A decade later , since the advent of Imatinib, the changing trends in the treatment and the introduction of new TKIs have shed light on various aspects of CML.[4] In this era of 2nd and 3rd generation TKI, it is important to understand the basic trends of CML disease, tolerability of the drug, drug resistance and need of transplant in our Indian patients.

The fact that there is scarcity of the data from India on CML and on the changing trends in the treatment of CML in India, a meeting was conceived to share the in-depth views and clinical data of CML patients from all over India as shown in Figure 1. This meeting “Indian evidence of CML-mylestone” was held on 24th and 25th July 2010.[5] It was organized by Dr. Kumar Prabhash, Associate Professor, TMH Mumbai in collaboration with Indian Cooperative Oncology Network. In this meeting, there was representation from 22 major cancers centers in India comprising 8115 patients. It was the first collaboration of such huge data on CML in Indian patients. 18 Oncology centers also submitted their manuscripts and in this article we are presenting the summary of the collaborated data from the submitted manuscripts. It is imperative to say that this data is retrospective and has its limitations; however, at the same time it gives useful insight to the presentation, treatment modalities and its outcome in an Indian patient with CML.

| Fig. 1 Map of India showing location of 22 Oncology centers represented at myelstone chronic myeloid leukemia meeting July 2010

| Fig. 2 Number of patients from various oncology centers represented at myelstone – Chronic myeloid leukemia meeting July 2010

1. Incidence: As stated in various cancer registries , CML is one of the commonest adult leukemia in Indian population accounting for 30% to 60% of all adult leukemias.[6] The data presented at CML meeting showed that the incidence of CML cases varied from 70% of all leukemia cases at IGIMS, RCC, Patna to 16.6% GCRI, GujaratThis huge difference in incidence of CML cases at two different centres is difficult to explain, as these are not population based registries and may be because of different cancer populations they cater to.
2. Sex ratio: There is male preponderance. The male to female sex ratio varied from 1:08 (Sterlings, Gujarat) to 3:1 (TMH, Mumbai).
3. Median age: The median age of the population varied from minimum 32 years (Nizam Institute of medical sciences, Hyderabad, South India) to maximum 42 years (Ashirwad center, Mumbai, Southwest India). This decade younger population was the most consistent fact presented in almost all studies confirming that in India, median age at presentation is a decade younger compared with the age presented in European (median age 55years)as well as in American (median age 66 years) literature.[7,8]
4. Symptoms at presentation: The most common symptom was splenomegaly ranging from 100% (WIA, Chennai) to 81% (IGIMS, Patna) followed by hepatomegaly, fatigue, weakness, dragging pain, pallor or sometimes asymptomatic seen in 30% cases (HCG, BIO, Bangalore). No Organomegaly was seen in 5.4% patients (IHTM, Kolkata)In comparison to western data where approximately 40% of patients are asymptomatic and diagnosed on the basis of abnormal counts, majority of Indian patients are symptomatic and mostly present with dull aching pain in the left hypochondriac region secondary to splenomegaly.[7]
5. Blood counts at presentation: The median hemoglobin (hb) ranged from 9 g/dl (IGIMS, Patna) to 11 g/dl (AIIMS, India); the median white blood cell count ranged from 0.46 × 109/cumm (RGCI, Delhi) to 1.86 × 109/cumm (WIA, Chennai). CML is a myeloproliferative disease, but it can present with as low counts as 0.18 × 109/cumm (PGI, Chandigarh).
6. CML phase at presentation: The percentage of patients presenting in chronic phase varied from 85% (PGI, Chandigarh) to 97% (IGIMS, Patna) with a median of 89.5% as shown in Figure 3, while in European data, the presentation of CML in chronic phase has been reported to be as high as 96.8%.[7]

| Fig. 3 Chronic myeloid leukemia phase at the time of diagnosis

Sokal risk category: The Sokal risk category data being retrospective is not complete. However, few centers have presented their data and it seems the majority of patients are in Intermediate risk category ranging from 27% to 47%, while low risk category range from 25% to 55% and high risk category range from 12% to 28% of patients as shown in Figure 4.

| Fig. 4 Sokal risk category at the time of chronic myeloid leukemia diagnosis

Monotoring and response

It is difficult to interpret the treatment response from various centers. As the time taken for response varies and also the treated population is quite heterogeneous. The most of the centers there is no mention of early chronic phase (ECP) or late chronic phase (LCP) at presentation. In many of the centers patients were treated with hydroxyurea, interferon at first and then shifted to imatinib. Details can be found in the individual chapters from various centers. The primary resistance to imatinib in newly diagnosed patients can vary from 0.1% (Omega, Hyderabad) to 3% (AIO, Raheja). AIIMS has reported 2 patients out 525 patients having primary resistance. The response from various centers is shown in Table 2.

Table 2

Survival

The survival varies from 81% to 100% in various studies as shown in Table 4.

Table 4

| Fig. 1 Map of India showing location of 22 Oncology centers represented at myelstone chronic myeloid leukemia meeting July 2010

| Fig. 2 Number of patients from various oncology centers represented at myelstone – Chronic myeloid leukemia meeting July 2010

| Fig. 3 Chronic myeloid leukemia phase at the time of diagnosis

| Fig. 4 Sokal risk category at the time of chronic myeloid leukemia diagnosis

REFERENCES