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Larfors G, Moreno Berggren D, Garelius H, Nilsson L, Rasmussen B, Hellström-Lindberg E, Ejerblad E. MDS-Comorbidity Index using register data has prognostic impact in Swedish MDS patients. Leuk Res 2023; 134:107386. [PMID: 37690322 DOI: 10.1016/j.leukres.2023.107386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/12/2023]
Abstract
Comorbidities influence the mortality in patients with myelodysplastic syndromes, and a growing body of evidence suggest that comorbidity history should be used in addition to established prognostic indices. A comorbidity index specific for MDS, the MDS-CI, was introduced a decade ago. In this study we aim to construct an MDS-CI version based on diagnoses from register data only, to expand its use beyond the clinical setting to retrospective and register based studies. We further test this version on a Swedish population-based MDS cohort of 2947 patients, and compare its prognostic accuracy to that of Charlson Comorbidity Index. Our register based MDS-CI divided patients into three risk groups of similar proportions as have been published for the original MDS-CI. Compared to low risk patients, intermediate and high risk patients had 50 % and 70 % higher mortality, respectively. The prognostic value of MDS-CI was equal to that of Charlson comorbidity index. Adding MDS-CI to the established prognostic factors IPSS-R and age increased the prognostic accuracy. In summary, we demonstrate that MDS-CI can be adequately estimated from diagnoses recorded in registers only, and that it is a useful tool in any future study on myelodysplastic syndromes with a need to adjust for comorbidities.
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Affiliation(s)
- Gunnar Larfors
- Unit of Haematology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
| | - Daniel Moreno Berggren
- Unit of Haematology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Hege Garelius
- Section of Haematology and Coagulation, Department of Specialist Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Nilsson
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Bengt Rasmussen
- Department of Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Eva Hellström-Lindberg
- Centre for Haematology and Regenerative Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabeth Ejerblad
- Unit of Haematology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Rozema J, Graafsma J, Hoogendoorn M, Kibbelaar R, Veeger N, van Roon E. Treatment patterns in older patients with myelodysplastic syndromes: A population-based analysis reflecting the real world. J Geriatr Oncol 2023; 14:101418. [PMID: 36657246 DOI: 10.1016/j.jgo.2022.101418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/27/2022] [Accepted: 12/08/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Treatment for myelodysplastic syndromes (MDS) is complex, options are limited, and insight into consecutive treatments is lacking. We performed this study to assess the outcomes in a real-world cohort of patients with MDS. MATERIALS AND METHODS An observational population-based study was performed using the HemoBase registry. Treatment patterns and overall survival (OS) were analyzed with Kaplan-Meier analyses. RESULTS In 144 of 280 (51.4%) patients with MDS >50 years, first-line treatment was initiated. The median age was 75.1 years (range: 52.6-92.0); the majority were male (72.2%). Hypomethylating agents (HMA), intensive chemotherapy, lenalidomide, and erythropoiesis-stimulating agents (ESA) were given as first-line treatment to 31.1% (n = 45), 12.5% (n = 18), 2.8% (n = 4), and 53.5% (n = 77) of the population, respectively. The median treatment duration was 5.8 months (95% Confidence Interval [CI]: 1.1-10.4) for HMA, 1.7 months (95%CI: 0.9-2.6) for intensive chemotherapy, 10.8 months (95%CI: 4.7-17.0) for lenalidomide, and 14.8 months (95%CI: 11.4-18.1) for ESA. Consecutive treatments were given to 27.2% of patients. The main reasons for first-line treatment discontinuation were treatment failure (45.8%), toxicity (6.9%), or death (20.1%). Median OS after termination of the initial, second, and third treatment was 5.8 months (95%CI: 3.2-8.5), 9.3 months (95%CI: 0.0-19.6), and 1.0 months (95%CI: 0.0-5.1), respectively. DISCUSSION This study shows the treatment outcomes in a real-world population of older patients with MDS. Treatment duration and median OS after treatment discontinuation were relatively limited. There is still an urgent need for new treatment options, strategies to further optimize duration of existing treatments, and communication of realistic treatment goals and expectations, especially for older, higher-risk patients with MDS with a poor prognosis.
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Affiliation(s)
- Johanne Rozema
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Antonius Deusinglaan 1, Groningen, the Netherlands; Department of Clinical Pharmacy & Pharmacology, Medical Centre Leeuwarden, Henri Dunantweg 2, Leeuwarden, the Netherlands.
| | - Jetske Graafsma
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Antonius Deusinglaan 1, Groningen, the Netherlands
| | - Mels Hoogendoorn
- Department of Internal Medicine, Medical Centre Leeuwarden, Henri Dunantweg 2, Leeuwarden, the Netherlands
| | - Robby Kibbelaar
- Pathology Friesland, Jelsumerstraat 6a, Leeuwarden, the Netherlands
| | - Nic Veeger
- MCL Academy, Medical Centre Leeuwarden, Henri Dunantweg 2, Leeuwarden, the Netherlands; Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, Groningen, the Netherlands
| | - Eric van Roon
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Antonius Deusinglaan 1, Groningen, the Netherlands; Department of Clinical Pharmacy & Pharmacology, Medical Centre Leeuwarden, Henri Dunantweg 2, Leeuwarden, the Netherlands
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Owens TJ, Patel SA, Greiner TC, Cannatella JJ, Grant WJ, Langnas AN, Vo HD. High-grade myelodysplastic syndrome in a pediatric multi-organ transplant recipient: A case report and literature review. Pediatr Transplant 2022; 26:e14287. [PMID: 35403329 DOI: 10.1111/petr.14287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/27/2021] [Accepted: 03/31/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pediatric myelodysplastic syndrome is a rare but life-threatening condition requiring prompt recognition and management. METHODS We herein present the only reported case of a pediatric multi-organ transplant recipient developing myelodysplastic syndrome. RESULTS The patient was a 14-year-old girl on chronic calcineurin inhibitor therapy who presented with peri-rectal pain approximately 13 years after liver, small bowel, and pancreas transplant. The initial workup revealed pancytopenia and parvovirus B19 viremia. Her definitive diagnosis was complicated by a lack of adequate bone marrow biopsy specimens and expert consultation that resulted in treatment for hemophagocytic lymphohistiocytosis. She was later diagnosed with high-grade myelodysplastic syndrome. Although curative treatment with chemotherapy and hematopoietic stem cell transplantation was strongly considered, it was not performed due to the child's rapid clinical progression, ventilator status, and active infections. The patient died approximately 6 months following symptom onset. CONCLUSIONS This case emphasizes the importance of early recognition of myelodysplastic syndrome in multi-organ transplant recipients on chronic immunosuppression. Pancytopenia is a common presentation in the post-transplant period that requires thorough investigation. Multiple confounding considerations such as infection, immunosuppression, and systemic inflammation can delay the diagnosis of underlying hematological malignancies. Transplant care providers should be aware of myelodysplastic syndrome and advocate for a comprehensive evaluation, given early recognition and intervention can significantly improve outcomes.
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Affiliation(s)
- Trudie J Owens
- Department of Surgery, Transplantation Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sachit A Patel
- Department of Pediatrics, Division of Blood and Marrow Transplantation, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Timothy C Greiner
- Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jeffrey J Cannatella
- Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Wendy J Grant
- Department of Surgery, Transplantation Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Alan N Langnas
- Department of Surgery, Transplantation Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Hanh D Vo
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Rozema J, Hoogendoorn M, Potma I, ten Seldam I, Veeger NJGM, Kibbelaar RE, van de Loosdrecht AA, van Roon EN. Increased prescription rate of anti-infective agents after diagnosis of myelodysplastic syndromes. EJHAEM 2022; 3:775-784. [PMID: 36051088 PMCID: PMC9422012 DOI: 10.1002/jha2.422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 12/21/2022]
Abstract
The a priori risk for infections in patients with myelodysplastic syndromes (MDS) is unknown. This study examines prescription rates of anti-infective agents in MDS patients before and after diagnosis, in both in- and outpatient settings, to provide information on infection management in clinical practice. We performed a population-based study using the HemoBase registry, containing data of all MDS patients diagnosed since 2005 in Friesland, the Netherlands. Community and hospital pharmacies provided prescription data from 1995 to 2020. Data were obtained for 203 of 292 patients (70%). Patients received significantly more anti-infective agents, predominantly antibacterials (70%), after diagnosis compared to before: 148.7 defined daily dose/1000 days (DID) (95% CI: 146.9-150.5) and 55.1 DID (95% CI: 54.5-55.8, p < 0.01), respectively, corresponding to median 23.5 and 7.6 treatment days/year. Higher-risk (449.9 DID) and lower-risk patients (129.1 DID) both received significantly more anti-infective agents after diagnosis; comorbidities, neutropenia, and age did not show significant differences relative to prescription rates. Before diagnosis, 10% of patients had infection-related hospital admissions versus 38% after diagnosis. In conclusion, MDS patients received significantly more anti-infective agents compared to before diagnosis. This is the first study that has quantified the prescription rate of anti-infective agents within and beyond the clinical setting in MDS.
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Affiliation(s)
- Johanne Rozema
- Unit of PharmacotherapyEpidemiology and EconomicsDepartment of PharmacyUniversity of GroningenGroningenThe Netherlands
- Department of Clinical Pharmacy and PharmacologyMedical Centre LeeuwardenLeeuwardenThe Netherlands
| | - Mels Hoogendoorn
- Department of Internal MedicineMedical Centre LeeuwardenLeeuwardenThe Netherlands
| | - Iris Potma
- Unit of PharmacotherapyEpidemiology and EconomicsDepartment of PharmacyUniversity of GroningenGroningenThe Netherlands
| | - Inge ten Seldam
- Unit of PharmacotherapyEpidemiology and EconomicsDepartment of PharmacyUniversity of GroningenGroningenThe Netherlands
| | - Nic J. G. M. Veeger
- Science BureauMedical Centre LeeuwardenLeeuwardenThe Netherlands
- Department of EpidemiologyUniversity of GroningenUniversity Medical Centre GroningenGroningenThe Netherlands
| | | | | | - Eric N. van Roon
- Unit of PharmacotherapyEpidemiology and EconomicsDepartment of PharmacyUniversity of GroningenGroningenThe Netherlands
- Department of Clinical Pharmacy and PharmacologyMedical Centre LeeuwardenLeeuwardenThe Netherlands
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Comorbidities and malignancies negatively affect survival in myelodysplastic syndromes: a population-based study. Blood Adv 2021; 5:1344-1351. [PMID: 33656535 DOI: 10.1182/bloodadvances.2020003381] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/02/2021] [Indexed: 11/20/2022] Open
Abstract
Population-based studies that contain detailed clinical data on patients with myelodysplastic syndrome (MDS) are scarce. This study focused on the real-world overall survival (OS) of MDS patients in association with comorbidities, specifically malignancies. An observational population-based study using the HemoBase registry was performed, including all patients with MDS diagnosed between 2005 and 2017 in Friesland, a Dutch province. Detailed information about diagnosis, patient characteristics, previous treatment of malignancies, and comorbidities according to the Charlson Comorbidity Index (CCI) was collected from electronic health records. Patients were followed up until June 2019. Kaplan-Meier plots and Cox regression analyses were used to study survival differences. In the 291 patients diagnosed with MDS, the median OS was 25.3 months (95% confidence interval [CI], 20.3-30.2). OS was significantly better for patients with CCI score <4, age <65 years, female sex, and low-risk MDS. Fifty-seven patients (20%) had encountered a prior malignancy (excluding nonmelanoma skin cancer), and a majority (38 patients; 67%) were therapy related. Both therapy-related and secondary MDSs were associated with worse OS (hazard ratio, 1.51; 95% CI, 1.02-2.23 and 1.58; 95% CI, 0.95-2.65, respectively), as compared with de novo MDS patients (P = .04). Patients in remission at time of MDS diagnosis had a similar median OS compared with patients with de novo MDS (25.5 vs 28.3 months). This population-based study involving all newly diagnosed MDS patients over a 13-year period in Friesland showed that multiple comorbidities, including previous malignancies, are associated with shorter OS. OS was not related to the use of radiotherapy or chemotherapy.
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Larfors G, Moreno Berggren D, Garelius H, Jädersten M, Nilsson L, Rasmussen B, Ejerblad E. Income, education and their impact on treatments and survival in patients with myelodysplastic syndromes. Eur J Haematol 2021; 107:219-228. [PMID: 34028869 DOI: 10.1111/ejh.13641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To assess whether socioeconomic indices such as income and educational level can explain part of the variation in survival among patients with myelodysplastic syndromes, and further to assess whether these factors influence care and treatment decisions. METHODS Population-based cohort study on 2945 Swedish patients diagnosed between 2009 and 2018 and included in the Swedish MDS Register. Relative mortality was assessed by Cox regression, whereas treatment differences were assessed by Poisson regression. Regarding mortality, patients were also compared to a matched comparison group from the general population. RESULTS Mortality was 50% higher among patients in the lowest income category compared to the highest and 40% higher in patients with mandatory school education only compared to those with college or university education. Treatment with hypomethylating agents and allogeneic stem cell transplantation, as well as investigation with cytogenetic diagnostics were also linked to income and education. The findings were not explained by differences in risk class or comorbidity at the time of diagnosis. CONCLUSIONS Income and education are linked to survival among patients with myelodysplastic syndromes. Socioeconomic status also seems to influence treatment intensity as patients with less income and education to a lesser degree receive hypomethylating agents and transplants.
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Affiliation(s)
- Gunnar Larfors
- Unit of Haematology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel Moreno Berggren
- Unit of Haematology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Hege Garelius
- Section of Haematology and Coagulation, Department of Specialist Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin Jädersten
- Department of Medicine Huddinge, Centre for Haematology and Regenerative Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Nilsson
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Bengt Rasmussen
- School of Medical Sciences, Örebro University Hospital, Örebro, Sweden
| | - Elisabeth Ejerblad
- Unit of Haematology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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