The 2025 iCMLf South Asia Regional Discussion Group (RDG) series offered a powerful window into the evolving realities of CML care across the region.

Held across three Zoom-based sessions between April and July, the program convened 190 CML physicians from India, Pakistan, Nepal, Sri Lanka, Bangladesh, and further afield, alongside international experts, to discuss dose reduction and treatment-free remission (TFR), TKI sequencing strategies, and difficult real-world cases.

But beyond the individual session topics, a deeper story emerged - of clinicians consistently navigating limited evidence or testing to guide decisions, infrastructure gaps, and treatment constraints with ingenuity, collaboration, and commitment to best practice.

Here are three key themes that surfaced across the series:

1. Decision-making beyond guidelines

Whether choosing a third-line TKI or considering a second TFR attempt, physicians repeatedly emphasised the need to adapt clinical guidelines to regional realities. In many settings, key tools assumed in international recommendations - such as access to BCR::ABL1 mutation testing, next-generation TKIs, or routine PCR monitoring - are limited or unavailable.

Rather than leading to clinical inertia, these constraints often sharpen clinical decision-making. Participants shared how they balance patient comorbidities, toxicity profiles, prior responses, and financial considerations to make individualised treatment choices - sometimes relying on empirical strategies grounded in clinical experience when data is lacking.

As one clinician put it: “The guidelines provide a path, but we often have to build a bridge of our own to reach it.”

2. Monitoring as a gatekeeper, and a barrier

Monitoring capacity emerged as a central theme across all three sessions. It underpins eligibility for TFR, response assessment, and treatment switching - yet remains one of the most uneven aspects of care across the region.

Several speakers highlighted the risks of stopping treatment without robust molecular follow-up, while others described how dose reduction strategies are used in place of TFR when monthly PCR is not feasible. In rural or low-resource settings, clinicians often rely on clinical markers and hematologic response in the absence of molecular data.

This reality doesn’t undermine the science of CML - it underscores the need to invest in diagnostic infrastructure and to contextualise decision-making frameworks for environments where ideal monitoring is not yet possible. 

3. Regional expertise, peer learning, and practical solutions

A defining feature of the RDG format is its focus on peer-to-peer learning, and this year’s discussions again showed how powerful that can be. Some of the most useful insights came not from global guidelines but from regional colleagues sharing how they manage challenging patients with limited options.

From pediatric blast crisis cases to elderly patients with cardiac comorbidities, clinicians exchanged ideas, asked critical questions, and validated each other’s strategies. It was a reminder that expertise is not only global - it’s regional, local, and deeply lived.

The discussions also revealed a growing appetite for regionally informed practice tools - such as South Asia-specific protocols or decision aids that account for drug access, monitoring availability, and patient literacy.

Looking ahead

As the science of CML continues to evolve, so too must the systems and frameworks that support its delivery - especially in resource-variable settings. This year’s South Asia RDG series highlighted both the constraints and the excellence present across the region: physicians practicing at the edge of innovation and adaptation, often without the tools their counterparts elsewhere may take for granted.

The iCMLf remains committed to supporting this regional community, not just through education, but through platforms that elevate practical insight, contextual guidance, and cross-border collaboration.

We extend our thanks to all speakers and participants for their contributions, and we look forward to building on this year’s insights in 2026.

You can watch all three sessions at our YouTube Channel.

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With particular thanks to our panel of regional and international experts:

• Professor Mehreen Ali Khan - Rawalpindi, Pakistan
• Professor Raghunadharao Digumarti - Visakhapatnam, India
• Assistant Professor Stalin Bala Chowdary - Visakhapatnam, India
• Dr Mipsang Lama - Lalitpur, Nepal
• Professor Hemant Malhotra -  Jaipur, India
• Professor Akhil Ranjan Biswas - Dhaka, Bangladesh
• Professor Mhairi Copland - Glasgow, UK
• Professor Jeff Lipton - Toronto, Canada
• Professor Gianantonio Rosti - Meldola (FC), Italy
• Associate Professor Kendra Sweet - Tampa, USA
• Professor Jane Apperley - London, UK
• Professor Philippe Rousselot - Paris-Saclay, France