Canadian Study Highlights Care Variability for Older Patients With MDS/AML

A recent survey of Canadian hematologists highlights variations and gaps in supportive care strategies for older adults with myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) receiving less intensive therapy. The study, published in Annals of Hematology, explored current practices in the use of tranexamic acid (TXA) and prophylactic antimicrobials in this patient population, finding the need for evidence-based guidelines in this setting.¹

Older patients with AML or MDS do not always receive the same care recommendations, a study found | image credit: fizkes - stock.adobe.com

The survey, which had a response rate of 52%, included responses from 105 hematologists who actively treat patients with MDS/AML. The respondents practiced primarily in academic or tertiary care settings (92%), which included a wide range of clinical experience, with 43% practicing for more than 15 years.

The study revealed that while 95% of respondents use prophylactic platelet transfusions, only 57% use prophylactic TXA. "The survey results suggest that prophylactic transfusion is relatively common practice, despite the fact that guidelines establishing the role of prophylactic platelet transfusion in this setting do not exist," the authors noted. Among those who use platelet transfusions, 83% commonly employ a transfusion threshold of < 10 × 109/L for afebrile outpatients with MDS/AML. Interestingly, 87% indicated they would transfuse platelets regardless of whether the patient is on active chemotherapy treatment.

"Uncertainty about the benefits or harms" of TXA was cited by 54% of respondents as a barrier to its use, the study noted, followed by concerns regarding venous thromboembolism (VTE) (30%) and the cost of TXA (28%). The majority of hematologists considered gross hematuria (87%) and active VTE (65%) as contraindications to TXA use. Despite these reservations, nearly all respondents (95%) agreed on the need for clinical trials to assess TXA's role in thrombocytopenic outpatients.

Infection is a leading cause of morbidity and mortality in patients with MDS and AML, mainly due to neutropenia and granulocyte dysfunction.² 69% of respondents indicated they would not use prophylactic antimicrobials for patients receiving the best supportive care without active chemotherapy. In contrast, antimicrobial prophylaxis was more likely to be prescribed for patients receiving hypomethylating combination therapy or cytarabine combination therapy.¹

When antimicrobial prophylaxis was used, fluoroquinolones were the most prescribed antibacterials (90%), followed by trimethoprim/sulfamethoxazole (21%). Among antifungals, fluconazole (66%) and voriconazole (36%) were the preferred choices. Barriers to prophylactic antimicrobial use included insufficient evidence (70%), concerns about antimicrobial resistance (60%), and risks such as Clostridioides difficile infections (50%). Most respondents (94%) "agreed that a clinical trial is needed (n = 82), or potentially needed (n = 17), to evaluate optimal antimicrobial prophylaxis in this at-risk patient population," the authors state.

The variation in supportive care strategies among survey respondents highlights the lack of sufficient evidence and formal guidelines to inform clinical decision-making for older patients with MDS and AML undergoing less intensive therapy. The study's authors stressed the importance of these findings, concluding that, "The greatest barrier to the clinical use of prophylactic agents for bleeding and infection is the inadequacy of the existing body of published research."

As the population ages and the incidence of these diseases increases, developing evidence-based guidelines for supportive care becomes increasingly necessary. Although this survey highlights that while there is general consensus on using prophylactic agents, there is still some variation in specific thresholds and criteria used. This suggests a need for more standardized, evidence-based guidelines for supportive care in these patients. 

The authors propose that “The results of this survey will help to inform the design of clinical trials to assess the benefits and risks of these prophylactic strategies.”

References:

1. Blankstein AR, Choi N, Mozessohn L, et al. Supportive care strategies in myelodysplastic syndromes and acute myeloid leukemia in older adults: a national survey of Canadian hematologists. Ann Hematol. Published online November 20, 2024. doi:10.1007/s00277-024-06085-0
2. Hansen BA, Wendelbo Ø, Bruserud Ø, Hemsing AL, Mosevoll KA, Reikvam H. Febrile neutropenia in acute leukemia: epidemiology, etiology, pathophysiology, and treatment. Mediterr J Hematol Infect Dis. 2020;12(1):e2020009. doi:10.4084/MJHID.2020.009