Allogeneic hematopoietic stem cell transplant remains the only therapy for myelofibrosis with curative potential. However, it may not be the right choice for all eligible patients, so using a shared decision-making process to weigh the benefits and risks for each individual patient is important.

Allogeneic hematopoietic stem cell transplant outcomes have advanced, even in just the last 5 years. Treatments have reduced the rate and severity of graft-versus-host disease and liver failure, and engraftment issues are less common. So, transplant outcomes continue to get better, which opens up the opportunity for more patients to get this potentially curative therapy.

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However, you do have to consider potential complications in your discussions with patients, so it is important not to discount the transplant process. Transplant is a personal decision, and each person must weigh the risks against the benefits. After I go through the expected mortality, complications, and transplant outcomes data that we know of, some patients say that transplant is too risky, while others are willing to take on that risk and wish that they had been told of this option sooner.

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In my practice, getting most patients with myelofibrosis plugged in with the transplant team, completing the human leukocyte antigen typing, and getting the logistics for transplant sorted out are important, even if they may not be going to transplant now—or even within the next 5 or 6 years. I think that there is a misconception that sending patients for a transplant referral means that they are going to get transplanted. However, our transplant colleagues are very keen on not transplanting patients who do not need it, so getting them involved earlier in the process is always better than getting them involved later.

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We make some exceptions at my practice. For low-risk, asymptomatic patients, I mention transplant when I see them but do not typically go beyond that. There are also patients on the other end of the spectrum in whom I think that a transplant would lessen their survival, such as patients with a lot of comorbidities or of an advanced age, although that discussion must be individualized.

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There is some practical information about the long-term management of myelofibrosis that we can get from a patient’s response to a JAK inhibitor in the frontline setting. Patients who are doing well for a long time on a JAK inhibitor, such as those who are transfusion independent with a spleen volume reduction of at least 30%, are not the patients whom we should be referring for potential transplant. However, if a patient is not hitting those types of cut points of response after 3 or 6 months of treatment, we need to either pivot to other agents or consider transplant in those who could potentially benefit.

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I think that there are times when we want to strongly encourage patients with myelofibrosis to consider a transplant, including those who have received at least 1 or 2 JAK inhibitor(s), those who have refractory thrombocytopenia, those with high-risk genetics and cytogenetics, and those who begin to fail anemia-directed agents and are moving toward becoming transfusion dependent. The predictive models that are available can help us counsel these patients, but, at the end of the day, I think that the key thing is the shared decision-making process with the patient. You should educate the patient on their disease risk and on what you think the transplant risks are for them, and you should have a conversation to determine whether receiving a transplant fits with their life experiences and goals going forward.