Long-term blood product transfusion support for patients with myelodysplastic syndromes (MDS): cost analysis and complications
Introduction
Myelodysplastic syndromes (MDS) are one of the most frequently occurring bone marrow neoplastic disorders in adults, with an annual incidence of 10 000–20 000 new cases in the US [1]. With the increasing proportion of elderly individuals in the population, the prevalence of MDS will likely rise further in the future [2].
These chronic disorders are characterized by persistent cytopenias and an increased risk of transformation to acute myeloid leukemia (AML) [3]. Allogeneic bone marrow transplantation is the only known curative therapy for MDS [4], but is not feasible for the majority of patients diagnosed with MDS who are elderly and frequently afflicted with other medical conditions. In these patients, death occurs more often from the complications of chronic cytopenias than from transformation to AML [5], [6], [7]. The presence of cytopenias also contributes significantly to an impaired quality of life [8]. The mainstay of therapy often remains supportive, and many patients become dependent on long-term blood transfusions. As compared to younger patients, transfusion requirements may be greater in these elderly patients who have co-existing cardiorespiratory diseases or vascular insufficiency, in order to maintain an adequate hematocrit for tissue oxygenation. Despite the common use of long-term transfusion support for patients with MDS, its costs and complications have not been determined.
Long-term growth factor therapy with erythropoietin (EPO) alone or with granulocyte colony-stimulating factor (G-CSF) has recently been shown to improve anemia and reduce transfusion requirements in patients with MDS [9], [10], [11], [12], [13]. However, this therapy is expensive, and benefits only a proportion of patients with MDS. Novel treatment approaches may ameliorate cytopenias in some patients [14]. Intensive chemotherapy or allogeneic transplantation incurs high short-term costs and morbidity, but has the potential for reducing transfusion support in patients who achieve long-term freedom from disease [4], [15], [16], [17], [18], [19].
Treatment decision analyses for MDS must include a comparison of the costs and potential complications of supportive care (transfusion support) with therapeutic options such as growth factor therapy or transplantation. To assess the costs and complications of long-term transfusion support for MDS, we analyzed the blood product transfusion data on 50 MDS patients diagnosed, followed and transfused at the Minneapolis VA Medical Center (MVAMC).
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Patients
Fifty consecutive patients diagnosed with MDS at the MVAMC from 1992 to 1997 were identified retrospectively. Medical records and blood bank records were reviewed for clinical information including demographic data, therapy, transfusions requirements, complications of transfusions, and outcome of patients. The demographic characteristics of the patients and clinical features at presentation are summarized in Table 1. All patients were males, reflecting the patient population at the MVAMC. The
Transfusion requirements
Forty-one of 50 patients (82%) required blood product transfusions in the MDS phase of their disease, whereas 5/5 patients (100%) required transfusions after transformation to AML. In these 50 patients, the median number of units transfused per patient during the MDS phase was eight units pRBC (range, 0–186 units), eight units RDP (range, 0–344 units) and zero collections SDP (range, 0–47 collections). In the AML phase (n=5), median transfusion requirements per patient were 24 units (range,
Discussion
Long-term transfusion support for patients with MDS is costly, frequently requires specially processed blood products, and is complicated by a high incidence of reactions to the transfused blood products. This study provides data on transfusion support in a cohort of elderly patients with MDS who primarily received supportive care. Consistent with the marked range in the degree of anemia and thrombocytopenia that occurs in MDS, the transfusion requirements of individual patients in this study
Acknowledgements
Research grant supported by the United States Department of Veterans Affairs. P Gupta provided the concept, design, contribution to the analysis and interpretation of the data, helped to draft the paper, gave critical revision and final approval to the article and provided administrative and final support. S. LeRoy contributed to the analysis and data interpretation with statistical expertise, assisted with the assembly of the data and provided logistical support. S. Luikart provided technical
References (31)
- et al.
Infection in the myelodysplastic syndromes
Am. J. Med.
(1991) - et al.
Treatment of anemia in myelodysplastic syndromes with granulocyte colony-stimulating factor plus erythropoietin: results from a randomized phase II study and long-term follow-up of 71 patients
Blood
(1998) - et al.
Maintenance treatment of the anemia of myelodysplastic syndromes with recombinant human granulocyte colony-stimulating factor and erythropoietin: evidence for in vivo synergy
Blood
(1996) - et al.
Clinical application of recombinant erythropoietin in myelodysplasia
Hematol. Oncol. Clin. North. Am.
(1994) - et al.
Stimulation of hematopoiesis by amifostine in patients with myelodysplastic syndrome
Blood
(1997) - et al.
Effect of diagnosis (refractory anemia with excess blasts, refractory anemia with excess blasts in transformation, or acute myeloid leukemia [AML]) on outcome of AML-type chemotherapy
Blood
(1997) - et al.
TT virus in bone marrow transplant recipients
Blood
(1999) Meeting highlights: therapeutic strategies and supportive care in myelodysplastic syndromes: yesterday, today and tomorrow
Leuk. Res.
(1998)- et al.
Incidence of myelodysplastic syndrome is increasing. Careful diagnosis is necessary for choice of the treatment
Lakartidningen
(1994) - et al.
The French-American-British Co-operative Group: proposals for the classification of the myelodysplastic syndromes
Br. J. Haematol.
(1982)
Bone marrow transplantation for myelodysplasia in adults and children: when and who?
Leukemia. Res.
Chronic myelodysplastic syndromes: short survival with or without evolution to acute leukaemia
Br. J. Haematol.
Myelodysplastic syndromes: a scoring system with prognostic significance
Br. J. Haematol.
Quality of life and psychosocial adjustment in patients with myelodysplastic syndromes
Leuk. Res.
Efficacy of erythropoietin in the myelodysplastic syndromes: a meta-analysis of 205 patients from 17 studies
Br. J. Haematol.
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2012, Leukemia ResearchCitation Excerpt :Myelodysplastic syndromes (MDS) are a heterogeneous group of bone marrow disorders [1] with a higher incidence in the elderly [1–3]. Chronic anemia is one of the main clinical features of MDS [1,4] and can greatly compromise patients’ quality of life (QoL) [5,6]. Although erytropoietic stimulating agents (ESAs) and novel agents may provide some clinical benefits and prolonged transfusion independence in many patients [1,7–9], regular administration of red blood cells (RBCs) concentrates continues to represent the only effective measure for most of the patients [7–9].
The clinical, quality of life, and economic consequences of chronic anemia and transfusion support in patients with myelodysplastic syndromes
2012, Leukemia ResearchCitation Excerpt :RBC transfusion dependence has been shown to have a negative impact on clinical aspects, QoL, and economic burden in MDS patients. Long-term RBC transfusion need in MDS is associated with an increased probability of severe general transfusion-related complications, including infections, febrile or allergic transfusion reactions, skin rashes, and the development of alloantibodies to RBCs [18–21]. These data question the role of leukocyte-depleted RBCs in MDS patients, which could possibly reduce the potential for deleterious side effects.