Dr. Rami Komrokji on Trends in Real-World MDS Care

On “The HemOnc Pulse,” Chadi Nabhan, MD, MBA, FACP, spoke with Rami Komrokji, MD, Vice Chair of the Malignant Hematology Department at Moffitt Cancer Center in Tampa, Florida, about the state of myelodysplastic syndromes (MDS) care. Moffitt Cancer Center is home to a large MDS database, with clinical information on nearly 6,000 patients, a trove of real-world MDS data.

Drs. Nabhan and Komrokji first discussed MDS disease classification and risk stratification systems. Recent updates to the International Consensus Classification and World Health Organization classification systems show a trend of incorporating more molecular data and accounting for the heterogeneity of disease. Incorporating such data, considered among several factors, has helped Dr. Komrokji risk stratify his patients.

“Using the Molecular International Prognostic Scoring System, getting an idea of patient comorbidities, obviously patient goals, the dynamics of the disease, will give you a rough idea that, in the end, you’re going to put the patients in either that lower-risk group or higher-risk group and tailor your therapy accordingly,” Dr. Komrokji said.

He noted that in his practice, they observe rather than treat certain patients, regardless of risk group. As the ultimate aim in higher-risk patients is bone marrow transplantation, whether transplant will be performed also influences Dr. Komrokji’s therapy choices, such as the use of venetoclax and a hypomethylating agent (HMA).

“If patients are going to transplant, we aim for a regimen that’s almost like an induction bridge to transplant. If patients are not going to transplant, we’re looking at something that’s long term and thinking more about the sequence of therapies. For example, if HMAs stop working, what would be our next step,” Dr. Komrokji said.

Regarding oral decitabine and cedazuridine, he noted that patients and clinicians welcome an oral option for MDS care. However, more and clearer data are needed on its use in certain populations. Patients must also be monitored for myelosuppression and toxicities, as well as for an initial worsening of blood counts that occurs before therapy takes effect.

“You close your eyes, deliver two or three rounds, and assess, because those treatments don’t kick in immediately,” Dr. Komrokji said.

He is excited by new phase III data, such as the VERONA study, in which HMAs have been combined with other agents as MDS care, and also looks forward to news regarding targeted therapies and the generalizability of luspatercept for lower-risk disease.