Myelodysplastic syndrome (MDS) is a malignancy of the bone marrow resulting in a reduction of the healthy blood cells. The incidence of myelodysplastic syndrome is about 3.3-4.5 cases per 100,000 and the incidence is increasing each year, it is more common in White, elderly (usually, occurs in the seventh decade) male patients. A recent study has shown the incidence is about 75 per 100,000 in people aged more than 65 years, 86% patients diagnosed with myelodysplastic syndrome are more than 60 years (mean age of 76 years) and only 6% of patients were diagnosed on or before age 50. (1)
How Is Myelodysplastic Syndrome Treated In The Elderly?
If myelodysplastic syndrome is not treated, it invariably progresses into acute myeloid leukemia (AML), there are several types of myelodysplastic syndrome, some types rarely progress and some are common to progress into AML. The treatment methods for elderly people remains controversial, the type of myelodysplastic syndrome and severity, the age, comorbidities, and tolerance to the treatment are important aspects to consider before initiation of treatment. Age per se does not limit treatment as some patients tolerate treatment well. Some believe palliative care with supportive treatment is the best way. The ultimate goal of treatment is to prolong survival, reduce symptoms and improve quality of life.
Hypomethylating Agents– Hypomethylating agents can be used to treat lower-risk forms, drugs such as azacytidine (Vidaza) and decitabine (Dacogen) are the first choice. These drugs increase the blood counts, reduce the number of transfusions needed, reduce the risk of developing AML, prolong survival, and improve quality of life. These drugs have side effects similar to standard chemotherapy drugs but milder than those drugs. One of the main side effects is it reduces the blood counts initially and take some time for the drug response. Other side effects include fatigue, fever, nausea/vomiting, diarrhea or constipation. Other standard chemotherapy agents are less effective, but cytarabine, idarubicin, daunorubicin are used in some instances.
Immunomodulating Drugs– Myelodysplastic syndrome with isolated del (5q) type (mutation in chromosome 5) can be treated with lenalidomide (Revlimid) as the first choice, which is an immunomodulating drug. If it doesn’t work azacytidine can be used. Lenalidomide can also be used for other low-grade myelodysplastic syndrome types as well. It also reduces the need for blood transfusion for some time. The side effects are lower blood counts, fatigue, diarrhea, and constipation.
Immunosuppressive Drugs– Immunosuppressive drugs such as cyclosporine and anti-thymocyte globulin (ATG) can be used for patients with a low number of cells in the bone marrow.
Allogeneic Stem Cell Transplantation– Allogeneic stem cell transplantation (allo-HSCT) is the only definitive cure for myelodysplastic syndrome. However, allo-HSCT is not done commonly in elderly patients as transplantation have a high morbidity and mortality, most elderly patients have other comorbidities, finding a compatible donor is also a problem at this age. Therefore, usually, done in patients less than 60 years and unfortunately most patients are not candidates for transplantation.
Supportive Care And Other Treatment– If blood counts are low supportive care treatment with blood transfusions and blood cell growth factors can be given. Prophylactic treatment to prevent infections and treatment of infections needs to be done as well. (2)
The treatment of myelodysplastic syndrome in the elderly remains controversial. Most patients diagnosed with myelodysplastic syndrome are elderly patients most probably with other comorbidities. Some believe they should be offered palliative care with supportive treatment and some studies have proved that drugs prolong their life and reduce the risk of developing AML; however, some patients do not tolerate these aggressive treatments. The goal of treatment is to prolong life, reduce symptoms, and improve quality of life. When choosing a treatment plan to a patient, the risks and benefits of the treatment should be taken into account. The treatment options are hypomethylating agents (azacytidine and decitabine), lenalidomide, immunosuppressive agents (cyclosporine and ATG), allogeneic stem cell transplantation (not done commonly), supportive care with blood transfusions, blood cell growth factors, and prevention of infections; and palliative care.
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