Multiple areas of controversy surround the appropriate timing of transplantation in individuals with CML. Although the discussion focuses on transplantation as initial therapy, timing of transplantation in patients who first receive imatinib is equally important and more frequently encountered.

Age and the availability of a sibling donor are the two variables most commonly used to determine candidacy for transplantation as initial therapy. Older age does not appear to be a significant adverse factor for allogeneic transplantation when busulfan-based preparative regimens are used. Results with well-matched unrelated donors are similar to those achieved with sibling donors. The ability to assess preliminary results, estimate the probability of finding a suitable donor, and perform allogeneic transplantation quickly, has made early transplantation with unrelated donors a reasonable possibility in a sizable number of patients.

In patients who receive imatinib as initial treatment, monitoring Bcr-Abl transcript levels or, at the least, monitoring of marrow cytogenetics to evaluate initial response and early evidence of progression are vital to provide appropriate care. The effectiveness of reduced-intensity transplants, particularly in patients with progressive disease, has not been firmly established. Reduced-intensity transplantation and auto-grafting should be performed only on appropriate clinical trials.

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