Table 2.

Treatment options for older adults with MDS based on disease and patient characteristics

Disease Characteristics (Revised IPSS)	Goal of therapy	Patient Characteristics	Treatment Considerations (Comments)
Very low risk, low risk Asymptomatic	Improve QOL	Any	Observation (Evidence is lacking to support QOL or survival advantage with early therapy)
Very Low/low/intermediate Symptomatic
5q deletion	Improve QOL	Any	Lenalidomide (Understudied in “vulnerable/frail” patients. Dose adjust for impaired creatinine clearance.)
Absence of 5q- with erythropoeitin level <500	Improve QOL	Any	Erythropoeitin+/− GCSF (Discontinue if no response in 8 weeks)
			Consider Lenalidomide (Especially if isolated anemia)
	Improve QOL	Good performance status/minimal comorbidity	Consider hypomethylating agents (Observational data suggests benefit in lower risk MDS)
Intermediate/high/very high	Delay progression Extend life	Any age, good performance status, absence of major comorbidity	Hypomethylating agents (Strongest evidence supports use of 7-day azacitidine regimen)
	Cure	Age 60-75, excellent performance status, absence of major comorbidity	Consider referral for RIC HSCT versus hypomethylating agents. (Comprehensive geriatric assessment may help inform “fitness”, randomized data to support benefits of HCST are lacking)
	Delay progression, Extend life	Poor performance status and/or major comorbidity	Consider hypomethylating agents versus supportive care (Absence of data in frail patients, however given potential to improve survival and QOL would discuss with patient)

Abbreviations: QOL=quality of life; RCT= randomized controlled trial; GCSF=granulocyte colony stimulating factor; HSCT=hematopoietic stem cell transplantation; AML=acute myeloid leukemia; RIC=reduced intensity conditioning

Adapted from Klepin et al. J Clin Oncol 2014 2014 Aug 20;32(24):2541-52.