Approach To Patients

The Gratwohl score estimates transplant outcome using age, disease, stage, interval from diagnosis to transplant, type of donor, and donor-recipient gen-ders.35 IBMTR data have confirmed the value of this model.55

Newly diagnosed patients should be provided with extensive information on imatinib and on transplantation. Most patients who understand well the two approaches will determine their own initial treatment. Physicians must be certain that patients are well informed. Many do not understand the significant influence of treatment delay on transplant outcome, the ease with which the potential for unrelated donor matches can be determined, nor even that molecular evidence of disease is present in patients who respond well to imatinib.

For patients who receive imatinib as initial therapy, response to treatment is predictive of outcome. Patients who achieve a major cytogenetic remission have a prolonged survival. Those who achieve complete cytoge-netic remission enjoy the greatest survival advan-tage.5657 Quantitative assays demonstrate that patients who achieve complete cytogenetic remission with imatinib are more than twice as likely as those achieving complete remission with interferon plus cytara-bine to have 3 log reductions in Bcr-Abl transcript lev-els.58 All patients who achieve this level of reduction are free from progression at 2 years.5859 These patients should continue imatinib until they demonstrate progressive disease.

At many centers, patients who fail to achieve substantial reductions in Bcr-Abl positive cells within

3-4 months, or a cytogenetic remission by 6 months, are considered for allogeneic transplantation without further delay. For patients who achieve cytogenetic remission, but later have progressive increase in the proportion of Bcr-Abl positive cells, transplantation is similarly considered without delay.

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