Definitely agree with Tim with one minor exception. Given her age and co-morbidities, I would go with 50mg DAS. There are data from the OPTIM study, presented and soon to be published I hope, that suggests that 50mg is all that is needed. Increase dose if response is poor. Would not chase MR4.5 as an endpoint, but at least a stable CCyR or MMR. TFR should not be a major target on your radar. If she responds well and runs into toxicities, consider a switch to imatinib. Unless resistance and the appropriate mutation dictates, would avoid nilotinib because of the diabetes.

We still do a bone marrow at diagnosis to exclude advanced phase disease and to look at cytogenetics. I agree the value is limited in patients where an allograft would never be a consideration and I wouldn’t push too hard in these patients if they were not keen to have it done.

I would generally prefer a second gen TKI in patients with high Sokal score and dasatinib would be a good choice in this lady. I might not use 100 mg/day though – given her age-related high risk of pleural effusion. I would use 70 mg/day and only increase if her molecular response was not optimal.

We have a 74 year diabetic lady
Newly diagnosed CML
Sokal score high

Questions

1. Are you doing Bone marrow at diagnosis in 74 year old lady ?
2. Your choice of TKI in this patient will be imatinib or dasatinib ?