OpenOnco · Treatment Plan

Treatment plan — DIS-CML

PLAN-BMA-BCR_ABL1_E255K_CML-V1 · v1 · 2026-05-04

Patient

BMA-BCR_ABL1_E255K_CML · Algorithm: ALGO-CML-1L

Etiological driver

Etiological driver · etiologically_driven archetype

Chronic Myeloid Leukemia

BCR-ABL1 fusion arising from t(9;22)(q34;q11.2) (Philadelphia chromosome) in 100% — defining + targetable driver
p210 (Major BCR breakpoint, e13a2 / e14a2): classic CML (>95%)
p190 (minor BCR, e1a2): more often Ph+ ALL, occasionally lymphoid-blast-phase CML
p230 (micro BCR, e19a2): rare, indolent neutrophilic CML
Sporadic; rare environmental association (ionizing radiation)

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

✅ Covered biomarkers (matched in KB)

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
No clinically actionable variants matched in this profile.

⚠️ Not included in plan

Biomarker	Status
BIO-BCR-ABL1	Not in KB — ask clinician to verify

Treatment options (2 tracks)

Standard plan

★ DEFAULT

Indication

IND-CML-1L-IMATINIB

Regimen

Imatinib (CML chronic phase 1L)

Drugs + NSZU

Imatinib (DRUG-IMATINIB) 400 mg PO once daily with food + large glass of water · continuous, lifelong (or until durable deep molecular response permits TFR attempt per ELN 2020 criteria) · PO ✓ NSZU covered

Reason

Engine default per algorithm ALGO-CML-1L: {'step': 4, 'outcome': False, 'branch': {'result': 'IND-CML-1L-IMATINIB'}, 'fired_red_flags': [], 'winner_red_flag': None}

Aggressive plan

Indication

IND-CML-1L-2GEN-TKI

Regimen

2nd-generation TKI (dasatinib OR nilotinib OR bosutinib by comorbidity matrix) — CML chronic phase 1L for high-risk / younger seeking TFR

Drugs + NSZU

Dasatinib (DRUG-DASATINIB) 100 mg PO once daily — DEFAULT for low-CV-risk; AVOID if pulmonary disease · continuous; lifelong unless TFR achieved · PO ✓ NSZU covered
Nilotinib (DRUG-NILOTINIB) 300 mg PO BID on empty stomach (≥1 h before / ≥2 h after meals) — DEFAULT for low-CV-risk + no pancreatitis history; AVOID if CV disease, DM, hyperlipidemia · continuous · PO ✓ NSZU covered
Bosutinib (DRUG-BOSUTINIB) 400 mg PO once daily with food — for patients with CV comorbidity precluding nilotinib AND pulmonary precluding dasatinib · continuous · PO ✓ NSZU covered

Reason

Alternative track presented for HCP consideration

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-BCR-ABL-JAK2	BCR-ABL + JAK2 + CALR + MPL	Critical	genomic	CSD Lab ✓ (code TBC)	all tracks
TEST-BM-ASPIRATE	Bone Marrow Aspirate	Critical	histology	—	all tracks
TEST-BM-TREPHINE	Bone Marrow Trephine	Critical	histology	—	all tracks
TEST-CBC	Complete Blood Count with Differential	Critical	lab	—	all tracks
TEST-CMP	Comprehensive Metabolic Panel	Critical	lab	—	all tracks
TEST-FISH-PANEL	FISH (Fluorescence In Situ Hybridization)	Critical	genomic	CSD Lab ✓ (code TBC)	all tracks
TEST-FLOW-CYTOMETRY	Flow Cytometry	Critical	histology	CSD Lab ✓ (code TBC)	all tracks
TEST-HBV-SEROLOGY	Hepatitis B Serology Panel (HBsAg, anti-HBc total, anti-HBs)	Critical	lab	—	all tracks
TEST-HCV-ANTIBODY	HCV Antibody	Critical	lab	—	all tracks
TEST-KARYOTYPE	Karyotype	Critical	genomic	CSD Lab ✓ (code TBC)	all tracks
TEST-LDH	Lactate Dehydrogenase	Critical	lab	—	all tracks
TEST-LFT	Liver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin)	Critical	lab	—	all tracks
TEST-PREGNANCY	Beta-HCG	Critical	lab	—	all tracks
TEST-ECHO	Echocardiography	Standard	imaging	—	aggressive

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

CML high-risk by ELTS (EUTOS Long-Term Survival score) — favors 2nd-generation TKI (nilotinib / dasatinib / bosutinib) over imatinib for faster deep molecular response and improved long-term outcomesRF-CML-HIGH-RISK-ELTS
CML patient with comorbidity excluding specific 2nd-gen TKIs: significant cardiovascular disease (PAOD, prior MI/stroke, uncontrolled HTN — avoid nilotinib/ponatinib), pulmonary disease (COPD, prior pleural disease — avoid dasatinib), severe GI disease (avoid bosutinib), pancreatitis history (avoid nilotinib)RF-CML-ORGAN-DYSFUNCTION
CML with T315I gatekeeper mutation in the BCR-ABL1 kinase domain — resistant to all 1st/2nd-gen TKIs; requires ponatinib or asciminib (STAMP)RF-CML-T315I-MUTATION
CML in accelerated or blast phase: ≥10% blasts in PB or BM (accelerated), ≥20% blasts (blast phase), or extramedullary blasts. Treatment intent shifts from chronic-phase TKI to acute-leukemia-style induction + alloHCT.RF-CML-TRANSFORMATION-PROGRESSION
CML chronic phase with Hasford (EURO) high risk — supports 2nd-generation TKI 1L (dasatinib / nilotinib / bosutinib) over imatinib; comparable rationale to Sokal-highRF-HASFORD-HIGH
CML chronic phase with Sokal high risk — supports 2nd-generation TKI 1L (dasatinib / nilotinib / bosutinib) over imatinib for faster MMR/MR4.5 and improved long-term cumulative incidence of progressionRF-SOKAL-HIGH

CONTRA-AGGRESSIVE

Hard contraindications to escalation

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Standard plan (IND-CML-1L-IMATINIB)

Do not skip baseline BCR-ABL1 quantitative PCR — this is baseline for milestone monitoring.
Do not skip pre-TKI HBV screening — HBV reactivation on TKI has been described in cases.
Do not skip the fertility discussion in young patients — TKI safety during pregnancy is limited; interferon-α — alternative at conception.
Do not prescribe without food + a large glass of water — GI intolerance on empty stomach.
Do not repeat imatinib 400 mg on failure — switch per ELN criteria (3 mo / 6 mo / 12 mo) to a 2nd-gen TKI.
Do not start a TFR attempt without ≥3 years of TKI + sustained MR4.5 ≥2 years + qPCR monitoring q1-2mo after stopping.

Aggressive plan (IND-CML-1L-2GEN-TKI)

Do not prescribe nilotinib without baseline CV evaluation + ECG + lipid panel + glucose — boxed QT warning + cumulative vascular toxicity.
Do not prescribe dasatinib to patients with pulmonary comorbidity / prior pleural effusion — risk of severe effusion.
Do not prescribe bosutinib to patients with IBD / severe diarrhea history — diarrhea ~70% risk.
Do not skip pre-TKI HBV screening.
Do not skip the fertility discussion; TKI safety during pregnancy is limited.
Do not start without food for bosutinib (with food); STRICTLY on empty stomach for nilotinib (≥1h before / ≥2h after).

MDT brief

Skills (recommended) — for consideration (1)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
skill: clinical_pharmacistv0.1.0reviewed 2026-04-25STUBsign-offs: 0lead: TBD

Open questions (1, 0 blocking)

OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist

Data quality

Unevaluated RedFlags: RF-CML-COMORBIDITY-COMPLEX, RF-CML-FRAILTY-AGE, RF-CML-HIGH-RISK-ELTS, RF-CML-ORGAN-DYSFUNCTION, RF-CML-T315I-MUTATION, RF-CML-TRANSFORMATION-PROGRESSION, RF-HASFORD-HIGH, RF-SOKAL-HIGH

Skill catalog (1/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-ELN-CML-2020: European LeukemiaNet 2020 recommendations for treating chronic myeloid leukemia (2020)
SRC-ESMO-CML-2017: Chronic myeloid leukaemia: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up (2017)
SRC-IRIS-OBRIEN-2003: Imatinib compared with interferon and low-dose cytarabine for newly diagnosed chronic-phase chronic myeloid leukemia (2003)
SRC-NCCN-MPN-2025: NCCN Clinical Practice Guidelines in Oncology: Myeloproliferative Neoplasms (v.X.2025)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-05-04.

NCT	Title	Phase	Status	Sponsor	UA
NCT05549661	Onvansertib for the Treatment of Recurrent or Refractory Chronic Myelomonocytic Leukemia and Myelodysplastic Syndrome/MPN Overlap Neoplasms	PHASE1	RECRUITING	Mayo Clinic	—
NCT05963061	Chronic Myeloid Leukemia (CML) Real-Life Database	N/A	RECRUITING	University Hospital, Clermont-Ferrand	—
NCT06297161	A Study to Learn About the Study Medicine Bosulif in Adult Patients With Chronic Myeloid Leukemia(CML).	N/A	RECRUITING	Pfizer	—
NCT04708054	Venetoclax to Improve Outcomes of Fractionated Busulfan Regimen in Patients With High-Risk AML and MDS	PHASE2 / PHASE3	RECRUITING	M.D. Anderson Cancer Center	—
NCT06163430	A Phase 1/2 Clinical Study to Evaluate the Safety, Tolerability, Pharmacokinetics, and Efficacy of TERN-701 in Participants With Chronic Myeloid Leukemia (CARDINAL)	PHASE1 / PHASE2	RECRUITING	Terns, Inc.	—
NCT06111612	Intensive Conditioning withTHI/Bu/Flu/Ara-C in Allo-HSCT for Myeloid Malignancies With Extramedullary Involvement	N/A	RECRUITING	Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine	—
NCT03683433	Enasidenib and Azacitidine in Treating Patients With Recurrent or Refractory Acute Myeloid Leukemia and IDH2 Gene Mutation	PHASE2	RECRUITING	M.D. Anderson Cancer Center	—
NCT05943522	Asciminib RMP Study	N/A	RECRUITING	Novartis Pharmaceuticals	—
NCT06815003	Vedolizumab Plus Post-transplant Cyclophosphamide and Short Course Tacrolimus for the Prevention of Graft Versus Host Disease in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation After Reduced Intensity Conditioning	PHASE2	RECRUITING	City of Hope Medical Center	—
NCT07166419	Anti-CD19/20/22 Chimeric Antigen Receptor T Cells (TriCAR19.20.22 T Cells) for the Treatment of Relapsed or Refractory Non-Hodgkin Lymphoma, Acute Lymphoblastic Leukemia, and Chronic Lymphocytic Leukemia	PHASE1	RECRUITING	Ohio State University Comprehensive Cancer Center	—

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Standard plan Imatinib (CML chronic phase 1L) (REG-IMATINIB-CML)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Aggressive plan 2nd-generation TKI (dasatinib OR nilotinib OR bosutinib by comorbidity matrix) — CML chronic phase 1L for high-risk / younger seeking TFR (REG-2GEN-TKI-CML)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Trial · NCT05549661 Onvansertib for the Treatment of Recurrent or Refractory Chronic Myelomonocytic Leukemia and Myelodysplastic Syndrome/MPN Overlap Neoplasms No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05963061 Chronic Myeloid Leukemia (CML) Real-Life Database No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06297161 A Study to Learn About the Study Medicine Bosulif in Adult Patients With Chronic Myeloid Leukemia(CML). No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT04708054 Venetoclax to Improve Outcomes of Fractionated Busulfan Regimen in Patients With High-Risk AML and MDS No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06163430 A Phase 1/2 Clinical Study to Evaluate the Safety, Tolerability, Pharmacokinetics, and Efficacy of TERN-701 in Participants With Chronic Myeloid Leukemia (CARDINAL) No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06111612 Intensive Conditioning withTHI/Bu/Flu/Ara-C in Allo-HSCT for Myeloid Malignancies With Extramedullary Involvement No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT03683433 Enasidenib and Azacitidine in Treating Patients With Recurrent or Refractory Acute Myeloid Leukemia and IDH2 Gene Mutation No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05943522 Asciminib RMP Study No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06815003 Vedolizumab Plus Post-transplant Cyclophosphamide and Short Course Tacrolimus for the Prevention of Graft Versus Host Disease in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation After Reduced Intensity Conditioning No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07166419 Anti-CD19/20/22 Chimeric Antigen Receptor T Cells (TriCAR19.20.22 T Cells) for the Treatment of Relapsed or Refractory Non-Hodgkin Lymphoma, Acute Lymphoblastic Leukemia, and Chronic Lymphocytic Leukemia No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-05-04.

plan_id: PLAN-BMA-BCR_ABL1_E255K_CML-V1 | version: 1 | generated: 2026-05-04T14:13:16.565979+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.