Treatment of Myelodysplastic Syndrome
By Dr. C.D. Buckner M.D. Medically reviewed by C.H. Weaver 9/2018
Myelodysplastic syndrome (MDS) is curable and the prognosis is dependent on an age, overall health, and specific genetic or cytogenetic abnormalities. Treatment is designed to manage the complications associated with ineffective blood cell production, extend survival, and cure the disease when possible.
Treatment of MDS is individualized and depends on:
- The severity of low blood counts
- The risk of progression to acute myeloid leukemia
- Genetic abnormalities detected on cytogenetic analyses
The potential treatment options for MDS include the following:
- Destruction of abnormal cells through administration of chemotherapy, at either low, conventional, or high doses, depending on the condition of the patient and the aggressiveness of their disease.
- Supportive care through administration of growth factors to stimulate immature cells to development into mature blood cells.
- Replacement of damaged bone marrow with healthy cells that develop into blood cells, a procedure called stem cell transplantation
- Precision medicines or immunotherapies
- Participation in a clinical trial.
Currently, only stem cell transplant utilizing cells from a donor—called an allogeneic transplant—can consistently cure patients with MDS. Other therapies are directed at prolonging survival and decreasing the symptoms.,
Planning Treatment for Myelodysplastic Syndrome
Since a stem cell transplant utilizing cells from a donor—called an allogeneic stem cell transplant—holds the most hope for cure, a major decision faced by some patients with MDS is not whether to undergo transplantation, but when. Patients with MDS that is likely to progress to leukemia early—which results in shorter survival—may be willing to accept higher risks of treatment and proceed quickly to a stem cell transplant. Patients with MDS that progresses more slowly are likely to live longer and may wish to pursue a more conservative treatment approach, opting to use supportive care and wait for the development of new treatments or a longer period before undergoing a stem cell transplant.
Patients who choose conservative treatment approaches should always be prepared to receive more aggressive treatment in case their disease progresses more rapidly than anticipated. To prepare for a possible stem cell transplant, patients should consider arranging for a stem cell donor and/or having their own stem cells collected and stored shortly after diagnosis. This is important because as MDS progresses and treatment is initiated, it becomes increasingly difficult to collect stem cells.
In order to better plan treatment, doctors try to identify how quickly patients are likely to progress to acute myeloid leukemia (AML). A score is assigned that reflects this tendency to progress and is based on a system called the International Prognostic Scoring System (IPSS). A higher score is associated with a type of MDS that is likely to progress to leukemia more quickly. The IPSS score takes into account three important factors in MDS:
- The percent of bone marrow blasts—more blasts contributes to a higher score
- Genetic (cytogenetic) abnormalities—more abnormalities contribute to a higher score
- Severity of low white blood cell counts—lower counts of white blood cells, platelets, and red blood cells contribute to a higher score
Relationship between a patient’s risk of progressing to leukemia and timing of stem cell transplant:
Research shows that knowing a patient’s risk of progressing to leukemia is important for determining optimal timing of stem cell transplantation. Based on information about 1,000 patients who had been diagnosed with MDS, researchers from several U.S. cancer centers have determined that patients with a low or low-intermediate risk of progression to leukemia have better outcomes if their transplant was not performed at the time of diagnosis but was delayed. Patients with a high or high-intermediate risk experienced optimal survival if they underwent an allogeneic transplant at the time of diagnosis, without delay. Furthermore, the patients with lower risk achieved optimal outcomes if their transplant was administered prior to progression of their disease to acute myeloid leukemia compared to after progression.(3)
Genetic profiling can guide stem cell transplantation for patients with myelodysplastic syndrome
Based on an analysis of blood samples from 1,514 patients with MDS investigators from the Center for Blood and Marrow Transplant Research have determined that using a single blood test to genetically profile a patient’s blood cells and basic information about a patient’s medical status can also indicate which patients likely to benefit from a stem cell transplant.
- Blood cells that carry a mutation in the gene TP53 tent to survive for a shorter time after a transplant, and also relapse more quickly, than patients whose cells lacked that mutation.
- Individuals with RAS mutations have reduced survival and increased risk of only when treated with reduced-intensity conditioning. These patients may benefit from higher intensity conditioning regimens, the researchers indicated.
- TP53 mutations and mutations in PPM1D, a gene that regulates TP53 function, were far more common in patients with MDS that resulted previous cancer treatment.
These and other factors will continue to be identified and help determine which treatment is most appropriate.
Supportive Care with Growth Factors
While patients may not initially experience symptoms of their condition, the ineffective blood cell production that characterizes MDS eventually results in uncomfortable and life-threatening side effects. Low red blood cell production results in anemia and associated fatigue; low white blood cell production causes neutropenia, which increases the risk of infection; and low platelets causes thrombocytopenia and an increased risk of bleeding.
Patients who are at low risk of progressing to acute myeloid leukemia may not have any of these symptoms or they may require supportive treatments in order to prevent the complications associated with low blood counts. Several strategies exist for improving blood cell production and decreasing complications:
Anemia: Anemia can be treated with a red blood cell transfusion or by increasing red blood cell production with a naturally produced protein called erythropoietin. Erythropoietin stimulates the bone marrow to produce more red blood cells. When administered to some patients, it reduces the severity of anemia and can prevent red blood cell transfusions. Currently, there are two forms of erythropoietin available, epoetin alfa (Epogen® or Procrit®) and darbepoetin alfa (Aranesp®). Aranesp is a longer acting form that can be administered less frequently. Clinical trials have shown that Aranesp improves anemia and quality of life in patients with low or intermediate-risk MDS.,,,
Neutropenia: Neutropenia, or a low white blood count, increases a patient’s risk of infection. The white blood count can be temporarily increased with white blood cell growth factors which stimulate the production of white blood cells. This can decrease the chance of additional or worsening infections.
Thrombocytopenia: Drugs referred to as “platelet growth factors” such as (Nplate) (romiplostim) and Promacta (eltrombopag) might help some people with MDS who have very low platelet levels, although this is still being studied. Neumega (interleukin-11, IL-11, can also be used to raise platelet counts after chemotherapy and in some other diseases. But none of these drugs are specifically approved for primary treatment of MDS.
Immunotherapy and Precision Cancer Medicines
The immune system is a network of cells, tissues, and biologic substances that defend the body against viruses, bacteria, and cancer. The immune system recognizes cancer cells as foreign and can eliminate them or keep them in check—up to a point. Cancer cells are very good at finding ways to avoid immune destruction however, so the goal of immunotherapy is to help the immune system eliminate cancer cells by either activating the immune system directly or inhibiting the mechanisms of suppression of the immune system. There are several substances that generally boost, direct or restore normal immune defenses and include interferons and interleukins.
Not all cancer cells are alike – they may differ from one another based on what genes have mutations. The purpose of precision cancer medicine is to define the genomic (genetic) alterations in a cancers DNA that are driving that specific cancer. Precision cancer medicine utilizes molecular diagnostic testing, including DNA sequencing, to identify cancer-driving abnormalities in a cancer’s genome.
Precision cancer medicine uses targeted drugs and immunotherapies (monoclonal antibodies, vaccines) engineered to directly attack the specific abnormalities causing the cancer and leave normal cells largely unharmed. Precision cancer medicines and immunotherapy can be used both instead of and in addition to chemotherapy to improve treatment outcomes.
Revlimid (lenalidomide) is thought to regulate the immune system and cause anticancer effects by killing abnormal white blood cells, reducing inflammation, and inhibiting growth of new blood vessels. Revlimid is effective in the treatment of patients with low – risk MDS and a specific cytogenetic abnormality, partial loss of chromosome 5 (5q-). Response to treatment is reported to be rapid and long-lasting. Patients experienced an increase in hemoglobin, a component of red blood cells, within approximately one month (4.4 weeks) after the start of treatment.,
Antithymocyte globulin (ATG): Administering a drug that suppresses the immune system—a technique called immunosuppression—appears to provide some benefit in the treatment of MDS. Clinical trial results suggest that over 43% of patients with MDS respond to immunosuppression with ATG. This response lasted nearly two and a half years (29 months) on average.,
High Dose Therapy with Stem Cell Transplant
Without functioning stem cells in the bone marrow, the body cannot produce red blood cells, white blood cells, or platelets, bone marrow function however can be restored by replacing the damaged stem cells with healthy ones. This is a procedure known as a stem cell transplant.
There are two possible sources of stem cells for transplantation; they may be collected from the patient prior to undergoing high-dose therapy or they may be collected from a donor. A stem cell transplant that utilizes the patient’s own cells is called an autologous stem cell transplant. When the stem cells are from a donor the procedure is called an allogeneic stem cell transplant. Currently an allogeneic stem cell transplant offers the greatest chance for cure.
Hematopoietic Stem Cell Transplant is a standard and potentially curative treatment resulting in 3 to 4 year survival rates of 30% to 40%.1,2,13,14 Side effects and mortality from a SCT can be significant however a recent research report revealed that age alone doesn’t affect survival outcomes for MDS patients undergoing SCT. The Center for International Blood and Marrow Transplant Research compared patients aged 65 and older to those aged 55 to 64 with MDS who receive a SCT and found similar outcomes.
Researchers are working on improving stem cell transplant in several ways...
All patients with MDS should be evaluated for SCT at a transplant center with a dedicated research interest in MDS because many new treatment strategies are being developed and only physicians at those centers can speak to the progress being made.
Autologous Stem Cell Transplant utilizes the patient’s own stem cells thereby eliminating the need to find an appropriate stem cell donor. High-dose chemotherapy and autologous stem cell transplant had not been widely used to treat MDS because stem cells collected from the patient with myelodysplasia were thought to be abnormal. Results of a clinical trial however have demonstrated that ~27% of patients with MDS or AML secondary to survived cancer-free four years after transplant was similar for both types of transplant; patients who experienced a complete remission during therapy and received their transplant while in remission had slightly better outcomes.
Reduced-intensity Transplants: A reduced intensity or mini transplant involves lower doses of therapy prior to allogenic stem cell transplant and may allow more older patients to benefit from treatment. Mini-transplants are associated with fewer side effects and a lower treatment-related mortality than regular allogeneic stem cell transplants, while still providing the benefit of donor stem cells that can attack the patient’s cancer cells.,
A recent study has directly compared reduced-intensity and myeloablative allogenic transplants in patients with MDS or AML and found that the more intensive treatment produced better outcomes than the reduced intensity regimens. The researchers had planned to enroll 356 patients in the trial, but the study was stopped early when half the patients had been enrolled because the independent data safety monitoring committee saw a clear benefit for the myeloablative treatment.
As expected, acute GVHD in the first 100 days after transplant was lower for reduced-intensity conditioning (31.6% versus 44.7%) as was treatment-related mortality (4.4% versus 15.8%), however, by 18 months after treatment only 67.7% of patients treated with reduced-intensity regimens survived compared with 77.4% of those receiving myeloablative regimens. The relapse rate for reduced-intensity patients was 48.3% compared with only 13.5% for those getting the myeloablative regimens.
Umbilical cord transplantation: Results from a clinical trial conducted in Japan suggests that an umbilical cord transplant may be an effective option for patients with myelodysplastic syndrome who are eligible for an allogeneic stem cell transplant but cannot find a suitable donor. However, the major disadvantage of using umbilical cord blood is the low number of stem cells collected, which has limited the use of this technique, particularly in larger patients who require more stem cells.
Individuals with MDS who are unable or unwilling to undergo a SCT using donor cells or those planning to have their own stem cells collected for a future transplant can receive a variety of treatments not requiring stem cell support. Many patients can achieve a remission but most ultimately experience disease progression. While some patients may experience a long remission following therapy, remissions after conventional chemotherapy typically average less than 12 months.
Vidaza® (azacitadine): was the first drug to be approved specifically for the treatment of MDS. Approximately 15-20% of patients will have an anticancer response, improved quality of life, and no longer required blood transfusions to maintain appropriate hemoglobin levels.
Fludarabine plus cytarabine: Physicians from Italy have reported that the chemotherapy regimen consisting of fludarabine and cytarabine with the white blood cell growth factor, Neupogen® (filgrastim), produced remission in three-quarters of patients with advanced MDS. The 42 patients involved in this study survived 13 months, on average. Nine percent of patients died from complications of the treatment.
Vyxeos The U.S. Food and Drug Administration approved Vyxeos (liposome-encapsulated combination of daunorubicin and cytarabine) for the treatment of AML and MDS based on a study showing it prolonged survival compared to a standard combination of daunorubicin and cytarabine.
Dacogen™ (decitabine): FDA approval for Dacogen was prompted by results of clinical trials demonstrating that it effectively improved outcomes in patients with MDS when compared to supportive care. Overall, Dacogen provided anticancer responses in approximately 17%-26% of patients in trials-demonstrating a significant improvement over supportive care measures and reducing the need for blood transfusions in a significant portion of patients.
Topotecan/cytarabine may be more tolerable than standard idarubicin/cytarabine: A clinical study that involved 510 patients and compared four different chemotherapy combinations has revealed that anticancer responses and duration of survival were the same for all four treatments. However, treatment with topotecan/cytarabine resulted in fewer deaths than other regimens and may be considered an alternative to the standard idarubicin/cytarabine combination for the treatment of patients with progressive or high-risk MDS.
 Theo de Witte T, Suciu S, Verhoef G, et al. Intensive chemotherapy followed by allogeneic or autologous stem cell transplantation for patients with myelodysplastic syndromes (MDSs) and acute myeloid leukemia following MDS. Blood. 2001; 98(8):2326-2331.
 Deeg H, Storer B, Slattery J, et al. Conditioning with targeted busulfan and cyclophosphamide for hemopoietic stem cell transplantation from related and unrelated donors in patients with myelodysplastic syndrome. Blood. 2002;100:1201-1207.
 Cutler C, Lee S, Greenberg P, et al. A decision analysis of allogeneic bone marrow transplantation for the myelodysplastic syndromes: delayed transplantation for low-risk myelodysplasia is associated with improved outcome. Blood. 2004;104:579-585.
 Mannone L, Gardin C, Quarre MC, et al. For the Groupe Francais des Myelodysplasies (GFM). High response rate to Darbopoetin alfa in “low risk” MDS: results of a phase II study. Proceedings of the American Society of Hematology. Blood. 2004;104(suppl 1):24a, abstract 69.
 Stasi R, Abruzzese E, Lanzetta G, Terzoli E, Amadori S. Darbepoetin alfa for the treatment of anemic patients with low- and intermediate-1-risk myelodysplastic syndromes. Annals of Oncology. 2005; 16: 1921-1927.
 Musto P, Lanza F, Balleari E, et al. Darbopoetin alfa for the treatment of anaemia in low-intermediate risk myelodysplastic syndromes. British Journal of Haematology. 2005;128:204-209.
 Terpos E, Mougiou A, Kouraklis A, et al. Prolonged administration of erythropoietin increases erythroid response in myelodysplastic syndromes: a phase II trial in 281 patients. British Journal of Haematology. 2002;118:174-180.
 Santini V, Almeida A, Giagounidis A, et al. Randomized phase III study of lenalidomide versus placebo in RBC transfusion-dependent patients with lower-risk non-del(5q) myelodysplastic syndromes and ineligible for or refractory to erythropoiesis-stimulating agents. Journal of Clinical Oncology. 2016; 34 (25): 2988-2996. doi: 10.1200/JCO.2015.66.0118. Available at: http://jco.ascopubs.org/content/34/25/2988.abstract?jco-home. Accessed August 29, 2016.
 List A, Dewald G, Bennett J, et al. Hematolgoic and cytogenetic (CTG) response to lenalidomide (CC-5013) in patients with transfusion-dependent (TD) myelodysplastic syndrome (MDS) and chromosome 5q31.1 deletion: Results of a multicenter MDS-003 study. Proceedings from the 2005 annual meeting of the American Society of Clinical Oncology (ASCO). Presented May 14, 2005 at a plenary session. Abstract #5.
 Lim Z, Killick S, Cavenagh J, et al. European Multi-Centre Study on the Use of Anti-Thymocyte Globulin in the Treatment of Myelodysplastic Syndromes [abstract]. Blood. 2005;106:707a.
 Molldrem JJ, Leifer E, Bahceci E, et al. Antithymocyte globulin for treatment of the bone marrow failure associated with myelodysplastic syndromes. Annals of Internal Medicine. 2002;137:156-163.
 Source: Center for International Blood and Marrow Transplant Research. “Age doesn’t affect survival outcomes in patients with MDS who receive a HCT.” ScienceDaily. ScienceDaily, 6 December 2015. www.sciencedaily.com/releases/2015/12/151206164811.htm
 Scott B, Pasquini M, Logan B, et al. “Results of a phase III randomized, multi-center study of allogeneic stem cell transplantation after high versus reduced intensity conditioning in patients with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML): Blood and marrow transplant clinical trials network (BMT CTN) 0901”. American Society of Hematology. ASH 2015; Abstract LBA-8.
 Taussig DC , Davies AJ, Cavenagh JD, et al. Durable Remissions of Myelodysplastic Syndrome and Acute Myeloid Leukemia after Reduced-Intensity Allografting. Journal of Clinical Oncology. 2003;21:3060-3066.
 Ooi J, Iseki T, Takahashi S, et al. Unrelated cord blood transplantation for adult patients with advanced myelodysplastic syndrome. Blood. 2003 Jun 15;101(12):4711-3.
 Silverman LR, Demakos EP, Peterson BL, et al. Randomized controlled trial of azacitidine in patients with the myelodysplastic syndrome: a study of the cancer and leukemia group B. Journal of Clinical Oncology. 2002;20(10):2429-2440.
 Felicetto Ferrara, Franco Leoni, Antonio Pinto, et al. Fludarabine, cytarabine, and granulocyte-colony stimulating factor for the treatment of high risk myelodysplastic syndromes. Cancer.1999;86:2006-2013.
 Saba H, Rosenfeld C, Issa JP, et al. Clinical benefit and survival endpoints from a phase III trial comparing decitabine (DAC) vs supportive care (SC) in patients with advanced myelodysplastic syndromes (MDS). Proceedings of the 41st Annual Meeting of the American Society of Clinical Oncology. Orlando FL. 2005; Abstract #6543.
 Kantarjian H, Beran M, Cortes J, et al. Long-term follow-up results of the combination of topotecan and cytarabine and other intensive chemotherapy regimens in myelodysplastic syndrome. Cancer. 2006;106: 1099–1109.