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Case #823
Chronic Myeloid Leukemia

A 62-year-old Caucasian man with chronic myelogenous leukemia in cytogenetic relapse

Release Date: August 25, 2009
Expiration Date: August 24, 2010

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Chief Complaint

Fatigue, early satiety, and constipation

History of Present Illness

Robert is a 62-year-old Caucasian man with Philadelphia positive (Ph)-positive chronic myelogenous leukemia (CML) and now in cytogenetic relapse.

Robert was diagnosed with Ph-positive, Bcr Abl-positive, CML 12 months prior to this visit. He was subsequently treated with imatinib 400 mg orally daily. Robert continued therapy with imatinib and has been routinely monitored at 3-month intervals. He attained complete hematologic remission with partial cytogenetic remission at 6 months. At that time, Robert’s hematologist offered to increase the dose of imatinib, but Robert refused, wanting to wait for the next scheduled bone marrow cytogenetics at 12 months.

Robert returns for routine follow-up with his hematologist complaining of increased lethargy and fatigue, early satiety, and constipation. He reports that he becomes easily and increasingly fatigued particularly when trying to perform routine chores around the house. He also states that his appetite has decreased and he complains of increased feelings of early satiety. He denied any fevers, chills, or change in dietary habits.


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Disclosures and Important Information

Supported by an educational grant from Novartis Oncology.

Release Date: August 25, 2009

Expiration Date: August 24, 2010

Estimated time to complete this activity: 2.0 hours

Accreditation Statement

MedCases, LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education.

Credit Designation Statement

MedCases designates this educational activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Statement of Responsibility

MedCases takes responsibility for the content, quality, and scientific integrity of this CME activity.

Principal Faculty

Professor of Medicine
University of Michigan
Associate Director of Translational Research
University of Michigan Comprehensive Cancer Center
Associate Chief/Director of Hematologic Malignancies
Division of Hematology/Oncology
Ann Arbor, Michigan

Independent Reviewer

Assistant Professor of Oncology and Medicine
Myeloma Program, Director
Sidney Kimmel Comprehensive Cancer Center
Johns Hopkins University
Baltimore, MD

Target Audience

This activity is intended for medical oncologists, hematologists, hematologist-oncologists, pathologists, and other allied healthcare professionals.

Prerequisites

There are no prerequisites.

Statement of Need

The treatment of chronic myelogenous leukemia (CML) continues to challenge healthcare providers and patients. Integration of recent therapeutic advances in CML management strategies requires careful consideration of patient-specific characteristics, physician expertise, clinician comfort with the newer therapies, and availability of health system resources. Potential barriers to optimizing CML therapy include rapid advancement in development of novel therapeutic agents, lack of physician awareness of the most recent clinical trial data, swiftly evolving treatment guidelines, reduced awareness of pharmacogenetics and the impact of new assays to monitor patients with CML, and concerns about management of potentially significant toxicities from the newer therapeutic agents. If optimal treatment of patients with CML is to be realized, these barriers must be overcome.

Objectives

After completing this activity, you should be able to:

Identify potential roles for second generation BCR-ABL TKIs in Imatinib-refractory CML
Discuss the potential benefits of dose escalation of TKIs and the role of pharmacogenetics to identify probable patient responses
Analyze the impact of BCR-ABL by FISH and PCR assays on monitoring patients with CML, and discuss the implications of the results of those assays on treatment continuation.
Describe the potential barriers for optimal utilization of alloHSCT therapy and the possibility of improved outcomes with regimens combining alloHSCT and TKIs
Explain the efficacy and toxicity data of treatment options for CML patients
Interpret clinical data reviewing the implications of genetic mutations in refractory CML, and the potential activity of subsequent treatment selections

Method of Participation

This Internet-based activity takes approximately 2 hours to complete. You should review the objectives and cases, answer the multiple-choice posttest, and complete an evaluation form online. Once completed, you will be able to save your certificate to your own computer and print it on your own printer.

Disclosure Statement

As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is MedCases policy to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The following was reported:

Faculty
Moshe Talpaz, MD	Consultant Fees: Novartis Pharmaceuticals Grants/Research Support: ARIAD Pharmaceuticals, Inc., Deciphera Pharmaceuticals, Exelixis Inc., Novartis Pharmaceuticals, Takeda Pharmaceuticals/Millenium Pharmaceuticals, Inc. Speakers' Bureau: Novartis Pharmaceuticals

Independent Reviewer
Carol Ann Huff, MD	Advisory Board: Amgen Inc., Celgene Corporation Royalties: Syndax

Planning Committee

Dalia Mobarek, MD has indicated that she is on the Speakers' Bureau for Millenium Pharmaceuticals. Carolyn Darrow, MPH and Daryl Lynn Ehrentreu, RPh, MBA indicated that they have not received financial support for consultation, research, or, evaluation, or have a financial interest relevant to this online activity.

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Hardware/Software Requirements and Technical Assistance

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128 MB RAM
Windows 98 or newer
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Audio playback with speakers for programs that have video content
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Broadband connection highly recommended

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Confirmation

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