VIDEO: Treatment considerations for patients with low-, high-risk MDS

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We all know that MDS is a cancer of the bone marrow. The first step in the diagnosis of MDS or before even starting treatment is a thorough workup. Most patients with MDS will present with anemia or thrombocytopenia, or multiple cytopenias. And a lot of times we forget that workup for anemia including getting iron studies, B12, folate, copper B6, among other tests, can help us differentiate MDS from nutritional deficiencies. A common pet peeve of all of us in the myeloid world is that copper deficiency can produce MDS like morphology and can be misdiagnosed as MDS. So that's the first thing to do. After we rule out nutritional deficiencies the next important step is to get a thorough bone marrow review with a good pathologist. You know, as we rely heavily on our pathology colleagues to tell us what kind of MDS we are dealing with; What is the specific classification system that we're using to diagnose MDS, if dysplasia is seen, how much of dysplasia is present and what cell lineage that dysplasia is present. After we do these things, the next step is to get a chromosomal analysis and then next generation sequencing or mutation testing. After we combine all these things, we've come up with a risk stratification or a risk score. I like to explain to my patients that MDS lies on a spectrum from very low risk to very high risk and the treatment of MDS is specialized, and it's not a one treatment fit all strategy. It is specialized to each patient or each person based on what they present with. So the newest score that we all use is called IPSS-M or international prognostic scoring system molecular. It combines blood counts, blast percentage, age, chromosomal abnormalities and mutations all together into a score, and tells us where this patient lies on the spectrum of myelodysplastic syndrome. And this is important because if someone has very low, low risk or intermediate risk MDS, we focus on quality of life on cytopenias and in what symptoms that patient presents with a lot of times we use growth factors we use ESAs, or erythropoiesis-stimulating agent or EMAs, erythroid maturation agents, to help with cytopenias to help get the hemoglobin better, so that the patient can lead a good life, have significant improvement in quality of life. Whereas if someone presents with high risk MDS, we change gears and here we are trying to prevent progression into something like acute myeloid leukemia, or progression of MDS itself from intermediate to high risk. And here we usually get help from our transplant colleagues because as we all know, allogeneic stem cell transplantation is the only cure for MDS. And then we employ strategies to bring the blast percentage down to control disease before sending them to transplant to give them the best possible shot at cure.