Case 2 Discussion: High-Risk CML in a 67-Year-Old Female

The panel discusses the case of a 67-year-old female patient diagnosed with high-risk chronic myelomonocytic leukemia (CML-1) who presents with intermediate risk scores and abnormal blood counts, including elevated white blood cells, mild thrombocytopenia, and anemia. She also exhibits symptoms of fatigue and early satiety related to splenomegaly. Her medical history includes mild chronic kidney disease, hypertension, and arthritis, and she prefers home-based therapy due to reliance on public transportation and work obligations. She has not received prior treatment and is hesitant about intravenous therapies because of the logistical burden.

Dr. Shastri highlights that patients with high-risk CML require prompt and effective therapy to manage symptoms and prevent leukemic progression. HMAs remain the first-line treatment for such patients. Although low-risk patients may be managed with supportive care alone, higher-risk patients, like this case, are at increased risk of disease progression and acquisition of additional mutations, making early intervention crucial.

Oral formulations of HMAs, such as oral decitabine, are emphasized as effective and convenient options, particularly for patients wishing to minimize clinic visits. Dr. Shastri notes that these oral agents can be used alone or in combination with other treatments like venetoclax, with encouraging response rates demonstrated in phase 2 studies. Importantly, patients should also undergo HLA typing and transplant evaluation early, as disease progression may necessitate allogeneic stem cell transplantation.

The discussion underscores the importance of balancing efficacy and quality of life by using oral therapies that reduce clinic time while maintaining careful monitoring. Personalized care planning, including anticipation of transplant needs and consideration of comorbidities, is essential for optimizing outcomes in patients with high-risk CML.