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Myelodysplastic Syndrome & Acute Myeloid Leukemia

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Special Considerations in Older Patients With High-Risk MDS

patient care perspectives by Rami S. Komrokji, MD

Overview

Our featured expert provides an overview of special considerations in the management of myelodysplastic syndrome (MDS) in older patients.

Expert Commentary

Rami S. Komrokji, MD

Senior Member
Section Head, Leukemia and MDS
Vice Chair, Department of Malignant Hematology
Moffitt Cancer Center
Professor of Medicine & Oncologic Sciences
University of South Florida Health Morsani College of Medicine
Tampa, FL

“While we do not want to undertreat older patients with high-risk MDS, we also want to be mindful of each patient's individual capacity to tolerate therapy. We must tailor therapy in older patients with MDS rather than withhold therapy.”

Rami S. Komrokji, MD

The average age at which MDS is diagnosed is 72 years, so the majority of patients whom we are treating for MDS are actually older. While we do not want to undertreat older patients with high-risk MDS, we also want to be mindful of each patient's individual capacity to tolerate therapy. We must tailor therapy in older patients with MDS rather than withhold therapy.

Allogeneic stem cell transplantation is a potentially curative treatment option for MDS, and we consider it especially for patients with high-risk MDS; however, because of its inherent risk, its role in older patients is controversial. In fact, it is no trivial matter to consider transplantation in this population. It is an option for some individuals who have excellent performance and no major comorbidities. At my institution, we perform transplantations in those who are up to the age of 75 years—maybe even slightly older if the patient is in very good health. I think that the margin of benefit is an important concept when discussing transplantation (ie, if cure is achieved, the expected margin of benefit is not as great in an older patient, such as a 78 year old, as it is in someone who is much younger).

When gauging the treatment options, we want to be wary of the interplay between MDS and common comorbidities in older patients, such as anemia in those with coronary artery disease and heart failure. Supportive care is also a little bit different in older patients. A young patient may tolerate a hemoglobin level of 7 g/dL, whereas an older patient in their 80s with coronary artery disease, for example, often has a lower threshold for transfusion, since, generally, you would not want their hemoglobin level to get as low as 7 to 8 g/dL. Thus, older patients may need more support.

In a patient with renal insufficiency or liver problems, therapy can often be adjusted or tailored, or you may be able to choose a particular treatment over another based on the patient’s underlying comorbidities. Older patients may have limited mobility and/or functional status, and the newer oral therapies can offer an advantage in these individuals.

References

Atallah E, Bylow K, Troy J, Saber W. Treatment of older patients with high-risk myelodysplastic syndromes (MDS): the emerging role of allogeneic hematopoietic stem cell transplantation (Allo HSCT). Curr Hematol Malig Rep. 2014;9(1):57-65. doi:10.1007/s11899-013-0195-9

Buckstein RJ. Integrating patient-centered factors in the risk assessment of MDS. Hematology Am Soc Hematol Educ Program. 2019;2019(1):373-380. doi:10.1182/hematology.2019000041

Castelli R, Schiavon R, Lambertenghi Deliliers G. The impact of anaemia, transfusion dependency, comorbidities and polypharmacy in elderly patients with low-risk myelodysplastic syndromes. Med Oncol. 2018;35(3):33. doi:10.1007/s12032-018-1094-7

Finn L, Dalovisio A, Foran J. Older patients with acute myeloid leukemia: treatment challenges and future directions. Ochsner J. 2017;17(4):398-404.

Kim N, Norsworthy KJ, Subramaniam S, et al. FDA approval summary: decitabine and cedazuridine tablets for myelodysplastic syndromes. Clin Cancer Res. 2022 Apr 18;clincanres.4498.2021. doi:10.1158/1078-0432.CCR-21-4498

Kröger N, Sockel K, Wolschke C, et al. Comparison between 5-azacytidine treatment and allogeneic stem-cell transplantation in elderly patients with advanced MDS according to donor availability (VidazaAllo study). J Clin Oncol. 2021;39(30):3318-3327. doi:10.1200/JCO.20.02724

Loh KP, Abdallah M, Kumar AJ, Neuendorff NR, Dahiya S, Klepin HD. Health-related quality of life and treatment of older adults with acute myeloid leukemia: a Young International Society of Geriatric Oncology review paper. Curr Hematol Malig Rep. 2019;14(6):523-535. doi:10.1007/s11899-019-00552-6

Rami S. Komrokji, MD

Senior Member
Section Head, Leukemia and MDS
Vice Chair, Department of Malignant Hematology
Moffitt Cancer Center
Professor of Medicine & Oncologic Sciences
University of South Florida Health Morsani College of Medicine
Tampa, FL

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