A roundtable discussion on anemia management in myelodysplastic syndromes. Featuring moderator Guillermo Garcia-Manero, MD, of the University of Texas MD Anderson Cancer Center; Amy DeZern, MD, MHS, Johns Hopkins Medicine; Tiffany Tanaka, MD, of the University of California San Diego; and Uma Borate, MBBS, of Ohio State University.
The following is an unedited transcript:
What is the journey of someone receiving blood transfusions?
I think there’s a lot of pieces of that journey, because I may take us back even one step earlier where we have to make the diagnosis. And when a patient presents with anemia, certainly if they’re red cell transfusion dependent at that point, as Uma emphasized, we need to make the diagnosis and classify and prognosticate for them. And that goes into clinical factors, what we see under the microscope and the bone marrow.
Then certainly next generation sequencing and karyotype for the genetics that explain the biology. And for that individual who unfortunately may be red cell dependent, I think they’re tired, they’re often short of breath. And we want to choose the therapy that we think can ameliorate that anemia efficiently and raise the hemoglobin in a clinically meaningful way as efficiently as possible.
And we take all those prognostic factors and then clinical factors that we’ve received from their blood tests and their bone marrow to make that calculus.
So if I can summarize where we are. So Amy, you were telling us first we need to diagnose classify. We have really no powerful molecular tools to do that. Then we define what lower risk disease is. And then you were talking about this issue of transfusion dependency versus independency. That’s actually quite interesting. I may get back to you in a minute about this.
And then, Uma was already talking about ESAs versus luspatercept. So we’re going to start focusing first thing in first line. So let me ask you a direct question. And there’s no right or wrong answer. So there is a little bit of discrepancy or I don’t know, controversy maybe is the proper word in terms of what do we use in Ring Sideroblastic negative patients?
I think you mentioned Uma in the RS-positive. Very clear luspatercept is really active compound with great long lasting responses. But what do we do for RS-negative patients? Amy…you want to…
So I think if you look at the commands study and you and others have, you know, presented in various congresses, obviously I think the COMMAND study shows that in every sphere, including RS negative luspatercept seems to be doing better than ESAs. I think the question is, how much better? And do we feel compelled that that difference is enough to use luspatercept in front line?
If you think it might be effective in second line? Also, I think we can talk about financial considerations and other things which do come up in different therapies. ESAs are relatively more inexpensive than a drug like luspatercept. So I, I’ll be honest, I haven’t really made up my mind. I still probably favor using ESAs in that scenario, but I, I think if the data evolves, my position can evolve at the same time.
Tiffany, what do you think?
Yeah, no, I agree, it’s, an unknown, in the command study there is that small bit of superiority with luspatercept over ESAs. But the question is just how much? And it’s such a small patient population, so I definitely want to know more. I don’t I haven’t had issues with reimbursement and patient coverage, so I will be willing to give luspatercept.
But I am also curious within the imetelstat, too, how does that fit in? And in reality, I just don’t have experience with imetelstat.
