First-line treatment of chronic myeloid leukemia: imatinib versus nilotinib and dasatinib

Recently reported phase III trials showed that the second-generation BCR-ABL tyrosine kinase inhibitors nilotinib and dasatinib produce greater rates of cytogenetic and molecular responses at 1 year compared with imatinib as first-line treatment for chronic-phase chronic myeloid leukemia. Differences in the safety profiles of the two newer agents compared with that of imatinib were modest. Both nilotinib and dasatinib were recently approved by the FDA for use in this setting, giving us three remarkably effective drugs for first-line treatment. Issues to be considered in selecting among these three agents for first-line use, in addition to short-term efficacy and differences in toxicity patterns, include long-term response, survival, and toxicity; cost; sequencing in cases of resistance or intolerance; and potential for BCR-ABL resistance.