Great news on the availability of bosutinib in England

Yes David you are correct.

A criteria an adult patient would have to meet in order to be treated with bosutinib is a previous treatment with at least one TKI.

Currently in England this effectively limits the choice available to imatinib or nilotinib.  

In reality the overwhelming majority of patients would be treated with imatinib as a first TKI treatment. 

When the same real world experience is applied to bosutinib this would almost always result in its use as a 3rd or even 4th treatment.

Taking account of what's set out in previous NICE evaluations and if I'm in NICE mode, the figure I use is of some 90% of patients being treated with imatinib as a first TKI treatment with the treatment sequence for bosutinib being as above. 

Should dasatinib receive a positive recommendation from the current NICE evaluation of its use as a first TKI treatment later this year, I don't think this will change what's described above very much if at all.

That said, if dasatinib also receives a positive recommendation for its use in any of the three CML phases following TKI treatment failure, be that based on resistance or intolerance, then a patient could be treated with dasatinib as a second TKI treatment. I think this much more likely to change the treatment some patients receive.

The more fundamental point is that what is an effective TKI varies from patient to patient with a consideration of quality of life being especially important given treatment for the vast majority of patients is daily and forever.

In the context of NICE evaluations its difficult to get decision makers to understand for example, and limiting this to the quality of life point above, the impact a decades long regime of daily fasting makes on someone's life especially if they are still working and even more if work schedules vary and little control can be exerted over them.  

That's why this Discussion Forum is so important because its a spontaneous record, generally from patients, of life on treatment and, as important, its historical. There are rarely any survey type carefully pre prepared questions put up for people to answer and never any limited choice questions that attempt a single shot capture of reality before translating that into a statement about what the experience of a particular TKI treatment is like for everyone.

For me that's a crude method of describing what's a very personal experience and its vital that a qualifying brake be placed on exercises of this type.

It would, I think, be of less importance if treatment was brief (as most chemotherapy cycles are and remembering that technically TKIs are regarded as chemotherapy) but for CML this does not apply.