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When a High-Risk Patient with MDS Might Be Low-Risk

Panelists:James M. Foran, MD, FRCPC, Mayo Clinic Cancer Center; Azra Raza, MD, Columbia University Medical Center; David P. Steensma, MD, Dana-Farber Cancer Institute
Published: Thursday, Jun 23, 2016


Transcript:

Azra Raza, MD:
One of the calls I occasionally get from my referring hematologist colleagues is, “Dr. Raza, we have a patient who has high-risk disease so we are not supposed to chelate them, but the patient is now 2 years out and I feel kind of wrong not doing it.” And I’ll say, “You’re absolutely right. If the patient is 2 years out, they’re unlikely to have high-risk disease.” This is one of those inaccuracies of our classifying systems. If you follow just the natural history of the disease, the patient is behaving like a low-risk disease patient, by all means institute chelation. So, for me, there is no hard and fast rule that if this patient has been classified as high-risk, no matter how many transfusions they get and how high the ferritin, I’m not going to intervene because somebody at National Comprehensive Cancer Network (NCCN) Guidelines decided that this is the guideline and they shouldn’t do it. No. Those guidelines are very helpful, but they can’t be strictly applied to every individual patient because they’re just not real for an individual. And this is what I want to emphasize. Please do not try and limit your iron chelation therapy to only lower-risk patients.

James M. Foran, MD, FRCPC: You’re absolutely right. For deferasirox, there was a notation on the label that it is “not indicated for higher-risk MDS.” But that’s not the same as saying it’s contraindicated, and I think you have to make a decision for the person and how their disease course is behaving to see if that’s a valuable thing for them.

Azra Raza, MD: You know there is a recent book out by Dr. Vince DeVita—who was the director of the NCI for many, many years—called The Death of Cancer, in which he recounts one thing. He says as a Fellow in training, there was a patient who had brain metastasis, and his teacher was Dr. Freireich, who’s now at MD Anderson. And Dr. Freireich told him to give this medication; inject it into the spine, and give it intrathecally. And he said, “But on the bottle, it says do not inject intrathecally. Do you really want me to give it?” And Dr. Freireich stood there saying, “I order you to do it. Do it now.” And he did it and that saved the patient’s life.

In other words, there is some leeway, some kind of freedom to be able to use your own clinical judgment that at this point in time for this individual patient, I’m pushed into such a corner that the best way I can serve the patient is go against the grain and give him this drug. So, at one point, we had that freedom to use our clinical judgment. In today’s day and age, these kinds of lines drawn on the sand or etched in stone are beaten upon our cerebrum with such force that if you really do something even slightly different using your medical and clinical judgment, then you should be put in jail. That is not true. That’s not the practice of real medicine.

James M. Foran, MD, FRCPC: I do not think anybody will be incarcerated for chelation, not if it’s done appropriately, I hope. You’re bringing back to a point you started with, and it’s one with which I agree and I’m sure Dr. Steensma will agree also, that this is a disease where we have to treat the person. It’s a disease where there’s a person in front of you, and you have to do the right thing for that person.

Azra Raza, MD: And that person is in front of you for many years. You have observed the patient for 10 years sometimes. I mean, I’m friends with patients who have had children and grandchildren during the course of how long I have taken care of them. So, they become like family members. You know how their body is responding much better than some guideline is going to tell you.

Transcript Edited for Clarity
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Transcript:

Azra Raza, MD:
One of the calls I occasionally get from my referring hematologist colleagues is, “Dr. Raza, we have a patient who has high-risk disease so we are not supposed to chelate them, but the patient is now 2 years out and I feel kind of wrong not doing it.” And I’ll say, “You’re absolutely right. If the patient is 2 years out, they’re unlikely to have high-risk disease.” This is one of those inaccuracies of our classifying systems. If you follow just the natural history of the disease, the patient is behaving like a low-risk disease patient, by all means institute chelation. So, for me, there is no hard and fast rule that if this patient has been classified as high-risk, no matter how many transfusions they get and how high the ferritin, I’m not going to intervene because somebody at National Comprehensive Cancer Network (NCCN) Guidelines decided that this is the guideline and they shouldn’t do it. No. Those guidelines are very helpful, but they can’t be strictly applied to every individual patient because they’re just not real for an individual. And this is what I want to emphasize. Please do not try and limit your iron chelation therapy to only lower-risk patients.

James M. Foran, MD, FRCPC: You’re absolutely right. For deferasirox, there was a notation on the label that it is “not indicated for higher-risk MDS.” But that’s not the same as saying it’s contraindicated, and I think you have to make a decision for the person and how their disease course is behaving to see if that’s a valuable thing for them.

Azra Raza, MD: You know there is a recent book out by Dr. Vince DeVita—who was the director of the NCI for many, many years—called The Death of Cancer, in which he recounts one thing. He says as a Fellow in training, there was a patient who had brain metastasis, and his teacher was Dr. Freireich, who’s now at MD Anderson. And Dr. Freireich told him to give this medication; inject it into the spine, and give it intrathecally. And he said, “But on the bottle, it says do not inject intrathecally. Do you really want me to give it?” And Dr. Freireich stood there saying, “I order you to do it. Do it now.” And he did it and that saved the patient’s life.

In other words, there is some leeway, some kind of freedom to be able to use your own clinical judgment that at this point in time for this individual patient, I’m pushed into such a corner that the best way I can serve the patient is go against the grain and give him this drug. So, at one point, we had that freedom to use our clinical judgment. In today’s day and age, these kinds of lines drawn on the sand or etched in stone are beaten upon our cerebrum with such force that if you really do something even slightly different using your medical and clinical judgment, then you should be put in jail. That is not true. That’s not the practice of real medicine.

James M. Foran, MD, FRCPC: I do not think anybody will be incarcerated for chelation, not if it’s done appropriately, I hope. You’re bringing back to a point you started with, and it’s one with which I agree and I’m sure Dr. Steensma will agree also, that this is a disease where we have to treat the person. It’s a disease where there’s a person in front of you, and you have to do the right thing for that person.

Azra Raza, MD: And that person is in front of you for many years. You have observed the patient for 10 years sometimes. I mean, I’m friends with patients who have had children and grandchildren during the course of how long I have taken care of them. So, they become like family members. You know how their body is responding much better than some guideline is going to tell you.

Transcript Edited for Clarity
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