Older Patients with MDS: Uncovering Barriers to Allogeneic HCT

Only one-third of all patients with myelodysplastic syndromes (MDS) referred to an academic center undergo hematopoietic cell transplantation (HCT), according to a study of 362 patients with MDS treated at Memorial Sloan Kettering Cancer Center.

The retrospective study analyzed patients with MDS between 2008 and 2015, and found that 294 of the 362 patients (81%) were deemed eligible for transplantation. Among these, HCT was considered indicated in 244 (83%) patients, and 158 (65%) patients were referred for transplantation evaluation.

Transplantation evaluations took place at a median of 3.9 months from diagnosis, and overall 120 of 362 (33%) underwent transplantation at a median of 7.7 months from diagnosis. The major reason patients were ineligible for HCT was metastatic solid-organ malignancy (54%).

A multivariate analysis identified 3 factors significantly associated with a lower likelihood of referral for transplantation evaluation: Age ≥65 (p=0.001); <5% blasts at diagnosis (p=0.031); and diagnosis between 2008 and 2011 (p<0.001).

The authors note that patients diagnosed with MDS before 2012 were less frequently referred for transplantation, most likely because Medicare coverage for patients with MDS >65 years began in 2011 under a “Coverage with Evidence Development” mechanism.

Despite insurance coverage, the study found that patients ages ≥65 years remain less likely to undergo transplantation, independent of comorbidity and disease risk.

The ability to predict the outcomes of non-HCT and HCT therapies have improved with cytogenetic stratification provided by the revised IPSS (IPSS-R) and recent advances in somatic mutation profiling.

To further understand the role of HCT versus best supportive care for patients with MDS, the Blood and Marrow Transplant Clinical Trials Network trial 1102 is currently enrolling intermediate- and high-risk patients with MDS aged 50-75 years.

The authors conclude by recommending that all newly diagnosed patients with MDS age ≤75 years be referred for transplantation evaluation at diagnosis, regardless of disease risk, because “early referral may increase the likelihood of transplantation by minimizing complications acquired before HCT.”

Getta BM, et al. Biol Blood Marrow Transplant

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