ESH CML/MPN 2025 | The management of CMML in the UK

CMML is quite a rare disease. Many community physicians may not see that many CMML patients. And unfortunately, over the years, it’s been rather neglected by research and clinical trials. It’s often just been included as a subgroup of MDS trials, for example. And as a result, we don’t have many treatment options available. 

So the current management algorithm would really begin with an assessment of risk to decide whether treatment is required or not. We would apply one of the various scoring systems. CPSS molecular is one that people may be familiar with, it’s my favorite one at the moment. And for those with higher risk disease, generally, we consider that to be intermediate-2 or high-risk categories as opposed to the intermediate-1 or low, probably do justify treatment in most cases. 

And if that’s the case, then really our two major options are, for proliferative subtypes, so that’s those with white count above 13, if they need treatment, it would usually be with hydroxyurea. The general feeling is that although you can use other chemotherapy approaches, they probably add little over hydroxyurea except extra toxicity. The level at which you would treat is not, there’s no real consensus on that. My personal approach would be tailored to each individual case based on symptoms and patient preference. But broadly, consider it a white count of 30, and particularly if there are any symptoms, obviously consider it at lower levels if there are problems, for example, renal failure, that you may want to try and improve. 

If asymptomatic though it might be reasonable to watch and wait, and you know, at around 50 I’d start to get a bit twitchy, but there are patients who are very well and are not keen on therapy, it’s not curative treatment after all, and so sometimes it’s reasonable to let the white count go higher. 

The other obvious group of agents for this disease are hypomethylating agents, azacitidine being the one available in the UK. Technically, it’s only NICE-approved for patients with blast counts of above 10% in bone marrow and technically only for those with non-proliferative subtypes. So that’s those with a white count under 13. And so there are definitely patients who can benefit from azacitidine, but it generally works less well in CMML than in other diseases like MDS and hence the need for newer trials and treatments.

This transcript is AI-generated. While we strive for accuracy, please verify this copy with the video.