Shaping recommendations for managing pediatric CML in low-resource settings: What we've heard so far
The iCMLf and the I-BFM CML Working Group are developing the first dedicated clinical recommendations for managing pediatric CML in low- and middle-income countries (LMICs). To ensure these recommendations are grounded in the realities of practice across different resource settings, we launched a global survey earlier this year inviting clinicians with experience of treating children with CML to share their perspectives.
The response so far has been encouraging. Thirty-one clinicians from 19 countries across Latin America, Sub-Saharan Africa, South and Central Asia, the Middle East, Eastern Europe, and the Pacific have contributed their views. We are sharing a snapshot of the interim findings here, and we are asking you to add your voice.
What the data tells us
Perhaps the most striking finding is how consistently clinicians agree with the international treatment recommendations (1), even in settings where those recommendations are difficult to implement. Agreement with recommended TKI-switching cut-offs was unanimous. Near-universal consensus exists on the value of 3-monthly molecular monitoring, on transplant indications, and on recommended supportive care at presentation.
The challenge, as respondents have made clear, is structural. First-line TKI choice in most LMIC settings defaults to imatinib regardless of ELTS risk score, not because clinicians disagree with risk-adapted selection, but because second-generation TKIs remain inaccessible or unaffordable for upfront use in many countries. Molecular monitoring at the frequency required for treatment-free remission (TFR) is beyond reach for a significant proportion of centres. Plasma imatinib level testing, valuable for assessing both adherence and drug quality, is available at just one of the 31 centres surveyed to date.
On the question of generic TKIs, which are now the primary route to treatment for many patients in these settings, 39% of respondents with experience of generics remained uncertain whether they perform equivalently to branded products. This is a question the planned recommendations will need to address directly.
Despite these constraints, interest in TFR was strong: 74% of respondents said it should be included in LMIC-specific recommendations, with others supporting inclusion subject to realistic monitoring parameters. Encouragingly, 30 of 31 respondents expressed willingness to participate in the development of the recommendations process, a clear signal that the expertise and commitment exist to do this work well.
We need your input
These are interim findings. The recommendations being developed will apply to clinical practice across diverse settings worldwide, and the more perspectives they are built on, the stronger and more relevant they will be. If you treat children with CML in a low- or middle-income setting, or work alongside colleagues who do, we encourage you to complete the survey. It takes approximately 15–20 minutes.
Complete the survey here: https://forms.gle/y7hVfynCv1S9FGQn7
If you have questions about the survey or the recommendations initiative, please contact arlene@cml-foundation.org.
References
1) Millot, F., Ampatzidou, M., Moulik, N.R. et al. Management of children and adolescents with chronic myeloid leukemia in chronic phase: International pediatric chronic myeloid leukemia expert panel recommendations. Leukemia 39, 779–791 (2025). https://doi.org/10.1038/s41375-025-02543-4