An expert identifies situations in which bone marrow transplantation is appropriate for patients with myelodysplastic syndrome.
Amer Zeidan, MBBS, MHS: The management of patients with myelodysplastic syndrome [MDS] is largely connected to the risk-stratification status of the patients. Patients who have high-risk disease are going to be selected for bone marrow transplantation as long as, first of all, they agree to that risk. Going through bone marrow transplantation is associated with significant risks, especially for an older patient population that has multiple comorbidities, so that’s 1 consideration. We also look at the other concomitant medical problems the patient has. Is it their liver or their heart, their kidneys, their lungs? All these have to be in reasonable condition to go for a transplant.
We also have to have donors. In the past, this used to be a big problem in MDS patients because, as we know, patients with MDS are older, in their 70s, so a lot of their siblings would be in their 60s and 70s and might not be the best donors. However, with advances in typing and supportive care, we are now using more and more unrelated donors or even those who have matches: haploidentical transplants from the children of the patient. The donor issue is becoming less problematic; however, we still don’t transplant most patients with MDS. There are data suggesting that less than 5% to 10% of MDS patients are being transplanted.
We always discuss allogeneic bone marrow transplantation with patients as the only potential way to try to get cure into patients with high-risk MDS. In reality, despite those advances that we have with bone marrow transplantation and better identification of alternative donors aside from the traditional sibling donors, a majority of patients with high-risk MDS are not undergoing bone marrow transplantation. That’s largely related to the age of the patients. The median age of patients is 76, so most of them are in their seventh or eighth decade of life. At most centers in the past, we used to not transplant patients who were in their 60s. Now we are going to early or mid-70s, but most big centers probably would not do an allogeneic bone marrow transplantation for someone who is in their late 70s. Many patients are just being excluded from the get-go.
For patients who are on the younger spectrum, less than 74, many of them are not candidates because of concomitant medical problems: diabetes, hypertension, heart problems, liver problems, lung problems. For many of the patients, when they hear about the risks associated with bone marrow transplant, it’s not consistent with their goals. Many of them are at the point in their lives where they are more interested in therapy that maintains an outpatient and reduces the chance of being hospitalized. Bone marrow transplant is not the most effective procedure as well; only 30% to 40% of patients achieve long-term survival with bone marrow transplants. Many patients could die from complications with the transplant, or MDS relapses in more than 30% to 40%. The most common reason for failure of bone marrow transplant is in regard to myelodysplastic syndrome. Because of all these reasons, most patients with MDS would not undergo a bone marrow transplant. Registry, population, and survey data suggest that less than 5% to 10% of patients with MDS currently undergo bone marrow transplant.