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MDS: Before and After Stem Cell Transplantation

Panelists: Vinod Pullarkat, MD, City of Hope Medical Center; Jamile Shammo, MD, Rush University Medical Center; Rami S. Komrokji, MD, Moffitt Cancer Center; Thomas Prebet, MD, PhD, Yale Cancer Center; Ellen K. Ritchie, MD, New York Presbyterian Hospital
Published: Tuesday, Feb 21, 2017


Transcript:

Thomas Prebet, MD, PhD:
We also do not need to consider transplant as a hand by itself. It’s a platform, and we can definitely think about medical intervention, preemptive treatment after transplantation. That’s probably something we need to build in the MDS field. There are some data about azacitadine used as a post-transplant preemptive treatment. We can probably think about all the therapies. Lenalidomide does not seem to be the safest medication after transplantation, but with all the therapies, maybe there is something we can single out. So, it’s not a static field. Something is moving, playing on the conditioning, different ways of transplant and potentially preemptive treatment. I agree that definitely most of the patients need to be evaluated pretty early.

Vinod Pullarkat, MD: And also we talked earlier about the frailty, and there are, for transplant, other challenges identifying those factors. For example, there’s a hematopoietic transplant comorbidity index, but we know that by itself, it is not a very good predictor of the outcome. You have other features like performance status, age, maybe genomics. So, we have to consider all of that in taking a patient to transplant.

Ellen K. Ritchie, MD: And Andy Artz’s work looked at a geriatric assessment for some of these patients prior to transplant to determine whether or not they’re going to be able to withstand the treatment.

Vinod Pullarkat, MD: I think we shouldn’t deny anybody transplant just because of age, but we have to improve our assessment of who is a good candidate for transplant so we don’t do futile transplants in these patients.

Ellen K. Ritchie, MD: Well, the problem with age is that in the older age group, chronological age may not equal your functional age. And I’m sure all of us have seen 55-year-olds who really could be 80-year-olds and 80-year-olds who really could be more like 60-year-olds just on the basis of their functionality and their overall health.

Vinod Pullarkat, MD: But, their disease status at the time of transplant is always the most important.

Rami S. Komrokji, MD: I like the way Thomas put it in the first place. It’s like one of the options. It’s basically, we don’t have to think of it just like in separation from everything else we do. I think it’s always helpful to think of it for all the patients but think of the matter of timing. In lower-risk patients, we can wait. The higher-risk patients, we rush to it. And I like the concept that we should think of it into context of everything. What should we do before? What should we do after? And maybe by doing that kind of view more we would improve the outcomes as well, especially for the patients that you mentioned, that if they have mutations, they don’t seem to benefit from transplant. Maybe we can enroll those patients on clinical trials where we have a maintenance strategy or drug that targets that mutation, and see if the combination works. So, it’s a continuum, and it’s one of the options and one of the phases of the plan of the treatment.

Ellen K. Ritchie, MD: But, you have to plan. The important thing is to plan for that, so that you have that card already on the table. It’s not something that you’re reaching for at the last minute. I think making as many opportunities available to a patient as possible for treatment, as early on as possible, is reasonable.

Vinod Pullarkat, MD: Keeping them in the best shape when they need the transplant, getting the donor identification—we mentioned about monitoring transfusions, ferritin, all of these things—they set the stage for a successful transplant hopefully in the future. So, with that, this has been a very informative discussion, and before we conclude, I would like to get the final thoughts from each of you. Rami?

Rami S. Komrokji, MD: I agree, this was very informative. I think we had some counter points, which is always nice. I think it’s an exciting time. I think we really learned much about the biology of the disease. We have now new tools that will allow us to understand more, improve the risk assessment for patients in this disease. I think, hopefully, we are going to see new drugs approved in the coming few years. I think we are moving for that. We have several exciting studies that are going on, and this is an exciting time for MDS patients. Hopefully, we’ll be able to help them more, and the MDS community, in terms of research.

Ellen K. Ritchie, MD: I also think it’s a really exciting time, both in our ability to prognosticate for patients how they’re going to do and new agents that may be able to target specific mutations or immunologically target the patient’s disease. I can see that we’re entering—it’s not just medicine but in our entire culture—a period of time where technology, the understanding of big data, is getting better and better. I foresee the IPSS-R (Revised International Prognostic Scoring System) will be replaced by a really important big computer algorithm, actually, to allow us to assess, individually, patients’ risk for progression and what agents might be most helpful. So, I think this is a really exciting time for medicine and for hematologic malignancy and for myeloid malignancy in particular.

Vinod Pullarkat, MD: Thomas?

Thomas Prebet, MD, PhD: I completely agree with your assessment. It’s good to see basically that all the data we have over the last year on genomics begins to become something real in our day-to-day practice, that we have some clinical implications—treatment decision implications. And that’s something different that we have as compared to 4 or 5 years ago. There’s going to be more and more, I completely agree with you. I just expect not to be replaced by the computer in a few years, but basically, yes, this revolution is coming to a real practical consideration that we practice. That’s probably the biggest thing that we have.

Vinod Pullarkat, MD: Jamile?

Jamile Shammo, MD: And for me, I think I’m hopeful that actually after a decade of stagnation relative to novel treatments, that we might have something for patients as second-line treatment. But, I think there’s a lot to be done until this happens, which is basically optimizing the care of patients that we take care of on a daily basis, and assessing their comorbidities and making sure that the doses that they are taking from available therapies is exactly what they need.

Vinod Pullarkat, MD: So, thank you all for your important contributions to this discussion. I think this was a very lively and interesting discussion. On behalf of the panel, we thank you for joining us and we hope you found this Peer Exchange® discussion to be useful and informative.

Transcript Edited for Clarity
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Transcript:

Thomas Prebet, MD, PhD:
We also do not need to consider transplant as a hand by itself. It’s a platform, and we can definitely think about medical intervention, preemptive treatment after transplantation. That’s probably something we need to build in the MDS field. There are some data about azacitadine used as a post-transplant preemptive treatment. We can probably think about all the therapies. Lenalidomide does not seem to be the safest medication after transplantation, but with all the therapies, maybe there is something we can single out. So, it’s not a static field. Something is moving, playing on the conditioning, different ways of transplant and potentially preemptive treatment. I agree that definitely most of the patients need to be evaluated pretty early.

Vinod Pullarkat, MD: And also we talked earlier about the frailty, and there are, for transplant, other challenges identifying those factors. For example, there’s a hematopoietic transplant comorbidity index, but we know that by itself, it is not a very good predictor of the outcome. You have other features like performance status, age, maybe genomics. So, we have to consider all of that in taking a patient to transplant.

Ellen K. Ritchie, MD: And Andy Artz’s work looked at a geriatric assessment for some of these patients prior to transplant to determine whether or not they’re going to be able to withstand the treatment.

Vinod Pullarkat, MD: I think we shouldn’t deny anybody transplant just because of age, but we have to improve our assessment of who is a good candidate for transplant so we don’t do futile transplants in these patients.

Ellen K. Ritchie, MD: Well, the problem with age is that in the older age group, chronological age may not equal your functional age. And I’m sure all of us have seen 55-year-olds who really could be 80-year-olds and 80-year-olds who really could be more like 60-year-olds just on the basis of their functionality and their overall health.

Vinod Pullarkat, MD: But, their disease status at the time of transplant is always the most important.

Rami S. Komrokji, MD: I like the way Thomas put it in the first place. It’s like one of the options. It’s basically, we don’t have to think of it just like in separation from everything else we do. I think it’s always helpful to think of it for all the patients but think of the matter of timing. In lower-risk patients, we can wait. The higher-risk patients, we rush to it. And I like the concept that we should think of it into context of everything. What should we do before? What should we do after? And maybe by doing that kind of view more we would improve the outcomes as well, especially for the patients that you mentioned, that if they have mutations, they don’t seem to benefit from transplant. Maybe we can enroll those patients on clinical trials where we have a maintenance strategy or drug that targets that mutation, and see if the combination works. So, it’s a continuum, and it’s one of the options and one of the phases of the plan of the treatment.

Ellen K. Ritchie, MD: But, you have to plan. The important thing is to plan for that, so that you have that card already on the table. It’s not something that you’re reaching for at the last minute. I think making as many opportunities available to a patient as possible for treatment, as early on as possible, is reasonable.

Vinod Pullarkat, MD: Keeping them in the best shape when they need the transplant, getting the donor identification—we mentioned about monitoring transfusions, ferritin, all of these things—they set the stage for a successful transplant hopefully in the future. So, with that, this has been a very informative discussion, and before we conclude, I would like to get the final thoughts from each of you. Rami?

Rami S. Komrokji, MD: I agree, this was very informative. I think we had some counter points, which is always nice. I think it’s an exciting time. I think we really learned much about the biology of the disease. We have now new tools that will allow us to understand more, improve the risk assessment for patients in this disease. I think, hopefully, we are going to see new drugs approved in the coming few years. I think we are moving for that. We have several exciting studies that are going on, and this is an exciting time for MDS patients. Hopefully, we’ll be able to help them more, and the MDS community, in terms of research.

Ellen K. Ritchie, MD: I also think it’s a really exciting time, both in our ability to prognosticate for patients how they’re going to do and new agents that may be able to target specific mutations or immunologically target the patient’s disease. I can see that we’re entering—it’s not just medicine but in our entire culture—a period of time where technology, the understanding of big data, is getting better and better. I foresee the IPSS-R (Revised International Prognostic Scoring System) will be replaced by a really important big computer algorithm, actually, to allow us to assess, individually, patients’ risk for progression and what agents might be most helpful. So, I think this is a really exciting time for medicine and for hematologic malignancy and for myeloid malignancy in particular.

Vinod Pullarkat, MD: Thomas?

Thomas Prebet, MD, PhD: I completely agree with your assessment. It’s good to see basically that all the data we have over the last year on genomics begins to become something real in our day-to-day practice, that we have some clinical implications—treatment decision implications. And that’s something different that we have as compared to 4 or 5 years ago. There’s going to be more and more, I completely agree with you. I just expect not to be replaced by the computer in a few years, but basically, yes, this revolution is coming to a real practical consideration that we practice. That’s probably the biggest thing that we have.

Vinod Pullarkat, MD: Jamile?

Jamile Shammo, MD: And for me, I think I’m hopeful that actually after a decade of stagnation relative to novel treatments, that we might have something for patients as second-line treatment. But, I think there’s a lot to be done until this happens, which is basically optimizing the care of patients that we take care of on a daily basis, and assessing their comorbidities and making sure that the doses that they are taking from available therapies is exactly what they need.

Vinod Pullarkat, MD: So, thank you all for your important contributions to this discussion. I think this was a very lively and interesting discussion. On behalf of the panel, we thank you for joining us and we hope you found this Peer Exchange® discussion to be useful and informative.

Transcript Edited for Clarity
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