A Decision Analysis of Allogeneic Stem Cell Transplantation for MDS: Delayed Transplantation for Low Risk MDS Is Associated with Imporved Outcome

Reviewer: Julie Draznin Maltzman, MD
OncoLink
Last Modified: December 9, 2002

Presenter: Corey Cutler
Presenter's Affiliation: Dana Farber, Boston, MA
Type of Session: Reporting

Background

Therapies for MDS are limited and unrewarding. Allogeneic transplants can provide cure for 25-40% of the pts.
Low risk MDS pts have a life expectancy of several years with minimal medical intervention. Eventually however, pts become tranfusion dependent and transform into AML.
Current options for MDS include immediate transplant at the time of diagnosis, a delayed transplant at some time after the diagnosis, or a transplant at the time of AML transformation.
This study developed a decision analysis schema that may help in the decision making process of when to proceed with an allogeneic transplant in MDS.

Materials and Methods

A decision analysis is a statistical method that allows treatment strategies to be compared on the basis of the area under the survival curve.
Investigators believe that by using the area under the curve rather than individual numbers, both early mortality and late survival are factored into the analysis.
Using known published data as well as the IBMTR (international bone marrow transplant registry) database, survival multiple analyses were done.
This decision model compared three options: immediate transplant (at time of diagnosis) to transplant at the time of progression to AML and transplant at some delayed time after diagnosis. Various time points were used to define delayed time after diagnosis.

Results

The three year survival for low risk MDS patients who had a transplant immediately at the time of dianosis was 56%. 3 year survival was 90% after 2 years following diagnosis for the same group.
The high risk group however, had only a 25% 3 year survival if transplanted at the time of diagnosis and 0% survival if the transplant was delayed by 2 years.
Pts who were transplated at the time of transformation to AML had a 38% three year survival incidence.
Using various time points for delayed time of transplant after diagnosis, the model showed that 2.5 years was the optimal waiting period --giving best three year survival end points.
This study did not however take into account quality of life, GVHD outcomes following allo transplants, and non myeloablative transplant options.

Author's Conclusions

Early transplant for high grade MDS is preferred over delayed tranplant.
Delayed transplant is better for low risk MDS and yields better survival than transplant at the time of diagnosis.
Transplant for low risk MDS should be done before the transformation to acute leukemia.

Clinical/Scientific Implications

To the authors' knowledge, this is the first study to address timing for an allogeneic transplant in MDS patients as defined by thier grade of disease.
This may provide clinicians with a better idea of when to initiate this difficult therapy.

Oncolink's ASH Coverage made possible by an unrestricted Educational Grant from Ortho Biotech.