.

Leukemia - Chronic Myeloid - CML - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu.

People with CML may experience the following symptoms or signs. Or, the cause of a symptom may be another medical condition that is not leukemia. However, CML usually progresses slowly, meaning symptoms may not appear for a long time. The symptoms are usually mild at first and get worse slowly. And often, people with CML do not have any symptoms. CML is most commonly found with a blood test taken for another reason.

  • Fatigue or weakness, such as shortness of breath while doing everyday activities

  • Fever

  • Excessive sweating, especially at night

  • Weight loss

  • Abdominal swelling or discomfort due to an enlarged spleen. This may be particularly noticeable in the upper left part of the abdomen.

  • Feeling full when you have not eaten much

  • Itching

  • Bone pain

  • Bleeding

If you are concerned about any changes you experience, please talk with your doctor. Your doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.

If leukemia is diagnosed, relieving symptoms remains an important part of care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

The next section in this guide is Diagnosis. It explains what tests may be needed to learn more about the cause of the symptoms. Or, use the menu to choose another section to continue reading this guide.

Leukemia - Chronic Myeloid - CML - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

ON THIS PAGE: You will find a list of common tests, procedures, and scans that doctors use to find the cause of a medical problem. To see other pages, use the menu.

Doctors use many tests to find, or diagnose, leukemia. They also do tests to learn more about the extent of the disease. Doctors may also do tests to learn which treatments could work best.

For most types of cancer, a biopsy is the only sure way for the doctor to know whether an area of the body has cancer. In a biopsy, the doctor takes a small sample of tissue for testing in a laboratory. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis.  

This list describes options for diagnosing CML, and not all tests listed will be used for every person. Your doctor may consider these factors when choosing a diagnostic test:

  • The type of leukemia suspected

  • Your signs and symptoms

  • Your age and medical condition

  • The results of earlier medical tests

The following tests may be used to diagnose or monitor CML:

  • Blood tests. Many people are diagnosed with CML through a blood test called a complete blood count (CBC) before they have any symptoms. A CBC counts the number of different kinds of cells in the blood. A CBC is often done as part of a regular medical checkup. People with CML have high levels of white blood cells. However, white blood cell levels might also be caused by conditions that are not leukemia. When the CML is more advanced, there may also be low levels of red blood cells, a condition called anemia, and either elevated or decreased numbers of platelets.

  • Bone marrow aspiration and biopsy. These 2 procedures are similar and often done at the same time to examine the bone marrow. Bone marrow has both a solid and a liquid part. A bone marrow aspiration removes a sample of the fluid with a needle. A bone marrow biopsy is the removal of a small amount of solid tissue using a needle.

    A pathologist then analyzes the sample(s). A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease. A cytogenetic analysis (see below) may also be done on the marrow samples. A common site for a bone marrow aspiration and biopsy is the iliac crest of the pelvic bone (see the Medical Illustrations section), which is located in the lower back by the hip. The skin in that area is usually numbed with medication beforehand, and other types of anesthesia (medication to block awareness of pain) may be used.

  • Molecular testing. Your doctor may recommend testing the leukemia cells for specific genes, proteins, and other factors unique to the leukemia. Results of these tests will help determine whether your treatment options include a type of treatment called targeted therapy (see the Treatment Optionssection).

    Cytogenetics is a type of genetic testing that is used to analyze a cell’s chromosomes. It looks at the number, size, shape, and arrangement of the chromosomes. Occasionally, this test can be done on the peripheral or circulating blood when the CML is first diagnosed, but immature blood cells that are actively dividing need to be used. Because of this, a bone marrow sample (see above) is usually the best way to get a sample for testing.

    After treatment begins, cytogenetic and/or molecular testing is repeated on another bone marrow sample to find out if there are fewer cells with the Philadelphia chromosome. For most people with CML, the Philadelphia (Ph+) chromosome and the BCR-ABL fusion gene (described in the Introduction section) can be found through testing, which confirms the diagnosis. For a small number of patients, increased blood cell counts may suggest CML, but the Philadelphia chromosome cannot be found on the usual tests even though the BCR-ABL fusion gene is there. Treatment for these patients is the same and works as well as it does for patients with a detectable Philadelphia chromosome.

    Cytogenetic testing for CML is used to monitor how well treatment is working and if it is reducing the number of cells with the Philadelphia chromosome. The following tests are sometimes used with cytogenetic testing:

    • Fluorescence in situ hybridization (FISH) is a test used to detect the BCR-ABL gene and to monitor the disease during treatment. This test does not require dividing cells and can be done using a blood sample or bone marrow cells. This test is a more sensitive way to find CML than the standard cytogenetic tests that identify the Philadelphia chromosome.

    • Polymerase chain reaction (PCR) is a DNA test that can find the BCR-ABL fusion gene and other molecular abnormalities. PCR tests may also be used to monitor how well treatment is working. This test is quite sensitive and, depending on the technique used, can find 1 abnormal cell mixed in with approximately 1 million healthy cells. This test can be done using a blood sample or bone marrow cells.

  • Imaging tests. Doctors may use imaging tests to find out if the leukemia is affecting other parts of the body. For example, a computed tomography (CT or CAT) scan or ultrasound examination is sometimes used to look at and measure the size of the spleen in patients with CML.

    • A CT scan creates a 3-dimensional picture of the inside of the body using x-rays taken from different angles. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image. This dye can be injected into a patient’s vein or given as a liquid to swallow.

    • An ultrasound uses high-frequency sound waves to create a picture of the inside of the body.

After diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is CML, these results also help the doctor describe the phase of the disease.

The next section in this guide is Phases. It explains the system doctors use to describe the extent of the disease. Or, use the menu to choose another section to continue reading this guide.

Leukemia - Chronic Myeloid - CML - Phases

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

ON THIS PAGE: You will learn about how doctors describe the growth or spread of CML. This is called the phase. To see other pages, use the menu.

To help doctors plan treatment and predict prognosis, which is the chance of recovery, CML is divided into 3 different phases: chronic, accelerated, or blast.

  • Chronic phase. The blood and bone marrow contain less than 10% blasts. Blasts are immature white blood cells. This phase can last for several years. However, without effective treatment, the disease can progress to the accelerated or blast phases (see below). About 90% of people have chronic phase CML when they are diagnosed. Some people with chronic phase CML have symptoms when they are diagnosed and some do not. Most symptoms go away once treatment begins.

  • Accelerated phase. There is no single definition of accelerated phase. However, most patients with this phase of CML have 10% to 19% blasts in both the blood and bone marrow or more than 20% basophils in the peripheral blood. A basophil is a special type of white blood cell. These cells sometimes have new cytogenetic changes in addition to the Philadelphia chromosome, because of additional DNA damage and mutations in the CML cells.

  • Blast phase, also called blast crisis. In the blast phase, there are 20% or more blasts in the blood or bone marrow, and it is difficult to control the number of white blood cells. The CML cells often have additional genetic changes as well. The blast cells can look like the immature cells seen in acute lymphoblastic leukemia for about 25% of patients or acute myeloid leukemia for most patients. Patients in blast phase often have a fever, an enlarged spleen, weight loss, and generally feel unwell.

  • Resistant CML. Resistant CML is CML that has come back after treatment or does not respond to treatment. This is different from CML that has developed a resistance to treatment, which means that a specific treatment no longer works. If the CML does return, there will be another round of tests to learn about the extent of the disease. These tests and scans are often similar to those done at the time of the original diagnosis.

Without effective treatment, CML in chronic phase will eventually move into accelerated phase at first and then into blast phase in about 6 to 8 years after diagnosis. Patients who have more blasts or an increased number of basophils, chromosome changes in addition to the Philadelphia chromosome, high numbers of white blood cells, or a very enlarged spleen often experience blast phase sooner.

Information about the phase of CML will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. Or, use the menu to choose another section to continue reading this guide.

Leukemia - Chronic Myeloid - CML - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

ON THIS PAGE: You will learn about the different ways doctors use to treat people with CML. To see other pages, use the menu.

This section tells you the treatments that are the standard of care for this type of leukemia. “Standard of care” means the best treatments known. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn if it is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Your doctor can help you consider all your treatment options. To learn more about clinical trials, see the About Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. It is important that a hematologist or an oncologist experienced in blood cancers treats a person with CML. A hematologist is a doctor who specializes in treating blood disorders. An oncologist is a doctor who specializes in treating cancer. Cancer care teams also include a variety of other health care professionals, including physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Descriptions of the most common treatment options for CML are listed below, followed by information on measuring treatment effectiveness and the common treatment recommendations outlined by the disease phase. Treatments for CML have improved greatly in the last 16 years, completely changing how treatment is given and helping many patients live longer.

Treatment options and recommendations depend on several factors, including the phase of the disease, possible side effects, and the patient’s preferences and overall health. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. It is also important to talk with your health care team about the costs of treatment, as many of the drugs discussed below need to be continued throughout a person’s life. Learn more about making treatment decisions.

Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells. For CML, targeted therapy is prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication, or a hematologist.

Recent studies show that not all cancers have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors involved in your leukemia. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.

For CML, the target is the unique protein called the BCR-ABL tyrosine kinase enzyme. There are 5 drugs currently used to target tyrosine kinase enzymes for CML, called tyrosine kinase inhibitors or TKIs: imatinib (Gleevec), dasatinib (Sprycel), nilotinib (Tasigna), bosutinib (Bosulif), and ponatinib (Iclusig). All 5 drugs can stop the BCR-ABL enzyme from working, which causes the CML cells to die quickly. These drugs are described in more detail below.

It is important to note that men and women taking TKIs should avoid fathering a child or becoming pregnant while taking the drugs because of risk to the developing child. To find the best treatment, patients should talk with their doctors about the risks and benefits of these drugs, including the possible side effects and how they can be managed. For example, these drugs can cause inflammation of the liver, which is a problem for people with hepatitis. So, patients should be tested for hepatitis before starting treatment with any of these drugs. If a patient experiences too many side effects, another TKI can be used instead.

  • Imatinib (Gleevec). Imatinib was the first targeted therapy approved by the U.S Food and Drug Administration (FDA) for CML in 2001. It is taken as a pill once or twice a day. It works better than chemotherapy to treat CML and causes fewer side effects (see below). Nearly all patients with chronic phase CML have their blood counts return to healthy levels and their spleen shrink after receiving this drug. Most importantly, 80% to 90% of patients newly diagnosed with chronic phase CML who receive imatinib no longer have detectable levels of cells with the Philadelphia chromosome. Imatinib may also be used to treat other types of cancer, such as acute lymphoblastic leukemia (ALL) with the presence of the Philadelphia chromosome.

    The risk of developing resistant CML for patients whose CML completely responds to imatinib is very low. Patients with few numbers of cells with the Philadelphia chromosome remaining will stay in chronic phase longer by taking imatinib than they might have with previous treatments. It is too soon to know how long these responses will last or if patients will be cured with this medication alone. However, there are many patients who have been treated with imatinib since the first clinical trials in 1999 who still have no detectable cells with the Philadelphia chromosome.

    The side effects of imatinib are mild but can include slight nausea, which is very uncommon when imatinib is taken with food, changes in blood counts, fluid retention, swelling around the eyes, fatigue, diarrhea, and muscle cramps.

  • Dasatinib (Sprycel). Dasatinib is approved by the FDA as an initial treatment for patients with newly-diagnosed chronic phase CML and when other drugs are not working. It is a pill that is usually taken once a day, or sometimes twice a day depending on the dose. The side effects include anemia, a low level of white blood cells called neutropenia, a low level of platelets called thrombocytopenia, and lung problems that include fluid around the lung and/or pulmonary hypertension. The doctor will monitor a patient’s blood counts frequently after starting dasatinib and may adjust the dose or stop giving the drug temporarily if the patient’s blood counts drop too low. Dasatinib may also cause bleeding, fluid retention, diarrhea, rash, headache, fatigue, and nausea. Dasatinib requires stomach acid in order to be absorbed so patients should not take any anti-acid medications.

  • Nilotinib (Tasigna). Nilotinib is also approved by the FDA as an initial treatment for patients with newly-diagnosed chronic phase CML and when other drugs are not working. It is a capsule that patients take by mouth twice a day on an empty stomach. Common side effects include low blood counts, rash, headache, nausea, diarrhea, and itching. Other possible but uncommon serious side effects include high blood sugar levels, fluid build-up, and inflammation of the pancreas or liver. The most serious side effect of nilotinib includes possibly life-threatening heart and blood vessel problems that can lead to an irregular heartbeat, narrowing of the blood vessels, stroke, and possible sudden death. These side effects are very rare, but patients may need testing to check their heart health during treatment. There can be interactions with other medications that may increase these risks, so be sure to talk with your doctor about all medications you are taking.

  • Bosutinib (Bosulif). In 2012, bosutinib was approved by the FDA to treat CML when 1 of the other TKIs was not effective or if a patient experienced too many side effects. The most common side effects include diarrhea, nausea and vomiting, low levels of blood cells, abdominal pain, fatigue, fever, allergic reactions, and liver problems. 

  • Ponatinib (Iclusig). Ponatinib was also approved by the FDA in 2012 for patients when 1 of the other TKIs was not effective or if a patient experienced too many side effects. Ponatinib also targets CML cells that have a particular mutation, known as T315I, which makes these cells resistant to other currently approved TKIs. The most common side effects include high blood pressure, rash, abdominal pain, fatigue, headache, dry skin, constipation, fever, joint pain, and nausea. The FDA also warns that this drug may cause heart problems, severe narrowing of blood vessels, blood clots, stroke, or liver problems.

Measuring treatment effectiveness

Patients receiving a TKI should receive regular check-ups with the health care team to see how well the treatment is working. These tests are generally done every 3 months during the first year of treatment. The response of CML includes:

  • Complete hematologic response:

    •  Healthy levels of white blood cells and platelets

    • No signs of abnormal blood cells, such as blasts, in the blood

    • The spleen is a normal size and cannot be felt on a physical exam

    • There are no CML symptoms

  • Partial response: 

      • Blood counts are still abnormal 

        • There may still be some blasts in the blood

          • The spleen may still be enlarged 

            • Symptoms and blood test results have improved since treatment began.

          These responses can change over time, and there is a risk that the CML will worsen without more effective treatment. Sometimes this means continuing on the current TKI to see if the treatment helps further or it may mean changing to another TKI.

          Other specific tests are used to find the number of cells that have the Philadelphia chromosome or contain the BCR-ABL fusion gene. When CML is diagnosed, the Philadelphia chromosome is found in almost all of a person’s bone marrow and blood cells. Once a person’s CML shows a complete hematologic response, the doctor then looks for a cytogenetic response with tests such as FISH (see Diagnosis).

          • A complete cytogenetic response means that there are no cells with the Philadelphia chromosome found on the routine cytogenetic tests.

          • A partial cytogenetic response means that between 1% and 35% of the cells still have the Philadelphia chromosome.

          • A minor cytogenetic response means that more than 35% of the cells still have the Philadelphia chromosome.

          A molecular response can be determined when the PCR test is used to find the BCR-ABL fusion gene.

          • A major molecular response means that a very small number of cells (more than 1,000 times fewer than when diagnosed) with the BCR-ABL fusion gene are found in the bone marrow or peripheral blood.

          • A complete molecular response is when no cells with the BCR-ABL fusion gene are found in the bone marrow or peripheral blood.

          An important initial goal of treatment is to achieve a complete cytogenetic response. This may require doing another bone marrow biopsy if it is unclear whether the drug is working. Or, another bone marrow biopsy may be needed after 6 to 12 months of treatment to confirm a cytogenetic response. It is not clear whether any of these drugs can cure CML. The disease may come back if treatment is stopped. If treatment with 1 of these drugs is working, a patient no longer has evidence of cells with the Philadelphia chromosome in the bone marrow and has normal levels of blood cells. This is called a complete cytogenetic remission. It is currently recommended that patients take these drugs throughout their lives prevent the CML from coming back. Recent research suggests that some patients may be able to safely stop treatment after a deep and stable response.

          Monitoring

          More sensitive blood tests, such as PCR and occasionally FISH (see Diagnosis), are usually done every 3 months on a blood sample after a person has a cytogenetic response in the bone marrow cells. Patients who have no cells with the Philadelphia chromosome on regular cytogenetic tests often need to have PCR testing to find a molecular response. Patients who have a rapid decrease in the number of cells with the Philadelphia chromosome by 3 months after starting treatment may have the best long-term outcomes.

          The most sensitive test to look for remaining CML is called a quantitative reverse transcriptase PCR (Q-RT-PCR) test. This test is recommended every 3 months on a blood sample. Generally, this test can find 1 CML cell remaining among 1 million healthy blood cells, so, when this test is negative, it is very likely that the CML is nearly gone. On the other hand, if a person continues taking the medication as directed and the results of this test begin to rise, then the current treatment is no longer working. This means that it may be time to switch medications before the disease worsens

          Sometimes, a TKI stops working because the CML develops resistance to it. Resistance can occur if patients do not take their medication regularly, as prescribed, so it is important for patients to take their medication as prescribed. Even if patients do take the medication correctly, CML may become resistant to a TKI, which is why it is important to receive regular monitoring with cytogenetic testing, FISH, or PCR to see how well the drug is continuing to work.

          Both dasatinib and nilotinib have been shown to bring about a complete cytogenetic response sooner and in more people newly diagnosed with CML when compared with imatinib. However, imatinib has been used for longer. There is no difference in overall survival when using either imatinib or another TKI as initial treatment. Bosutinib and ponatinib are newer drugs but both have also produced complete cytogenetic responses in patients with CML. Because of possible severe side effects, caution and careful monitoring is needed if ponatinib is recommended after other drugs have stopped working. However, ponatinib is the only TKI that works for patients whose CML cells have the T315I mutation. If the medication you start with stops working, the dose may be increased or a different TKI may be used instead.

          Chemotherapy

          Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist or a hematologist.

          Systemic chemotherapy gets into the bloodstream to reach cancer cells throughout the body. Common ways to give chemotherapy include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). Chemotherapy can also be given by an injection under the skin called a subcutaneous injection.

          A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or combinations of different drugs at the same time.

          A drug called hydroxyurea (Droxia, Hydrea) is often given to lower the number of white blood cells until CML can be diagnosed with the tests described in the Diagnosis section. Given in capsule form, this drug works well to return blood cells to normal levels within a few days or weeks and reduce the size of the spleen, but it does not reduce the percentage of cells with the Philadelphia chromosome and does not prevent blast phase alone. Although hydroxyurea has few side effects, most patients newly diagnosed with chronic phase CML receive imatinib or another TKI (see above) as soon as possible. This means that they do not need hydroxyurea, or use it for only a short time. Side effects of chemotherapy depend on the specific drug and the dosage and usually become less severe over time.

          In 2012, the drug omacetaxine mepesuccinate (Synribo) was approved by the FDA for patients with chronic or accelerated phase CML that is not responding to the TKIs described above. Omacetaxine is given by injection under the skin daily for 7 to 14 days. The most common side effects include thrombocytopenia, anemia, neutropenia, diarrhea, nausea, fatigue, weakness, skin irritation where the drug was given, fever, and infection.

          Learn more about the basics of chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

          Stem cell transplantation/bone marrow transplantation

          A stem cell transplant is a medical procedure in which bone marrow that contains leukemia is replaced by highly specialized cells, called hematopoietic stem cells, that develop into healthy bone marrow. Hematopoietic stem cells are blood-forming cells found both in the bloodstream and in the bone marrow. Today, this procedure is more commonly called a stem cell transplant, rather than bone marrow transplant, because it is the stem cells in the blood that are typically being transplanted, not the actual bone marrow tissue.

          Before recommending transplantation, doctors will talk with the patient about the risks of this treatment and consider several other factors, such as the phase of CML, results of any previous treatment, and patient’s age and general health. Although a bone marrow transplant is the only treatment that can cure CML, they are used less often now. This is because they have a lot of side effects and TKIs are very effective for CML and have fewer side effects.

          There are 2 types of stem cell transplantation depending on the source of the replacement blood stem cells: allogeneic (ALLO) and autologous (AUTO). ALLO uses donated stem cells, while AUTO uses the patient’s own stem cells. In both types, the goal is to destroy cancer cells in the marrow, blood, and other parts of the body using chemotherapy and/or radiation therapy and then allow replacement blood stem cells to create healthy bone marrow. Only ALLO transplants are used to treat CML.

          Learn more about the basics of stem cell and bone marrow transplantation.

          Immunotherapy

          Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Interferon (Alferon, Infergen, Intron A, Roferon-A) is a type of immunotherapy. It can reduce the number of white blood cells and sometimes decrease the number of cells that have the Philadelphia chromosome.

          Interferon is given daily or weekly by an injection under the skin and sometimes causes flu-like side effects, such as fever, chills, fatigue, and loss of appetite. When given on an ongoing basis, it can also cause loss of energy and memory changes. Interferon therapy was the primary treatment for chronic phase CML before imatinib became available. However, interferon is no longer recommended as the first treatment for CML because research has shown that TKIs work better to treat CML and cause fewer side effects. However, unlike TKIs, interferon is safe to use during pregnancy. Learn more about the basics of immunotherapy.

          Getting care for symptoms and side effects

          Leukemia and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the disease, an important part of care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

          Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. People often receive treatment for the leukemia and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

          Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the leukemia, such as chemotherapy. Talk with your doctor about the goals of each treatment in your treatment plan.

          Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and palliative care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible. Learn more about palliative care.

          Treatment options by phase

          Chronic phase

          The immediate goals of treatment are to reduce any symptoms of CML. The longer-term goals are to decrease or get rid of the cells with the Philadelphia chromosome to slow down or prevent the disease from moving to blast phase. Treatment will often first include a TKI (see Targeted therapy, above). An ALLO stem cell transplantation would be considered afterwards only if TKI treatment does not work.

          Accelerated phase

          The same drugs used for chronic phase CML may also be used for accelerated phase CML. Although treatment with a TKI can work well for accelerated phase CML, it is less likely to work as well as it does for chronic phase CML. Dasatinib or nilotinib are more effective in providing longer remissions, but many patients have the CML return within about 2 years. Therefore, an ALLO stem cell transplantation should be considered when possible. If an ALLO stem cell transplantation is not recommended or if a matched donor cannot be found, the treatment plan may include a different TKI or a clinical trial.

          Blast phase

          Treatment with a TKI only works well for a few months for patients in blast phase, but it can help to control the CML while a stem cell/bone marrow transplant is being arranged. If the transplant can be done while imatinib or dasatinib is working, then the long-term results are better. Stem cell/bone marrow transplantation in the blast phase is less successful than in chronic phase, but this approach has worked well for some patients. Many people with CML in blast phase receive imatinib or dasatinib plus chemotherapy similar to that used for patients with acute leukemia, such as acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL). The chance of remission from this approach is about 20% to 30%, although the leukemia comes back for most patients within weeks to a few months. Hydroxyurea (see Chemotherapy, above) is often given to patients because it can help control blood cell levels. If stem cell/bone marrow transplantation is not an option, your doctor may recommend a clinical trial.

          Resistant CML

          If the leukemia does not respond to treatment, it is a good idea to talk with doctors who have experience in treating resistant CML. Doctors can have different opinions about the best standard treatment plan. Also, clinical trials might be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your treatment plan chosen. This discussion may include clinical trials.

          Your treatment plan may include a combination of targeted therapy, chemotherapy, and stem cell transplantation. Palliative care will also be important to help relieve symptoms and side effects.

          For most patients, a diagnosis of resistant leukemia can be very stressful. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

          Remission and the chance of having the CML return

          It is not yet proven whether imatinib, dasatinib, or nilotinib, or the newer drugs bosutinib, ponatinib, or omacetaxine can cure CML. A remission is when leukemia cannot be detected in the body by cytogenetic testing and there are no symptoms. This may also be called having “no evidence of disease” or NED.

          A remission may be temporary or permanent. This uncertainty causes many people to worry that the leukemia will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the disease returning. Understanding your risk of having the disease come back and the treatment options may help you feel more prepared if the leukemia does return. Learn more about coping with the fear of the CML returning.

          If the leukemia does return despite the original treatment, a cycle of testing will begin again to learn as much as possible about the disease. After testing is finished, you and your doctor will talk about your treatment options. Often the treatment plan will include the treatments described above such as targeted therapy, chemotherapy, and immunotherapy, but they may be used in a different combination or given at a different dose. Your doctor may also suggest clinical trials that are studying new ways to treat this type of leukemia. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

          People with leukemia that has come back after remission often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer CML that comes back.

          If treatment fails

          Recovery from leukemia is not always possible. If the leukemia cannot be cured or controlled, the disease may be called advanced or terminal.

          This diagnosis is stressful, and advanced leukemia is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and that pain and other side effects are well-managed is extremely important.

          Patients who have advanced disease and who are expected to live less than 6 months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

          After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

          The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Or, use the menu to choose another section to continue reading this guide.

          Leukemia - Chronic Myeloid - CML - About Clinical Trials

          This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

          ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu.

          What are clinical trials?

          Doctors and scientists are always looking for better ways to care for patients with CML. To make scientific advances, doctors create research studies involving volunteers, called clinical trials. In fact, every drug that is now approved by the FDA was tested in clinical trials.  

          Many clinical trials focus on new treatments. Researchers want to learn if a new treatment is safe, effective, and possibly better than the treatment doctors use now (called the “standard of care”). These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials can be some of the first to get a treatment before it is available to the public. However, there is no guarantee that the new treatment will be safe, effective, or better than what doctors use now.

          Some clinical trials study new ways to relieve symptoms and side effects during treatment. Others study ways to manage the late effects that may happen a long time after treatment. Talk with your doctor about clinical trials for symptoms and side effects. There are also clinical trials studying ways to prevent cancer.

          Deciding to join a clinical trial

          Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating CML. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with CML.

          Sometimes people have concerns that, in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” However, placebos are usually combined with standard treatment in most cancer clinical trials. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

          Patient safety and informed consent

          To join a clinical trial, patients participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. This discussion should also include the potential costs of the clinical trial for the patient and what will be covered by insurance and/or the clinical trial.

          Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends.

          Finding a clinical trial

          Research through clinical trials is ongoing for all types of cancer. For specific topics being studied for CML, learn more in the Latest Research section.

          Cancer.Net offers a lot of information about clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of leukemia.

          PRE-ACT, Preparatory Education About Clinical Trials

          In addition, this website offers free access to a video-based educational program about clinical trials, located outside of this guide.

          The next section in this guide is Latest Research. It explains areas of scientific research currently going on for CML. Or, use the menu to choose another section to continue reading this guide.

          Leukemia - Chronic Myeloid - CML - Latest Research

          This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

          ON THIS PAGE: You will read about the scientific research being done now to learn more about CML and how to treat it. To see other pages, use the menu.

          Doctors are working to learn more about CML, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Most cancer centers are actively involved in clinical trials aimed at increasing the number of people who are cured of CML. Always talk with your doctor about the diagnostic and treatment options best for you.

          • Improving current treatments. Research focused on increasing the effectiveness of CML treatments are listed below:

            • Combining imatinib with other drugs

            • Determining whether patients with CML can safely stop taking TKIs

            • Creating vaccines against BCR-ABL

            • Developing newer methods of stem cell transplantation aimed at decreasing the side effects

            • Evaluating other new TKIs for CML that does not respond to imatinib

            • Looking for unexpected long-term side effects

          • Treatment to target remaining CML cells. Several laboratory studies are focused on possible treatments that may help destroy the few remaining CML cells in most patients who have received TKIs so they can stop medical treatment.

          • Palliative care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current CML treatments to improve patients’ comfort and quality of life.

          Looking for More About the Latest Research?

          If you would like additional information about the latest areas of research regarding CML, explore these related items that take you outside of this guide:

          The next section in this guide is Coping with Treatment. It offers some guidance in how to cope with the physical, emotional, and social changes that CML and its treatment can bring. Or, use the menu to choose another section to continue reading this guide.  

          Leukemia - Chronic Myeloid - CML - Coping with Treatment

          This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

          ON THIS PAGE: You will learn more about coping with the physical, emotional, social, and financial effects of leukemia and its treatment. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu.

          Every treatment can cause side effects or changes to your body and how you feel. For many reasons, people don’t experience the same side effects even when given the same treatment for the same type of leukemia. This can make it hard to predict how you will feel during treatment.

          As you prepare to start treatment, it is normal to be worried about treatment-related side effects. It may help to know that your health care team will work to prevent and relieve side effects. Doctors call this part of treatment “palliative care.” It is an important part of your treatment plan, regardless of your age or the stage of disease.

          Coping with physical side effects

          Common physical side effects from each treatment option for CML are described within the Treatment Options section. Learn more about side effects of leukemia and its treatment, along with ways to prevent or control them. Changes to your physical health depend on several factors, including the leukemia’s phase, the length and dose of treatment, and your general health.

          Sometimes, physical side effects can last after treatment ends. Doctors call these long-term side effects. They call side effects that occur months or years after treatment late effects. Treating long-term side effects and late effects is an important part of survivorship care. Learn more by reading the Follow-up Care section of this guide or talking with your doctor.

          Coping with emotional and social effects

          You can have emotional and social effects as well as physical effects after a CML diagnosis. This may include dealing with difficult emotions, such as anxiety or anger, or managing your stress level. Sometimes, patients have problems expressing how they feel to their loved ones, or people don’t know what to say in return.

          Patients and their families are encouraged to share their feelings with a member of their health care team. You can also find coping strategies for emotional and social effects in a separate section of this website. This section includes many resources for finding support and information to meet your needs.

          Coping with financial effects

          Treatment for leukemia can be expensive. It is often a big source of stress and anxiety for people with CML and their families. In addition to treatment costs, many people find they have extra, unplanned expenses related to their care. For some people, the high cost stops them from following or completing their cancer treatment plan. This can put their health at risk and may lead to higher costs in the future. If you are having difficulties with covering the costs of treatment, talk with your health care team. They can direct you to resources that could help with the costs. Learn more about managing financial considerations, in a separate part of this website.

          Caring for a loved one with CML

          Family members and friends often play an important role in taking care of a person with CML. This is called being a caregiver. Caregivers can provide physical, practical, and emotional support to the patient, even if they live far away.

          Caregivers may have a range of responsibilities on a daily or as-needed basis. Below are some of the responsibilities caregivers take care of:

          • Providing support and encouragement

          • Giving medications

          • Helping manage symptoms and side effects

          • Coordinating medical appointments

          • Providing a ride to appointments

          • Assisting with meals

          • Helping with household chores

          • Handling insurance and billing issues

          Learn more about caregiving.

          Talking with your health care team about side effects

          Before starting treatment, talk with your doctor about possible side effects. Ask:

          • Which side effects are most likely?

          • When are they likely to happen?

          • What can we do to prevent or relieve them?

          Be sure to tell your health care team about any side effects that happen during treatment and afterward, too. Tell them even if you don’t think the side effects are serious. This discussion should include physical, emotional, and social effects of CML.

          Also, ask how much care you may need at home and with daily tasks during and after treatment. This can help you make a caregiving plan.

          The next section in this guide is Follow-up Care. It explains the importance of continuing regular check-ups. Or, use the menu to choose another section to continue reading this guide.

          Leukemia - Chronic Myeloid - CML - Follow-Up Care

          This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

          ON THIS PAGE: You will read about why follow-up care is important. To see other pages, use the menu.

          For many people with CML, targeted therapy is an ongoing cancer treatment. Any decision to stop taking these drugs should be made by a patient and doctor together, based on how well the drug continues to work and the side effects.

          Even after a successful stem cell/bone marrow transplant, care for people diagnosed with CML doesn’t end. Your health care team will continue to check to make sure the leukemia has not returned, manage any side effects, and monitor your overall health. This is called follow-up care.

          Your follow-up care may include regular physical examinations, medical tests, or both. Doctors want to keep track of your recovery in the months and years ahead. Learn more about the importance of follow-up care.

          Watching for resistant CML

          One goal of follow-up care is to check for CML that has come back or worsened. CML comes back or worsens because small areas of leukemia cells may remain undetected in the body. Over time, these cells may increase in number until they show up on test results or cause signs or symptoms. During follow-up care, a doctor familiar with your medical history can give you personalized information about your risk of developing resistant CML. Your doctor will also ask specific questions about your health. Some people may have blood tests or imaging tests as part of regular follow-up care, but testing recommendations depend on several factors including the type and phase of leukemia originally diagnosed and the types of treatment given.

          Managing long-term and late side effects

          Most people expect to experience side effects when receiving treatment. However, it is often surprising to survivors that some side effects may linger beyond the treatment period. These are called long-term side effects. In addition, other side effects called late effects may develop months or even years afterwards. Long-term and late effects can include both physical and emotional changes.

          Talk with your doctor about your risk of developing such side effects based on the type of leukemia, your individual treatment plan, and your overall health. If you had a treatment known to cause specific late effects, you may also have certain physical examinations, scans, or blood tests to help find and manage them.

          Keeping personal health records

          You and your doctor should work together to develop a personalized follow-up care plan. Be sure to ask about any concerns you have about your future physical or emotional health. ASCO offers forms to help create a treatment summary to keep track of the treatment you received and develop a survivorship care plan.

          This is also a good time to decide who will lead your follow-up care. Some survivors continue to see their hematologist or oncologist, while others transition back to the general care of their family doctor or another health care professional. This decision depends on several factors, including the type and phase of leukemia, side effects, health insurance rules, and your personal preferences.

          If a doctor who was not directly involved in your care for CML will lead your follow-up care, be sure to share your treatment summary and survivorship care plan forms with him or her, as well as all future health care providers. Details about your treatment are very valuable to the health care professionals who will care for you throughout your lifetime.

          The next section in this guide is Survivorship. It describes how to cope with challenges in everyday life after a CML diagnosis. Or, use the menu to choose another section to continue reading this guide.

          Leukemia - Chronic Myeloid - CML - Survivorship

          This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

          ON THIS PAGE: You will read about how to cope with challenges in everyday life after a diagnosis of CML. To see other pages, use the menu.

          What is survivorship?

          The word “survivorship” means different things to different people. Common definitions include:

          • For many cancers, it may be having no signs of cancer after finishing treatment.

          • For CML, it may be living with, through, and beyond cancer. According to this definition, cancer survivorship begins at diagnosis and includes people who continue to have treatment over the long term, to either reduce the risk of developing resistant CML or to manage chronic disease.

          Survivorship is one of the most complicated parts of having cancer. This is because it is different for everyone.

          Survivors may experience a mixture of strong feelings, including joy, concern, relief, guilt, and fear. Some people say they appreciate life more after a cancer diagnosis and have gained a greater acceptance of themselves. Others become very anxious about their health and uncertain of how to cope with everyday life.

          Survivors may feel some stress when visits to the health care team become less frequent. This may be especially true as new worries and challenges surface over time, such as any late effects of treatment, emotional challenges including fear of having the disease come back, sexuality and fertility concerns, and financial and workplace issues.

          Every survivor has individual concerns and challenges. With any challenge, a good first step is being able to recognize your fears and talk about them. Effective coping requires:

          • Understanding the challenge you are facing,

          • Thinking through solutions,

          • Asking for and allowing the support of others, and

          • Feeling comfortable with the course of action you choose.

          Many survivors find it helpful to join an in-person support group or an online community of survivors. This allows you to talk with people who have had similar first-hand experiences. Other options for finding support include talking with a friend or member of your health care team, individual counseling, or asking for assistance at the learning resource center of the center where you received treatment.

          Changing role of caregivers

          Family members and friends may also go through periods of transition. A caregiver may play a very important role in supporting a person diagnosed with CML, providing physical, emotional, and practical care on an as-needed basis. Many caregivers become focused on providing this support, especially when the treatment period lasts for many months or longer.

          A new perspective on your health

          For many people, survivorship serves as a strong motivator to make positive lifestyle changes.

          People with CML are encouraged to follow established guidelines for good health, such as not smoking, limiting alcohol, eating well, and managing stress. Regular physical activity can help rebuild your strength and energy level. Your health care team can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about making healthy lifestyle choices.

          In addition, it is important to have recommended medical check-ups and tests (see Follow-up Care) to take care of your health. Rehabilitation may also be recommended, and this could mean any of a wide range of services such as physical therapy, career counseling, pain management, nutritional planning, and/or emotional counseling. The goal of rehabilitation is to help people regain control over many aspects of their lives and remain as independent and productive as possible.

          Talk with your doctor to develop a survivorship care plan that is best for your needs.

          Looking for More Survivorship Resources?

          For more information about survivorship, explore these related items. Please note these links will take you to other sections of Cancer.Net:

          • ASCO Answers Cancer Survivorship Guide: Get this 44-page booklet that helps people transition into survivorship. It includes blank treatment summary and survivorship care plan forms. The booklet is available as a PDF, so it is easy to print out.

          • Cancer.Net Patient Education Video: View a short video led by an ASCO expert that provides information about what comes next when transitioning into survivorship.

          • Survivorship Resources: Cancer.Net offers an entire area of this website with resources to help survivors, including for survivors in different age groups.

          The next section offers Questions to Ask the Doctor to help start conversations with your health care team. Or, use the menu to choose another section to continue reading this guide.  

          Leukemia - Chronic Myeloid - CML - Questions to Ask the Doctor

          This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

          ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team, to help you better understand your diagnosis, treatment plan, and overall care. To see other pages, use the menu.

          Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to help manage your care.

          Questions to ask after getting a diagnosis

          • What is my diagnosis?

          • Can you explain my pathology report (laboratory test results) to me?

          • What phase is the CML in?

          • Can you recommend a leukemia specialist?

          Questions to ask about choosing a treatment and managing side effects

          • Where is the best place for me to receive treatment?

          • What are my options for treatment?

          • What clinical trials are available for me? Where are they located, and how do I find out more about them?

          • What treatment plan do you recommend? Why?

          • What are the pros and cons of each option?

          • What is the goal of each treatment? Is it to eliminate the leukemia, help me feel better, or both?

          • Do I need to start treatment right away?

          • Who will be part of my health care team, and what does each member do?

          • Who will be leading my overall treatment?

          • What kinds of symptoms should I call my health care team about?

          • What is my chance of remission and long-term benefit, including cure?

          • What are the possible side effects of this treatment, both in the short term and long term?

          • If I experience too many side effects, can I switch to a different treatment?

          • How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?

          • Could this treatment affect my sex life? If so, how and for how long?

          • If I am worried about managing the costs of care, who can help me?

          • What support services are available to me? To my family?

          • Whom should I call for questions or problems?

          • Is there anything else I should be asking?

          • How will the results of my treatment be monitored?

          Questions to ask about having targeted therapy

          • What type of treatment is recommended?

          • What is the goal of this treatment?

          • How long will it take to give this treatment?

          • What side effects can I expect during treatment?

          • What are the possible long-term effects of having this treatment?

          • What can be done to relieve the side effects?

          • Will the medicine for CML interfere with any of my other medications?

          • Are there foods I should avoid while taking a TKI?

          • Can I stop TKI treatment to start a family? What if my partner and I conceive while I am taking a TKI?

          • What are the risks of trying to conceive a child while taking a TKI?

          Questions to ask about having chemotherapy and/or a stem cell transplant

          • What type of treatment is recommended?

          • What is the goal of this treatment?

          • How long will it take to give this treatment?

          • What side effects can I expect during treatment?

          • What are the possible long-term effects of having this treatment?

          • What can be done to relieve the side effects?

          • Could this treatment affect my ability to become pregnant or have children? If so, should I talk with a fertility specialist before cancer treatment begins?

          • Will the medicine for CML interfere with any of my other medications?

          • Am I a candidate for an ALLO stem cell transplantation, and when should it be considered?

          Questions to ask about planning follow-up care

          • What is the risk of the CML returning or worsening? Are there signs and symptoms I should watch for?

          • What is the chance that the leukemia will come back?

          • What follow-up tests will I need, and how often will I need them?

          • How do I get a treatment summary and survivorship care plan to keep in my personal records?

          • Who will be leading my follow-up care?

          • What survivorship support services are available to me? To my family?

          The next section in this guide is Additional Resources. It offers some more resources on this website beyond this guide that may be helpful to you. Or, use the menu to choose another section to continue reading this guide.

          Leukemia - Chronic Myeloid - CML - Additional Resources

          This section has been reviewed and approved by the Cancer.Net Editorial Board, 11/2016

          ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Chronic Myeloid Leukemia. To go back and review other pages, use the menu.

          Cancer.Net includes many other sections about the medical and emotional aspects of cancer, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond.

          Beyond this guide, here are a few links to help you explore other parts of Cancer.Net:

          This is the end of the Cancer.Net’s Guide to Chronic Myeloid Leukemia. Use the menu to select another section to continue reading this guide.