Dear colleagues,
I completely agree with the tactics proposed by Professor Gianantonio Rosti and Dr. Valentin Garcia Gutierrez/ Currently, no G-CSF assignment is required. Combined therapy with imatinib and chemotherapy is usually well tolerated by patients

Assuming the cml is under good control, continue the imatinib. Remember that IM and other tKIs have little effect on normal stem cells. I have treated several cml patients with breast, lung, lymphoma, colon and in only one case of bladder, did the TKI have to be held.

GCSF unlikely to be necessary because of the CML, but little evidence that it impacts CML

TKI needed in parallel to neoadjuvant CT as CT alone might not be sufficient to induce a CHR and is not going to trigger an EMR.

I would use the TKI with lowest risk of cytopenia and non hematologic AE, in my opinion ASCIMINIb 1st line would be best, full dose (if no e3 transcript).
Any idea of Karyotype and ELTS?

I would try to maintain TKI full dose until MR2/MMR with indeed, hematopoietic growth factors/supportive care whenever needed and to interrupt/dose reduce TKI only of jeopardizing optimal breast cancer therapy or safety.

This is a situation we have encountered in patients who develop breast cancer in the course of CML treatment. At the initiation of breast cancer chemotherapy we discontinue TKI s since peripheral blood counts tend to remain stable.
We administer prophlyactic G-CSF as required to avoid severeneutropenia(G4) and encounter no problems. After completion of chemotherapy we resume TKIs.

This is not an unusual situation in clinical practice. It would be hoped that both malignancies are associated with normal or near normal life span if optimal treatment and response are achieved. It would be useful to know the grade of the breast cancer. I note it is hormone sensitive. I think I would defer the Neo-adjuvant ACT until WCC <20, with Imatinib and then commence the ACT with Epo and G-CSF support as required. I would try to maintain Imatinib therapy throughout, but it may be the patient requires a reduced dose. I would interrupt imatinib therapy at the time of surgery for 7-10 days to optimise wound healing (length dependent on blood counts as well as extent of surgery). I wouldn't switch to dasatinib unless patient was failing on Imatinib and they had received adequate Imatinib therapy during the breast cancer treatment.

In this situation, I would personally wait to see how the patient tolerates the first cycle of chemotherapy before starting the TKI. I would consider initiating the TKI after recovery from the nadir of the first cycle.