Would you define supportive care and active treatment, and what the differences are between them?
How are decisions made about using these two different approaches?
Patients should not think of supportive care and active treatment as completely independent approaches that never happen concurrently – often, they are used at the same time. Several of the drugs used in MDS treatment are ones that will initially make blood counts decrease before they start to increase. So while patients are receiving active treatment, we also support them with transfusions to counteract this initial effect of treatment. This is an example of why supportive care and active treatment might be used concurrently. So you can say that supportive care helps the symptoms of the disease, and active treatment is used to treat the disease itself.
What are some of the treatments that categorize within each?
There are also hypomethylating agents, which are the two FDA-approved drugs azacitidine (Vidaza®) anddecitabine (Dacogen®). These are the primary treatment for the majority of MDS patients who require active treatment. Another FDA-approved agent in this group that also improves blood counts is lenalidomide (Revlimid®), but it has a different mechanism of action from hypomethylating agents and is categorized as an immunomodulatory agent. Lenalidomide has been shown to be best suited for a subset of MDS patients whose disease is associated with the chromosomal abnormality known as ‘deletion 5q’.
The other active treatment for MDS, one that is potentially curative, is an allogeneic stem cell transplant, but not all patients are suited for or otherwise eligible for this treatment.
What factors infl uence a decision to move from supportive care to active treatment and does active treatment ever go back to supportive care?
It certainly can go both ways. Patients who are started on supportive care alone are generally those whose treatment team assesses their overall characteristics and determine that the patient may not tolerate active treatment therapy very well. This often can be due to co-morbid conditions that would make active treatment for MDS unsafe.
By the time an MDS patient needs regular and frequent blood transfusions, the disease is declaring itself that active treatment is needed. In MDS patients considered to have lower-risk disease by contemporary prognostic scoring systems, growth factors are often tried initially. If these do not generate satisfactory results, then we would next consider a hypomethylating agent. If the counts improve, we keep these therapies going, with transfusion support as required especially in the initial phase of treatment.
Are supportive care techniques considered to be therapies?
How are supportive care and active treatment aligned with MDS subtypes and the several prognostic scoring systems that are used?
What is most important for patients to remember about supportive and active treatment for MDS?
- acute myeloid leukemia (AML)
- myelodysplastic syndromes (MDS)
- myeloproliferative neoplasms (MPN)
Dr. Odenike is Professor of Medicine and Director of the Leukemia Program at the University of Chicago. Her clinical interests are in acute and chronic leukemias, myeloproliferative neoplasms, myelodysplastic syndromes, and stem cell transplantation. Her research is focused on the development of novel therapeutic agents for the treatment of acute and chronic leukemias, and chronic myeloproliferative diseases, with the ultimate goal of improving treatment options for patients with these diseases. She is the principal investigator on a number of clinical trials investigating molecularly targeted agents in this patient population.
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