Chronic Myelogenous Leukemia (CML)

Chronic myelogenous leukemia (CML) is a type of blood cancer that starts in the bone marrow, where blood cells are made. In CML, the bone marrow makes too many white blood cells, especially a group called myeloid cells. These cells do not work normally and slowly crowd out healthy blood cells. CML usually grows slowly at first and can often be controlled for many years with modern medicines.

Chronic myelogenous leukemia (CML), also called chronic myeloid leukemia, is a blood cancer that starts in the bone marrow where blood cells are made. In CML, a genetic change creates an abnormal “fusion” gene called BCR-ABL1, usually due to the Philadelphia chromosome, which makes a very active enzyme (tyrosine kinase). This enzyme causes white blood cells to grow too fast and live too long, crowding out normal red cells and platelets. Modern tyrosine kinase inhibitor (TKI) tablets can turn CML into a long-term, well-controlled disease for many people, often with near-normal life expectancy when treatment is taken regularly and monitoring is done on time.[]

CML is almost always linked to a special change in the DNA of a bone-marrow stem cell. A small piece of chromosome 9 swaps places with a piece of chromosome 22. This swap makes a new “fusion gene” called BCR-ABL1 on chromosome 22, also called the Philadelphia chromosome. The BCR-ABL1 gene tells the cell to make a protein that is always “switched on” and makes the cell divide too fast and live too long. This genetic change happens during life; people are not born with it and usually do not pass it to their children.

Other names of chronic myelogenous leukemia

Doctors and books may use different names for the same disease. Chronic myelogenous leukemia is also called:

• Chronic myeloid leukemia (CML) – this is now the most common name

• Chronic granulocytic leukemia (CGL) – older name

• Chronic myelocytic leukemia – another older name

All of these names describe the same condition in which myeloid white blood cells grow in an uncontrolled way in the bone marrow.

Types of chronic myelogenous leukemia

Doctors divide CML into “phases” based on how many blast cells (very immature cells) are in the blood and bone marrow, and how sick the person is. There are three main phases.

1. Chronic phase
   Most people are first found to have CML in the chronic phase. In this phase, blast cells are low, usually less than 10% of cells. Many people feel normal or only a little tired. The white blood cell count is high on a blood test, but serious problems are not yet common. With modern targeted medicines, many people can stay in this phase for a very long time.

2. Accelerated phase
   In the accelerated phase, the disease becomes more active. Blast cells rise (about 10–19%), the spleen may grow larger, and blood counts can become unstable (very high or very low). People may feel more tired, lose weight, or have fever and night sweats. This phase is a warning that the disease may move toward a more dangerous stage if not controlled quickly.

3. Blast phase (blast crisis)
   In the blast phase, CML behaves like an acute leukemia. Blast cells are 20% or more of the blood or bone-marrow cells. People usually feel very unwell, with fever, infections, bleeding problems, and bone pain. This phase is a medical emergency and needs fast, intensive treatment.

Causes and risk factors of chronic myelogenous leukemia

The direct cause of CML is the BCR-ABL1 fusion gene, but many things can influence the chance of this gene change happening. Often, no clear risk factor is found.

1. Philadelphia chromosome and BCR-ABL1 fusion gene
   The basic cause of CML is the DNA swap between chromosome 9 and 22, forming the Philadelphia chromosome and the BCR-ABL1 gene. This gene makes an abnormal tyrosine kinase protein that drives the over-growth of myeloid cells. Without this fusion gene, true CML is usually not present.

2. Random DNA damage during life
   The change that creates BCR-ABL1 usually happens by chance in a single stem cell. As we age, our cells collect random DNA damage from normal cell division and everyday exposures. Sometimes one of these random errors affects genes that control cell growth, leading to diseases like CML.

3. Older age
   CML can occur at any age but is most common in middle-aged and older adults. The average age at diagnosis is around the 60s. As people get older, blood stem cells have had more time to collect mutations, which may help explain the higher risk.

4. Male sex
   CML is seen slightly more often in men than in women. The reason is not fully clear. It may be related to differences in lifestyle or occupational exposures, but it may also involve biological factors that researchers are still studying.

5. High-dose ionizing radiation
   Studies in people exposed to atomic-bomb blasts and high radiation accidents show a clearly higher rate of CML many years later. Strong ionizing radiation can break DNA strands and cause the kind of chromosome swap seen in the Philadelphia chromosome. This type of exposure is rare in daily life but is a proven risk factor.

6. Previous therapeutic radiation for cancer
   Some people receive high-dose radiation to treat another cancer. This medical radiation can also damage bone-marrow DNA. A small number of those patients may later develop myeloid leukemias, including CML, as a long-term complication of therapy. The benefit of treating the original cancer usually outweighs this small risk.

7. Long-term benzene exposure
   Benzene is a chemical used in industries like rubber, oil, and certain manufacturing, and it is also found in petrol and cigarette smoke. Long-term exposure is a known risk for some leukemias and may slightly increase the risk of CML as well. It can damage bone-marrow stem cells and cause chromosome changes.

8. Cigarette smoking
   Cigarette smoke contains benzene and many other chemicals that can damage DNA. A meta-analysis suggests that smoking may increase the risk of CML in a dose-dependent way, meaning heavier smoking gives higher risk. This effect is still smaller than for some other cancers but is another reason to avoid smoking.

9. Obesity (high body-mass index)
   Some large population studies suggest that obesity is linked to a higher risk of several cancers, including CML. Extra fat tissue can cause low-grade inflammation and hormonal changes that may stress bone-marrow cells and favor cancer development over many years.

10. Previous chemotherapy for other cancers
    Certain chemotherapy drugs, especially older alkylating agents, can injure bone-marrow DNA. These drugs are more strongly linked with acute myeloid leukemia, but they may also contribute to a small increased risk of chronic myeloid leukemias in some people.

11. Family history and genetic susceptibility
    CML usually does not run in families, but rare family clusters have been reported. This suggests that some people may inherit a tendency for their bone-marrow cells to be more easily damaged, even though the BCR-ABL1 fusion itself is not inherited.

12. Clonal hematopoiesis and aging of stem cells
    In older adults, blood-forming stem cells sometimes form “clones” with acquired mutations. This is called clonal hematopoiesis and is linked to a higher general risk of blood cancers, especially myeloid ones, although most people with it never develop leukemia. It shows how aging stem cells can step toward leukemia.

13. High environmental radiation near nuclear sources
    People living or working close to nuclear accidents or poorly protected reactors may be exposed to higher ionizing radiation. Over time this can raise leukemia risk, including CML, in a similar way to atomic-bomb survivors, though modern safety standards aim to keep this risk very low.

14. Occupational exposure in petrol, rubber, and chemical industries
    Workers in some factories, refineries, or chemical plants may breathe higher levels of benzene and other solvents. Studies show that such long-term occupational exposure increases leukemia risk. This is especially important in workplaces without good ventilation and protective rules.

15. Pesticides and other DNA-damaging chemicals
    Some pesticides and industrial pollutants can act as mutagens, meaning they can directly damage DNA or interfere with repair systems. While links to CML are not as strong as for some other cancers, these chemicals can contribute to the background risk of blood cancers over time.

16. Chronic inflammation and immune stress
    Long-lasting inflammation from various health problems can stress bone-marrow stem cells. Conditions that disturb normal blood-cell production, such as some myelodysplastic syndromes or myeloproliferative disorders, show how stressed marrow is more likely to evolve into leukemia, although this pattern is clearer for AML than for CML.

17. Other bone-marrow diseases and overlap syndromes
    People with mixed myelodysplastic/myeloproliferative diseases have an increased risk of transforming into acute leukemias. This supports the idea that any long-term disorder of the marrow can create an environment where additional mutations, like BCR-ABL1, become more likely, even if this exact path to CML is uncommon.

18. Combination of lifestyle and workplace factors in men
    Men have higher CML rates, and in many countries they are more likely to smoke or work in heavy industry. These patterns may partly explain the male–female difference, showing how several small risks can add up over many years.

19. Medical imaging and radiation over a lifetime
    Ordinary X-rays and scans use much lower radiation than atomic bombs, and the individual risk from one scan is very small. However, repeated high-dose imaging over a lifetime adds to the general radiation load and may slightly contribute to long-term leukemia risk, though this is difficult to measure for CML alone.

20. Unknown or unidentifiable causes
    For most people with CML, doctors cannot find any clear risk factor. The disease seems to arise from unlucky DNA damage in a single stem cell combined with normal aging. Knowing this can help patients understand that they did not “cause” their illness by something they did or did not do.

Symptoms and signs of chronic myelogenous leukemia

Symptoms can be mild at first. Many people are diagnosed during routine blood tests before they feel sick.

1. No symptoms (found on routine blood test)
   Many people with chronic-phase CML feel completely normal. A high white blood-cell count is found on a blood test done for another reason, such as a check-up. This silent start is one reason CML is often caught at a relatively early phase today.

2. Feeling very tired (fatigue)
   Fatigue is one of the most common complaints. It happens because the bone marrow is crowded and cannot make enough healthy red blood cells, and because the body is working hard against the leukemia. People may feel exhausted even after small tasks.

3. Weakness and low energy
   Weakness is similar to fatigue but often feels like loss of physical strength. Climbing stairs, carrying bags, or even walking short distances can feel harder than before. This is often related to anemia and general illness.

4. Unplanned weight loss
   Some people lose weight without trying. The body uses extra energy because of the cancer, and appetite may be poor because of spleen enlargement or feeling unwell. Any unexplained weight loss should be checked by a doctor.

5. Loss of appetite and early fullness
   An enlarged spleen can press on the stomach. People may feel full after only a few bites or have little interest in food. This can make weight loss worse and may be felt as pressure under the left ribs.

6. Night sweats
   Waking up with the bed and clothes soaked in sweat is a classic symptom. Night sweats can happen even in a cool room and without fever. They reflect the body’s reaction to the leukemia and are often grouped with fever and weight loss as “B symptoms.”

7. Fever
   Some people have unexplained fevers, especially in more active phases of CML. Sometimes fever is due to infections because the abnormal white cells do not fight germs well. Persistent or repeated fever should always be assessed by a doctor.

8. Enlarged spleen (splenomegaly)
   The spleen often becomes bigger because it traps extra leukemia cells. People may feel a lump or heaviness under the left ribs or in the upper left belly. A doctor can usually feel an enlarged spleen during a physical exam.

9. Abdominal discomfort or pain
   A large spleen can cause pain, pressure, or a sense of bloating in the abdomen. This can make sitting, eating, or bending over uncomfortable. Severe sudden pain may be a warning of spleen problems and needs urgent care.

10. Bone or joint pain
    As leukemia cells build up in the bone marrow, they can push on the hard outer shell of the bone and irritate nearby tissues. People may feel deep bone pain in the legs, hips, ribs, or other areas, or aching joints.

11. Shortness of breath with activity
    When red blood cells are low (anemia), the body cannot carry enough oxygen. People may feel out of breath when walking, climbing stairs, or even talking. This may come together with dizziness or pounding heartbeats.

12. Pale skin (pallor)
    Anemia can make the skin and the inside of the eyelids look paler than usual. Family or friends may notice that the person looks “washed out” or “unwell.” This is a common sign in many blood diseases, including CML.

13. Easy bruising or bleeding
    The platelet count can be low or platelets may not work normally. People may notice frequent nosebleeds, bleeding gums, tiny red spots on the skin (petechiae), or bruises after only minor bumps. Any new or severe bleeding needs urgent medical attention.

14. Frequent or repeated infections
    Even though the white blood cell count is high, many of these cells are abnormal and do not fight infection. People may get more colds, chest infections, or other bacterial illnesses than usual, or they may take longer to recover.

15. General feeling of being unwell (malaise)
    Many people with CML describe a vague feeling of illness, low mood, or lack of interest in activities. This can come from the cancer itself, anemia, poor sleep from night sweats, or worry about health. It is real and important and should be discussed with the care team.

Diagnostic tests for chronic myelogenous leukemia

Doctors use a mix of physical examination, blood tests, bone-marrow tests, genetic tests, and sometimes heart and imaging tests. Together, these confirm CML, define the phase, and help plan safe treatment.

Physical examination and manual tests

1. Full medical history and general physical exam
   The doctor asks about symptoms (fatigue, weight loss, night sweats, infections) and examines the whole body. They check temperature, heart rate, blood pressure, and breathing, and look for signs like pale skin or bruises. This first step guides which blood and bone-marrow tests are needed next.

2. Palpation (feeling) of the spleen
   The doctor gently presses under the left rib cage to feel whether the spleen is enlarged. In CML, the spleen often stretches downward and can be felt as a firm edge or mass. How big the spleen is helps judge how active the disease is.

3. Palpation of the liver
   The doctor also feels under the right ribs to check if the liver is enlarged. Liver enlargement is less specific than spleen enlargement but can happen when many abnormal cells circulate in the blood and collect in organs.

4. Examination of lymph nodes and skin
   The neck, armpits, and groin are checked for swollen lymph nodes, and the skin is examined for bruises, petechiae, or rashes. These findings can suggest bleeding problems or other blood cell changes that fit with CML or help rule out other diseases.

5. Checking vital signs (temperature, pulse, blood pressure)
   Basic measurements help detect fever, fast heart rate, or low blood pressure, which might signal infection, anemia, or advanced disease. Changes in these signs can also help monitor how well treatment is working or if complications are starting.

Lab and pathological tests

6. Complete blood count (CBC) with differential
   This is the key first blood test. It measures numbers of white cells, red cells, and platelets. In CML, the white blood cell count is usually very high, with many myeloid cells at different stages of maturity. Red cells and platelets may be low or sometimes high.

7. Peripheral blood smear
   A drop of blood is spread on a glass slide and looked at under a microscope. The doctor can directly see the mix of cell types. In CML, there are many granulocytes (neutrophils, basophils, eosinophils) at various stages, often with increased basophils and eosinophils. This pattern helps distinguish CML from simple infection.

8. Bone marrow aspiration and biopsy
   A needle is used to take liquid marrow (aspiration) and a small core of bone (biopsy), usually from the hip bone. The samples show how full the marrow is with myeloid cells and blasts, and whether scar tissue is present. This test is very important at diagnosis and sometimes later if the disease changes.

9. Conventional cytogenetic karyotyping for the Philadelphia chromosome
   Cytogenetics means looking at chromosomes in dividing cells. In CML, this test usually shows the t(9;22) translocation that forms the Philadelphia chromosome. It can also detect extra chromosome changes that may signal a higher-risk disease.

10. Fluorescence in situ hybridization (FISH) for BCR-ABL1
    FISH uses fluorescent probes that attach to specific parts of DNA. It can find the BCR-ABL1 fusion gene even when standard karyotyping misses it, such as in “cryptic” or hidden translocations. FISH is very helpful when chromosome studies look normal but CML is still suspected.

11. Quantitative RT-PCR (qPCR) for BCR-ABL1 levels
    RT-PCR is a very sensitive test that measures how much BCR-ABL1 RNA is in the blood or bone marrow. Doctors use this test at diagnosis and regularly during treatment to monitor how well the leukemia is responding. Results are often reported on an “international scale” (IS).

12. BCR-ABL1 transcript type and mutation analysis
    Different patients can have slightly different BCR-ABL1 transcript types (for example e13a2 or e14a2). Knowing the type helps with accurate PCR monitoring. Later, if treatment stops working, the gene may be tested for additional mutations (such as T315I) that cause resistance and guide choice of a new drug.

13. Blood chemistry tests (kidney and liver function, electrolytes)
    Tests such as creatinine, urea, liver enzymes, and electrolytes check how well the kidneys and liver are working. They help make sure it is safe to start tyrosine kinase inhibitor (TKI) medicines and to adjust doses if side effects occur.

14. Uric acid and lactate dehydrogenase (LDH)
    When many leukemia cells are present or dying (for example soon after starting treatment), uric acid and LDH levels can rise. High levels may cause kidney problems and gout-like joint pain. Monitoring these helps doctors prevent and treat tumor lysis-related issues.

15. Coagulation and platelet function tests
    Tests like PT, aPTT, and platelet counts check how well the blood can clot. In CML there may be too few or too many platelets, and platelets may work poorly. Knowing the clotting status is important before any procedures and when there is bruising or bleeding.

Electrodiagnostic tests

16. Electrocardiogram (ECG or EKG)
    An ECG records the electrical activity of the heart. Some CML drugs, especially nilotinib and a few other TKIs, can slightly prolong the QT interval, which is the time the heart takes to recharge between beats. Doctors often do a baseline ECG and follow-up ECGs to keep treatment safe.

17. Continuous ECG (Holter) monitoring when needed
    If there is concern about heart rhythm, or if the QT interval is borderline, a longer-term ECG recording (such as a 24-hour Holter monitor) may be used. This test is not used to diagnose CML itself but to watch for drug-related heart rhythm problems while treating the leukemia.

Imaging tests

18. Abdominal ultrasound
    Ultrasound uses sound waves to create images of organs. It can show the size of the spleen and liver without radiation. In CML, ultrasound is helpful to measure an enlarged spleen and to follow whether it shrinks with treatment.

19. CT scan or MRI of abdomen and chest (when needed)
    CT or MRI scans are not always needed for CML, but they may be used if the spleen or liver are very large, if there is pain that needs explanation, or if doctors are looking for leukemia deposits in other organs. These scans give more detailed pictures than ultrasound.

20. Chest X-ray
    A chest X-ray is sometimes done to look for lung infections, heart size, or fluid around the lungs. This can be important if a person with CML has fever, cough, or breathing problems, or if doctors are checking for treatment complications.

Non-pharmacological Treatments (Therapies and Others)

Each of these is used together with medicines, not instead of them.

1. Education and treatment adherence support
   The most powerful non-drug step is learning what CML is, why TKIs must be taken every day, and how missing doses can let the leukemia grow again. Nurses, pharmacists, and online programs can teach pill routines, phone reminders, and how to manage common side effects. Good adherence is strongly linked to deeper molecular responses and better long-term survival.[]

2. Regular specialist follow-up and BCR-ABL monitoring
   Visiting a hematologist and doing regular blood counts and BCR-ABL1 PCR tests helps check if treatment is working. If the leukemia level does not fall as expected, the doctor can change the dose or switch to another TKI early, which improves outcomes and lowers the chance of advanced-phase disease.[]

3. Infection prevention and hygiene
   People with CML and those on TKIs can still get serious infections if white cells or neutrophils drop. Simple steps like frequent hand-washing, keeping cuts clean, avoiding close contact with people who are very sick, and quick evaluation of fevers help prevent complications and hospital stays.[]

4. Vaccinations (as advised by the doctor)
   Inactivated vaccines (like flu and COVID-19 shots) are often recommended because infections can be more dangerous in people with leukemia. Live vaccines are usually avoided or used carefully. A hematologist can create a safe vaccine plan depending on age, other illnesses, and treatment phase.[]

5. Smoking cessation
   Smoking damages blood vessels and the heart. Some TKIs (especially ponatinib) already increase the risk of blood clots and arterial events. Stopping smoking lowers heart attack and stroke risk and makes TKI treatment safer over many years.[]

6. Heart-healthy lifestyle (blood pressure, cholesterol, weight)
   Many TKIs can affect blood pressure, cholesterol, or heart vessels. A lifestyle that includes moderate exercise, weight control, limiting salt, and regular checks of blood pressure and lipids helps protect the heart and may reduce TKI-related vascular side effects.[]

7. Individualized exercise program
   Safe, moderate physical activity (like walking, light cycling, or stretching) can ease fatigue, improve mood, and maintain muscle mass and bone strength. Programs should be adjusted if anemia, low platelets, or bone pain are present, and guided by the healthcare team when counts are low.

8. Balanced nutrition counseling
   A dietitian can help design meals that provide enough calories and protein without excessive salt, sugar, or unhealthy fats. This supports energy, weight stability, and healing, and can be tailored for nausea, diarrhea, or taste changes caused by TKIs.

9. Stress-management and psychological support
   A leukemia diagnosis can cause anxiety, depression, and fear of relapse. Counseling, support groups, relaxation techniques, and mindfulness can reduce stress hormones, improve sleep, and help people stay consistent with their medication and appointments.

10. Sleep hygiene
    Good sleep (regular bedtimes, a dark quiet room, limiting screens before bed) helps reduce fatigue and improves immune function. This can make it easier to cope with the chronic nature of CML and its treatment.

11. Fertility counseling and family planning
    Some TKIs can harm an unborn baby and may affect fertility. Before pregnancy or sperm/egg freezing decisions, patients should meet fertility and hematology specialists to plan safe timing for conception, temporary treatment changes, or fertility preservation.

12. Sun and skin care
    Certain TKIs can cause skin rashes or make skin more sensitive. Using gentle soaps, moisturizers, and sunscreen, and avoiding harsh chemicals can reduce discomfort and prevent infections in irritated skin areas.[]

13. Oral and dental care
    Because gums can bleed more easily and mouth sores may occur, regular dental check-ups, soft brushing, and avoiding very hard or sharp foods help prevent infections and bleeding. Dentists should always know about the leukemia and current medicines.

14. Falls and injury prevention
    Low platelets increase the risk of bruising and internal bleeding. Removing trip hazards at home, using non-slip shoes, and being careful with sports or heavy lifting can protect against injuries that might otherwise require hospital care.

15. Work and school adjustments
    Fatigue, clinic visits, and side effects may require flexible schedules, rest breaks, or temporary remote work or schooling. Social workers can help patients request reasonable adjustments so they can continue education or employment safely.

16. Financial counseling and medication access help
    TKIs can be costly. Hospital social workers, patient foundations, or government programs may help with insurance paperwork, co-pay support, and access to generic medicines so patients do not skip doses for cost reasons.[]

17. Telemedicine and remote monitoring
    Telehealth visits and remote lab result review reduce travel, save time, and maintain close contact with the care team. This is especially helpful for patients who live far from cancer centers or are immunocompromised.

18. Rehabilitation and fatigue management programs
    Some people benefit from formal rehabilitation with physiotherapists and occupational therapists who teach energy-saving techniques, breathing exercises, and safe strength-building activities to manage chronic tiredness.

19. Integrative therapies (only with doctor approval)
    Gentle yoga, relaxation breathing, massage, or acupuncture may help symptoms such as pain, nausea, or anxiety. They must be done by trained professionals who understand bleeding risk and infection precautions in leukemia patients.

20. Palliative and supportive care services
    Palliative care is not only for end-of-life. It can be used early to control pain, itch, nausea, emotional distress, and complex decisions. This team-based support helps maintain quality of life throughout the CML journey.

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Drug Treatments

⚠️ Important: Drug names, doses, and schedules below come from FDA labels and expert reviews. They are not personal medical advice. Only a hematologist can choose and adjust treatment for an individual patient.

1. Imatinib (Gleevec, Imkeldi) – first-generation TKI
   Imatinib blocks the BCR-ABL tyrosine kinase that drives CML. Typical adult starting dose is around 400 mg once daily in chronic phase, higher in advanced phases. It is taken with food and water. It slows leukemia cell growth and helps normal blood formation. Common side effects are swelling, nausea, muscle cramps, diarrhea, and low blood counts.[]

2. Dasatinib (Sprycel, Phyrago) – second-generation TKI
   Dasatinib is stronger than imatinib and works against many resistant BCR-ABL changes. The usual adult starting dose for chronic-phase CML is about 100 mg once daily, with or without food. It can cause low blood counts, fluid around the lungs (pleural effusion), bleeding, and diarrhea, so doctors monitor chest symptoms and blood tests closely.[]

3. Nilotinib (Tasigna, Danziten, Nilotinib capsules) – second-generation TKI
   Nilotinib targets BCR-ABL more selectively than imatinib and may produce deeper molecular responses. A common chronic-phase dose in adults is 300 mg twice daily, taken on an empty stomach. It can prolong the QT interval on ECG and raise blood sugar and lipids, so ECGs and metabolic labs are monitored.[]

4. Bosutinib (Bosulif) – second-generation TKI
   Bosutinib is often used if earlier TKIs do not work or cause side effects, and can also be used first line. Doses like 400–500 mg once daily with food are used in adults, with adjustments for kidney or liver issues. Diarrhea, liver enzyme rises, rash, and fatigue are common, so liver tests and hydration are important.[]

5. Ponatinib (Iclusig) – third-generation TKI
   Ponatinib is designed to work against the T315I mutation and highly resistant CML. Typical doses in adults are around 15–45 mg once daily, individualized based on response and side effects. It carries boxed warnings for serious arterial and venous clots, heart failure, and liver injury, so doctors carefully assess cardiovascular risks and monitor closely.[]

6. Asciminib (Scemblix) – STAMP inhibitor
   Asciminib is a newer TKI that targets the myristoyl pocket of BCR-ABL instead of the ATP-binding site. It can be used in newly diagnosed CML and in patients who have failed several TKIs. Doses like 80 mg once daily or 40 mg twice daily are used, with higher doses for T315I mutation. It may cause low blood counts, pancreatic enzyme rises, and hypertension.[]

7. Omacetaxine mepesuccinate (Synribo)
   Omacetaxine is an injectable protein synthesis inhibitor used when CML is resistant or intolerant to at least two TKIs. It is given as subcutaneous injections in cycles, with induction and maintenance schedules such as 1.25 mg/m² twice daily for several days per cycle. It can cause severe low blood counts, infections, and bleeding, so it is usually used in specialized centers.[]

8. Hydroxyurea
   Hydroxyurea is an oral chemotherapy used mainly for short-term cytoreduction when white blood cell counts are extremely high and diagnosis is still being confirmed. It lowers counts quickly but does not target BCR-ABL, so it is replaced by a TKI once available. Side effects include low blood counts, mouth ulcers, and skin or nail changes.[]

9. Interferon-alpha (alone or with TKIs)
   Interferon-alpha is an immune signaling protein that can slow CML cell growth and has some activity against CML stem cells. It is now mainly used in special cases, such as during pregnancy when TKIs are avoided, or in combination regimens. It is given as injections and can cause flu-like symptoms, depression, and thyroid problems.[]

10. Cytarabine (Ara-C)
    Cytarabine is a backbone chemotherapy drug used more in accelerated or blast-phase CML to reduce blast cells, usually as part of combination regimens with TKIs. It interferes with DNA synthesis in rapidly dividing cells. Side effects include severe bone marrow suppression, infection risk, mucositis, hair loss, and nausea.

11. Cyclophosphamide
    Cyclophosphamide is an alkylating agent sometimes used in intensive regimens for advanced-phase CML or conditioning before stem cell transplant. It damages DNA in rapidly dividing cells. It can cause low blood counts, bladder irritation, infertility, and increased long-term cancer risk, so it is used carefully.

12. Anthracyclines (e.g., daunorubicin, doxorubicin)
    These drugs are used in blast crisis treated like acute leukemia, often with TKIs. They insert into DNA and create free radicals to kill leukemia cells. Main risks are heart damage at high doses, hair loss, nausea, and severe myelosuppression, so heart function is checked before and during treatment.

13. Allopurinol or rasburicase (tumor lysis prevention)
    When many leukemia cells die quickly at the start of therapy, tumor lysis syndrome can occur. Allopurinol tablets and rasburicase infusions help control uric acid to protect the kidneys. They are supportive drugs, not anti-leukemia agents, but are very important in high-risk patients starting intensive therapy.[]

14. Anti-nausea medicines (e.g., ondansetron)
    TKIs and chemotherapy can cause nausea and vomiting. Anti-emetic tablets or injections block serotonin or other pathways in the brain’s vomiting center to keep patients eating and hydrated. They are tailored to the emetogenic risk of each regimen.

15. Antibiotics and antifungals (as needed)
    When white blood cells are very low, broad-spectrum antibiotics or antifungal medicines may be started quickly to treat or prevent serious infections. Choices depend on local resistance patterns and patient factors; they save lives but can cause diarrhea, liver enzyme changes, or allergic reactions.

16. Proton pump inhibitors or H2 blockers (careful use)
    Some patients need acid-suppressing medicines for reflux or stomach irritation, but these can interact with the absorption of certain TKIs. Doctors choose specific agents and timing to minimize interaction while still protecting the stomach.

17. Growth factor support (e.g., G-CSF) – limited, selected use
    Granulocyte colony-stimulating factor can be used briefly to raise very low neutrophil counts in carefully selected situations, such as post-transplant or in serious infections, but is generally used cautiously in leukemia because it can also stimulate myeloid cells.

18. Antiplatelet or anticoagulant drugs (selected high-risk patients)
    In people taking TKIs with a higher risk of clots (like ponatinib) and with additional cardiovascular risk factors, doctors may use aspirin or other agents to lower clot risk. This must be balanced against bleeding risk, especially when platelets are low.

19. Lipid- and blood pressure-lowering drugs
    Some TKIs worsen cholesterol or blood pressure, adding to vascular risk. Statins and antihypertensives are used to protect the heart and blood vessels. Doctors must check for drug interactions when choosing specific agents.

20. Pain and symptom-control medicines
    Paracetamol (acetaminophen) and other carefully chosen pain relievers, anti-diarrheal drugs, and topical creams help manage daily symptoms from TKIs or from enlarged spleen and bones. Non-steroidal anti-inflammatory drugs are used cautiously because of bleeding and kidney risks.

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Dietary Molecular Supplements

Evidence for supplements in CML is limited. They must never replace TKIs.

1. Vitamin D
   Many people with cancer have low vitamin D, which is important for bone health, immune function, and muscle strength. If levels are low, doctors may suggest oral vitamin D drops or tablets in doses such as 800–2000 IU per day, adjusted by blood tests.[]

2. Vitamin B12
   B12 deficiency can worsen anemia and fatigue. Replacement with oral or injectable B12 restores normal red blood cell production and nerve function. Dose and route depend on how severe the deficiency is and whether absorption from the gut is normal.

3. Folate (folic acid)
   Folate is important for DNA synthesis in healthy cells. If folate is low due to poor diet or past chemotherapy, low-dose folic acid tablets can improve anemia and energy. Large doses should be supervised to avoid masking B12 deficiency.

4. Omega-3 fatty acids (fish oil)
   Omega-3 capsules or oily fish in the diet may support heart and vessel health and help manage triglycerides, which is important for patients on TKIs that increase vascular risk. High doses can increase bleeding tendency, so they must be discussed with the doctor, especially if platelets are low.

5. Probiotics
   Probiotics may help restore gut bacteria balance after repeated antibiotics or diarrhea. They can improve stool consistency and comfort but should be used cautiously in people with very low immunity; only medically approved products should be considered.

6. Curcumin (from turmeric)
   Laboratory studies suggest curcumin may have anti-inflammatory and anti-cancer effects, but human data in CML are limited. Low doses in food are generally safe, but concentrated capsules can affect liver enzymes and drug metabolism, so must be cleared with the hematologist.[]

7. Green tea extract (EGCG)
   EGCG has antioxidant and possible anti-cancer properties in lab studies. However, high-dose extracts can cause liver toxicity and may interact with drug metabolism pathways used by TKIs, so they should only be used, if at all, under medical supervision.

8. Resveratrol
   Resveratrol from grapes and berries has been shown in preclinical work to influence cancer cell growth and signaling, but clinical safety and dosing in CML are not established. Small amounts from food are safe; supplements should be avoided unless part of a clinical trial.

9. Selenium
   Selenium is an essential trace element with antioxidant roles. In deficiency, small-dose supplements may support normal immune function, but high doses are toxic. Blood levels and thyroid function should be monitored if long-term supplementation is considered.

10. Coenzyme Q10
    CoQ10 supports mitochondrial energy production and may help with fatigue in some patients. It may interact with blood thinners, so doctors must check medication lists. Typical doses are modest (e.g., 30–100 mg daily) and adjusted individually.

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Immune-Boosting / Regenerative / Stem-Cell-Related Drugs

These medicines are supportive and used in specific situations, often around stem cell transplant or severe cytopenias.

1. Filgrastim (G-CSF)
   Filgrastim is a lab-made version of granulocyte colony-stimulating factor. It stimulates the bone marrow to produce neutrophils, helping the body fight infections after intensive treatment or transplant. It is given as subcutaneous injections, and doses depend on weight. Bone pain and very high white cell counts are common side effects.

2. Pegfilgrastim (long-acting G-CSF)
   Pegfilgrastim works like filgrastim but stays longer in the body, so it is usually given as a single injection per chemotherapy cycle. It helps shorten the period of severe neutropenia, reducing infection risk, but can cause bone pain and rarely splenic enlargement.

3. Epoetin alfa or darbepoetin alfa (erythropoiesis-stimulating agents)
   These drugs stimulate red blood cell production in selected patients with symptomatic anemia not due to active leukemia. They are injected under the skin and adjusted based on hemoglobin levels. They can increase the risk of blood clots if hemoglobin is pushed too high.

4. Eltrombopag or romiplostim (thrombopoietin receptor agonists)
   In rare cases of long-lasting low platelets not due to active CML, these drugs can be used to stimulate platelet production. They act on the thrombopoietin receptor in bone marrow. Side effects can include liver test abnormalities and increased clot risk, so careful monitoring is required.

5. Plerixafor (stem cell mobilizer)
   Plerixafor is used together with G-CSF to move hematopoietic stem cells from the bone marrow into the bloodstream so they can be collected for transplant. It blocks the CXCR4 receptor, loosening stem cells from their niches. Side effects include diarrhea, injection-site reactions, and rare splenic rupture.

6. Intravenous immunoglobulin (IVIG)
   IVIG is a purified antibody preparation used to support immunity in people with very low antibody levels or recurrent severe infections. It is infused intravenously over hours. Headache, infusion reactions, and, rarely, kidney problems or clots can occur.

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Surgeries / Procedures

1. Allogeneic hematopoietic stem cell transplantation (bone marrow transplant)
   This major procedure replaces the patient’s diseased blood-forming stem cells with healthy donor cells after high-dose chemotherapy (sometimes with radiation). It can cure CML but carries significant risks of infection, graft-versus-host disease, organ damage, and death. Today it is usually reserved for advanced or TKI-resistant CML, or for certain high-risk patients.[]

2. Leukapheresis
   Leukapheresis is a machine procedure, not a traditional “surgery,” but often done in hospital settings. Blood is passed through a device that removes excess white cells and returns the rest. It is used for very high white counts causing symptoms such as vision problems or breathing issues, and gives rapid temporary relief while drugs begin working.

3. Central venous catheter or port placement
   Some patients need a central line or port placed under the skin to allow safe repeated blood draws, chemotherapy, transfusions, or stem cell transplant procedures. This minor surgery is done under local or general anesthesia and carries small risks of infection or blood clots.

4. Splenectomy (spleen removal)
   Very rarely, if the spleen remains massively enlarged and painful or causes severe low blood counts despite treatment, surgeons may remove it. This can relieve pain and improve counts, but it permanently increases infection risk, so patients need vaccines and lifelong infection precautions.

5. Diagnostic bone marrow biopsy and aspiration
   This small surgical procedure is used at diagnosis and at key times later. A needle is inserted into the hip bone to collect liquid marrow and a small core. It confirms CML, assesses response, and looks for progression or additional changes. Local anesthesia is used; short-term pain and bruising are common but usually mild.

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Preventions (What Can Be Prevented)

CML itself cannot usually be prevented, but complications can often be reduced.

1. Take TKIs exactly as prescribed; do not skip or stop without medical advice.

2. Attend all scheduled blood tests and BCR-ABL monitoring visits.

3. Stop smoking and avoid vaping and tobacco products.

4. Keep blood pressure, cholesterol, and diabetes under good control.

5. Get recommended inactivated vaccines (flu, COVID-19, pneumonia, hepatitis, etc.).

6. Practice good hand hygiene and avoid close contact with people who are very sick.

7. Protect skin from cuts, burns, and sun damage to lower infection risk.

8. Tell doctors and dentists about all medicines before any procedure or new prescription.

9. Avoid unproven “cancer cures” or high-dose supplements that may interfere with TKIs.

10. Seek psychological and social support early to prevent burnout and treatment fatigue.

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When to See Doctors (Or Go to Emergency)

You should contact your doctor or go to emergency immediately if you notice:

• Fever 38°C (100.4°F) or higher, chills, or feeling suddenly very unwell.

• Shortness of breath, chest pain, or severe cough.

• Sudden severe headache, confusion, vision changes, or weakness on one side of the body.

• Bright red bleeding, black stools, vomiting blood, or bruises appearing without clear reason.

• Fast weight gain, swelling in legs, or trouble lying flat due to breathlessness.

• Severe abdominal pain or a feeling that the left upper abdomen (spleen area) is very tender.

• Yellow eyes or skin, dark urine, or severe itching that may suggest liver problems.

• Any new or rapidly worsening side effect after a dose change or starting a new drug.

For non-urgent issues (mild rash, mild diarrhea, tiredness, questions about pregnancy or supplements), schedule a clinic or telehealth visit with your hematologist.

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Things to Eat and Things to Avoid

Generally good to eat (if your doctor/dietitian agrees):

1. Plenty of fruits (like apples, bananas, berries) and cooked vegetables for vitamins and fiber.

2. Whole grains such as brown rice, oats, and whole-wheat bread for steady energy.

3. Lean proteins like fish, eggs, poultry, lentils, and beans to support blood and muscle.

4. Healthy fats from nuts, seeds, avocado, and olive oil for heart health.

5. Yogurt or other safe dairy for protein and calcium (pasteurized only).

6. Adequate fluids: clean water and herbal teas to stay hydrated, especially during treatment.

7. Small, frequent meals if you have nausea or poor appetite.

8. Lightly cooked foods that are easy to chew if your mouth is sore.

9. Foods rich in iron and B vitamins (e.g., fortified cereals, leafy greens, beans) if allowed.

10. Culturally familiar, comforting dishes adapted to be less oily and salty to support long-term adherence.

Wise to limit or avoid (unless your doctor says otherwise):

1. Raw or undercooked meat, fish, and eggs when neutrophils are low (infection risk).

2. Unpasteurized milk, cheese, or juices.

3. Street foods or salads from places with poor hygiene.

4. Very salty, processed foods (chips, instant noodles, processed meats) that strain heart and kidneys.

5. Large amounts of sugary drinks and sweets, which worsen weight gain and diabetes risk.

6. Heavy alcohol use, which can damage the liver already stressed by TKIs.

7. Grapefruit and Seville oranges and their juices with some TKIs (they affect drug levels).

8. High-dose herbal or “detox” products that have unknown interactions with TKIs.

9. Energy drinks with very high caffeine that can worsen palpitations or blood pressure.

10. Smoking and recreational drugs, which worsen vascular and immune problems.

Always ask your doctor or dietitian before making big diet or supplement changes.

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Frequently Asked Questions (FAQs)

1. Is CML still a deadly disease?
   With modern TKIs, many people with chronic-phase CML live nearly normal life spans, especially if treatment starts early and is taken correctly. Long-term survival now exceeds 80–90% in many series.[]

2. Will I need treatment for life?
   Most patients take TKIs for many years. Some who achieve very deep and stable molecular responses may, under expert supervision, carefully try treatment-free remission, but this is not safe for everyone. Stopping medicine must only be done in a controlled program.

3. Can CML turn into a more aggressive leukemia?
   Yes, untreated or poorly controlled CML can progress to accelerated phase or blast crisis, which behaves like acute leukemia. Good adherence to TKIs and regular monitoring greatly lowers this risk.[]

4. Can I go to school or work normally?
   Many people continue school or work with some adjustments. Fatigue, clinic visits, or side effects may require flexible schedules, but with support and planning, normal activities are often possible.

5. Is it safe to become pregnant if I have CML?
   TKIs can harm a developing baby, so pregnancy planning must be done closely with a hematologist and high-risk obstetrician. Some patients pause TKIs and use other options like interferon-alpha during pregnancy; this is very individualized and must never be done alone.

6. Will I lose my hair?
   TKIs usually do not cause complete hair loss like some traditional chemotherapies. Some people notice hair thinning or texture changes. Intensive chemotherapy used in blast phase or before transplant can cause more obvious hair loss.

7. Can I exercise?
   Yes, light to moderate exercise is encouraged if blood counts and heart function are stable. Your doctor can advise on what level is safe based on your hemoglobin and platelet counts and any bone or spleen issues.

8. Can traditional or herbal medicines cure CML?
   No herbal or traditional therapy has been proven to cure CML. Some may interfere with TKIs or damage the liver or kidneys. Always discuss any herb or supplement with your hematologist before using it.

9. What happens if I miss a dose of my TKI?
   Usually you should take the dose as soon as you remember unless it is almost time for the next dose, in which case you skip and continue as normal. You should not double-dose. Always follow the specific instructions given with your medicine.

10. Do TKIs affect the heart and blood vessels?
    Some TKIs, particularly ponatinib and, to a lesser degree, others, can increase the risk of clots, high blood pressure, or heart problems. Doctors check your cardiovascular risk, monitor regularly, and may adjust treatment or add protective medicines.[]

11. What if my TKI stops working?
    If BCR-ABL levels start rising or you do not meet response milestones, your doctor may order mutation testing and switch to another TKI such as dasatinib, nilotinib, bosutinib, ponatinib, or asciminib, or consider transplant or other treatments depending on the situation.[]

12. Are generic TKIs as good as brand-name ones?
    Approved generic imatinib and others must meet the same quality and bioequivalence standards as brand-name drugs. Many patients worldwide use generics successfully; however, any concerns should be discussed with your hematologist.

13. How often will I need blood tests?
    At the beginning, blood tests and BCR-ABL monitoring are more frequent (for example, every 3 months or as your doctor advises). If you respond well and remain stable, the interval may be lengthened, but regular testing remains essential.

14. Can I travel?
    Yes, many patients travel. Plan ahead by carrying extra medicine, keeping TKIs in hand luggage, knowing where to get medical help at your destination, and scheduling blood tests around longer trips. Avoid missing doses or running out of tablets.

15. Who should manage my CML?
    Ideally, a hematologist/oncologist with experience in CML should lead your care, often in partnership with your primary doctor, nurses, pharmacists, and support services. Treatment decisions can be complex, and expert guidance improves safety and outcomes.

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: January 25, 2025.