Highlight from ASCO 2018: Intensive Chemotherapy vs. HMAs in Younger Patients with MDS

Clinical Commentaries published on July 26, 2018
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Naval Daver, MD
Assistant Professor
Department of Leukemia
The University of Texas MD Anderson Cancer Center
Houston, Texas
Highlight from ASCO 2018: Intensive Chemotherapy vs. HMAs in Younger Patients with MDS

My name is Naval Daver. Today, I am going to be talking about data presented at the ASCO 2018 meeting. This was an abstract that look at the outcomes of intensive chemotherapy versus hypomethylating agent-based therapy in patients with MDS who were younger than 60 years of age, and who had greater than or equal to 10% blasts. This abstract is addressing a very important question in the community as to whether patients with 10% blasts or higher, who would be eligible for both intensive chemo as well as hypomethylating agents, would be better served by one form of therapy or the other. For a long time there has been a debate, with certain groups feeling that the hypomethylating agents are a better approach if the patient is truly MDS (even with high blast percentage), and others feeling that intensive chemotherapy similar to what we would do for a younger AML patient would be the best way to go about it. Now we have the data, and there were 107 patients who were looked at. This is a retrospective analysis, so it does have the caveats of a retrospective data set. What they noticed was about 49 patients received the hypomethylating-based therapy, either with azacitidine or decitabine, and about 55 patients received intensive chemotherapy. They specifically looked at patients who got single-agent azacitidine or decitabine versus standard of care intensive chemotherapy, not including patients who had targeted or immune-based approaches because those may have differential outcomes.

Overall, what they noticed was that the response rates were higher with intensive chemotherapy at 80%, versus hypomethylating-based therapy at 60%. They also noticed that the responses occurred quicker – within one cycle as opposed to a median of two cycles – for the intensive chemotherapy versus hypomethylating-based treatment. The duration of response also was significantly improved with intensive chemotherapy as compared to hypomethylating-based therapy, both on univariate and multivariate analysis. The most important factor that was looked at was the median overall survival. They did notice that the overall survival was improved with intensive chemotherapy as compared to patients who got hypomethylating-based therapy, both on univariate and multivariate analysis using other factors such as cytogenetic risk, transplant or no transplant; and in spite of all that, the intensive chemotherapy did seem to show improved median overall survival. The summary from the authors is that intensive chemotherapy in the younger MDS patients who have more than 10% blasts (a very specific group) do benefit from intensive chemotherapy, similar to their AML counterparts, as opposed to hypomethylating agent-based therapy. For the younger patients who have MDS with less than 10% blasts, the jury is still out and we do not know the final endpoint. At this time, hypomethylating agents are still the most frequently used ones and until that data can be analyzed, we do not have any recommendation to change treatment. This is a retrospective analysis but answers quite an important question. Of course, at the end of the day, we have a number of new molecular immune therapies and the authors conclude that we have to look at those both in combination with hypomethylating agents, as well as with chemo, because we may see differential outcomes and differential synergies. Thank you.

Reference

Strati P, Garcia-Manero G, Kadia TM, et al. Intensive chemotherapy (IC) versus hypomethylating agents (HMA) for the treatment of younger patients with myelodysplastic syndrome (MDS) and elevated bone marrow blasts. J Clin Oncol. 2018;36:(suppl; abstr 7064)
https://meetinglibrary.asco.org/record/162492/abstract

Last modified: July 26, 2018