Treating Iron Overload in Patients With Myelodysplastic Syndromes
National Comprehensive Cancer Network (NCCN) guidelines for the management of MDS state that treatment for iron overload should be instituted for "relatively low-risk patients with excessive iron accumulation resulting from the number of red blood cell transfusions received" (1).
Patients most likely to benefit from treatment
Consensus recommendations developed by leading MDS clinicians and researchers describe the patients considered most likely to benefit from monitoring and treatment for iron overload. These include (2):
- Patients with low-risk myelodysplastic syndromes (International Prognostic Scoring System: low- or intermediate-risk; World Health Organization: refractory anemia (RA), refractory anemia with ringed sideroblasts (RARS), and 5q- syndromes)
- Patients with documented stable MDS
- Transfusion-dependent patients
- Patients free of comorbidities that severely limit prognosis
- Candidates for allograft
These recommendations take note of the significant differences in survival expectancies among different MDS patient subtypes as reported by Malcovati and colleagues (3).
Significant differences in survival times among MDS subtypesSignificant differences in survival times among MDS subtypes
Half of all patients with refractory anemia can expect to survive over 9 years after diagnosis (108 months). Adapted with permission from Macovati, et al (3).
When to treat iron overload in MDS
NCCN guidelines recommend beginning treatment for iron overload (1):
- After 20 blood transfusions
and
- When serum ferritin levels are >2500 mcg/L
- When continuation of transfusions is anticipated
The MDS expert consensus statement recommends a more aggressive approach to treatment, beginning at serum ferritin >1000 mcg/L and continuing as long as transfusion therapy is provided. This view was repeated in a recent article by Takatoku and colleagues,(4) who demonstrated improvement in organ function among iron overloaded MDS patients despite mean transfusion burdens of 61.5 RBC units in the previous year.