Therapies for myelodysplastic syndromes (MDS) often achieve hematological responses but their impact on overall survival has generally not been evaluated. The Duesseldorf MDS Registry allowed us to perform matched-pair analyses to assess a possible survival benefit of treatment with thalidomide, valproic acid, low-dose Ara-C, antithymocyte globulin (ATG), induction chemotherapy, or allogeneic stem cell transplantation (allo-SCT). For all treatment modalities, lengthening of survival was restricted to certain subgroups of patients. With the exception of allo-SCT, MDS treatment was generally palliative. Recently, epigenetic treatment with demethylating agents proved to be the first therapy that can significantly prolong survival in patients with higher-risk MDS.