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    Patent Pending

    Sokal Index for Chronic Myelogenous Leukemia (CML)

    Predicts survival of CML based on clinical and lab information.
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    INSTRUCTIONS

    Use to predict prognosis at the time of CML diagnosis, before starting treatment.

    When to Use
    Pearls/Pitfalls
    Why Use

    In the US, the Sokal Score can be used to determine risk and decide on therapy based on the NCCN guidelines for CML. While the EUTOS score is easier to calculate and more accurately identifies high risk patients in the era of tyrosine kinase inhibitors, it has not been adopted by the NCCN guidelines.

    • The Sokal Index, also referred to as the Sokal Score, was developed using patients treated in the pre-tyrosine kinase inhibitor era and thus can not necessarily be applied today. Survival outcomes have drastically improved since then.
    • Although scores are stratified into low, intermediate, and high risk, some studies have shown that low and intermediate risk have similar outcomes.
    • Some advocate combining the Sokal and EUTOS Scores for better predictive value.
    • NCCN guidelines for CML treatment recommend use of the Sokal and Hasford Scores over EUTOS for clinical risk stratification.
    • The Sokal Score is also preferentially used in clinical trials so that comparisons can be made to prior trials.
    years
    cm
    × 10³/µL
    %

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Whether the patient meets milestones for cytogenetic and molecular response is more predictive of outcome once therapy is started.

    Management

    Although the Sokal Score has limited usefulness outside of clinical trials today, in general, low and intermediate risk patients can be started on standard dose imatinib, and high risk patients should be considered for newer generation TKIs or be monitored more closely to ensure complete molecular response.

    Critical Actions

    Can only be applied in a newly-diagnosed patient prior to starting therapy.

    Formula

    Sokal Score = exp[0.0116 × (age in years – 43.4)] + [0.0345 × (spleen size in cm – 7.51)] + [0.188 x ((platelets in 109/L / 700)2 – 0.563)] + [0.0887 × (blasts in % – 2.10)]

    Facts & Figures

    Interpretation:

    Risk Group

    Sokal Score

    2-year Survival

    Median Survival

    Low

    <0.8

    90%

    5 years

    Intermediate

    0.8–1.2

    65-90%

    2.5-5 years

    High

    >1.2

    65%

    2.5 years

    Evidence Appraisal

    The original derivation study included 813 European and American patients treated before imatinib was available. The validation study was done during the era of interferon treatment and showed that, even then, the Sokal Score was no longer predictive, and the Hasford Score was a better predictor of survival. Outcomes have significantly improved after the use of imatinib and led to the development of a new score called the EUTOS Score.
    There are two major studies (Uz 2013, Yahng 2012) suggesting the EUTOS Score outperforms the Sokal Score and one study (Marin 2011) showing the converse.

    Literature

    Other References

    Research PaperUz B, Buyukasik Y, Atay H, et al. EUTOS CML prognostic scoring system predicts ELN-based 'event-free survival' better than Euro/Hasford and Sokal systems in CML patients receiving front-line imatinib mesylate. Hematology. 2013;18(5):247-52.Research PaperYahng SA, Jang EJ, Choi SY, et al. Comparison of Sokal, Hasford and EUTOS scores in terms of long-term treatment outcome according to the risks in each prognostic model: a single center data analyzed in 255 early chronic phase chronic myeloid leukemia patients treated with frontline imatinib mesylate. Blood 2012;120:Abstract 2794.Research PaperMarin D, Ibrahim AR, Goldman JM. European Treatment and Outcome Study (EUTOS) score for chronic myeloid leukemia still requires more confirmation. J Clin Oncol 2011;29:3944–5. Research PaperYamamoto E, Fujisawa S, Hagihara M, et al. European Treatment and Outcome Study score does not predict imatinib treatment response and outcome in chronic myeloid leukemia patients. Cancer Sci. 2014;105(1):105-9.Research PaperPfirrmann M, Baccarani M, Saussele S, et al. Prognosis of long-term survival considering disease-specific death in patients with chronic myeloid leukemia. Leukemia. 2016;30(1):48-56.
    Dr. Joseph E. Sokal

    About the Creator

    Joseph E. Sokal, MD, (d. 1988) was a researcher in cancer treatment and a scholar in residence at Duke University. Previously, he was chief cancer research clinician at Roswell Park Memorial Institute in Buffalo and an assistant professor at Yale University.

    To view Dr. Joseph E. Sokal's publications, visit PubMed

    Content Contributors
    Reviewed By
    • Michael Mauro, MD
    About the Creator
    Dr. Joseph E. Sokal
    Content Contributors
    Reviewed By
    • Michael Mauro, MD