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Blood, 15 July 2004, Vol. 104, No. 2, pp. 304-305.
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TRANSPLANTATION
When to transplant in myelodysplasia? Markov helps
Jeff Szer
THE ROYAL MELBOURNE HOSPITAL
A collaborative study has shown that allogeneic stem cell transplantation offers the best chance for long-term survival when offered at diagnosis for patients with the highest-risk disease but should be delayed to a later time for patients, particularly younger ones, in lower-risk groups.
When the best therapy for a condition is also the most dangerous, assistance is required in determining the optimal timing of that treatment. The first paper clearly showing that allogeneic bone marrow transplantation (BMT) was curative therapy for myelodysplastic syndromes (MDSs) was published in 19841 and subsequent studies have confirmed this observation. In this issue of Blood, Cutler and colleagues (page 579) tell us that in order to maximize survival, HLA-matched sibling donor allogeneic BMT is best performed at diagnosis for patients in the highest-risk groups, based on the International Prognosis Scoring System (IPSS), and delayed to a time prior to leukemic transformation for those with lesser IPSS scores. For the younger patients in the study, the effect of delay was even more noticeable. These decisions are important, especially in a condition where improvements in the understanding of clinical and biologic prognostic factors have improved the overall selection of therapies, curative and palliative.2
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Markov decision model. See the complete figure in the article beginning on page 579.
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The Markov approach to decision analysis has been used to define prognosis for particular patient groups dependent on clinical scenarios for over 20 years.3 "Patients and methods" of Cutler et al's paper describes this sophisticated statistical technique in terms readily understandable by the hematologist. In this study, the process looked at the movement of patients between various states of health (alive, dead, before and after BMT, with MDS, with acute myelogenous leukemia [AML]) and adjusted outcome probabilities as these transitions were made.
The potential for new therapies that, while not curative, may modify the natural history of and improve the quality of life for patients with MDS, along with changes in the clinical practice of BMT, means that the results of these types of studies become essential aids to clinical decision making. That prospectively collected data from disparate centers and research groups can be brought together to perform these studies is encouraging and engenders optimism that the correct answers to difficult clinical questions in the field of BMT and myeloid malignancies can be obtained in the most reliable way.
References
- Appelbaum FR, Storb R, Ramberg RE, et al. Allogeneic marrow transplantation in the treatment of preleukemia. Ann Intern Med. 1984;100: 689-693.[Abstract/Free Full Text]
- Howe RB, Porwit-MacDonald A, Wanat R, Tehranchi R, Hellstrom-Lindbderg E. The WHO classification of MDS does make a difference. Blood. 2004;103: 3265-3270.[Abstract/Free Full Text]
- Myers LE, Paulson DF, Berry WR, Cox EB, Laszlos J, Stanley W. A time-dependent statistical model which relates current clinical status to prognosis: application to advanced prostatic cancer. J Chronic Dis. 1980;33: 491-499.[CrossRef][Medline]
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Related Article in Blood Online:
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A decision analysis of allogeneic bone marrow transplantation for the myelodysplastic syndromes: delayed transplantation for low-risk myelodysplasia is associated with improved outcome
- Corey S. Cutler, Stephanie J. Lee, Peter Greenberg, H. Joachim Deeg, Waleska S. Pérez, Claudio Anasetti, Brian J. Bolwell, Mitchell S. Cairo, Robert Peter Gale, John P. Klein, Hillard M. Lazarus, Jane L. Liesveld, Philip L. McCarthy, Gustavo A. Milone, J. Douglas Rizzo, Kirk R. Schultz, Michael E. Trigg, Armand Keating, Daniel J. Weisdorf, Joseph H. Antin, and Mary M. Horowitz
Blood 2004 104: 579-585.
[Abstract]
[Full Text]
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