Research Suggests Diagnostic Evaluation May Be of Little Value to Older Patients With MDS

Demographic and clinical disparities exist in the accurate diagnosis of older patients with myelodysplastic syndromes (MDS), according to new research published in The Oncologist.

Investigators also found receipt of diagnostic evaluation (DE) influenced subsequent treatment in these patients, but not survival, suggesting the process may be considered low-value care.

“Older patients with MDS, particularly those with no or 1 cytopenia and no transfusion dependence, typically have an indolent course. Approximately half of these receive the recommended DE for MDS,” authors explained.

Low-value care is typically defined as a service that provides little or no clinical benefit to patients and can be linked with additional unnecessary testing or treatment.Although literature has been published on low-value care in solid tumors, limited data exist evaluating low-value care in patients with hematological malignancies, the authors said.

Furthermore, low-value care is especially prevalent across the entire spectrum of health care among older patients, encompassing diagnostic testing, procedures, imaging, cancer screening, and medication use, they added.

To better understand factors determining DE in these patients and its impact on treatment and outcomes, the researchers assessed Medicare data collected from 2011 to 2014. All included individuals were at least 66 years old and had an MDS diagnosis.

They also examined factors like demographics, comorbidities, nursing home status, and investigative procedures performed. A total of 16,851 patients were included in the analysis, and 51% underwent DE.

Analyses revealed these findings:

• Patients with MDS with no cytopenia (n = 3908) had the lowest uptake of DE (34.7%)
• Compared with patients with no cytopenia, those with any cytopenia had nearly 3 times higher odds of receiving DE (adjusted odds ratio [AOR], 2.81; 95% CI, 2.60-3.04); odds were higher for men than for women (AOR, 1.39; 95%CI, 1.30-1.48) and for non-Hispanic Whites vs everyone else (AOR, 1.17; 95% CI, 1.06-1.29)
• The Classification and Regression Tree showed DE as the principal discriminating node, followed by the presence of any cytopenia for receiving MDS treatment
• The lowest percentage of treatment was observed in patients without DE (14.6%)

“In the absence of any clinical benefit beyond establishing diagnosis, DE for all patients presenting with no or 1 cytopenia and no transfusion dependence who are presumed to have MDS may be deemed as low-value care and can be safely deferred in most of these patients,” the authors wrote.

Nearly 90% of MDS cases in the United States are diagnosed in individuals over the age of 60. The highest incidence is found in those aged 80 or older. However, most patients with MDS are in lower-risk categories based on the International Prognostic Scoring System. For these individuals, treatment options can include active surveillance or supportive care like transfusions.

Overall, the researchers observed no clear patterns in clinical decision-making regarding DE in older patients with MDS who had no or 1 cytopenia and were transfusion independent at the time of diagnosis.

“In the cohort of patients with no cytopenia and not transfusion dependent (23% of study cohort), a condition where index of suspicion for MDS is typically low, a third received DE for MDS for reasons that remain unclear,” they said.

Results also call into question the justification for subjecting these patients to an invasive bone marrow biopsy—the gold standard of diagnostic tests for MDS—which can be associated with pain and anxiety.

Overall, “our findings suggest adopting a tiered approach of DE for MDS in ­transfusion-independent patients presenting with 1 peripheral cytopenia. A reasonable strategy could be watchful waiting and reserving [bone marrow] biopsy or additional DE procedures in certain circumstances such as patient preference, clonal cytopenia, detection of peripheral circulating blasts, worsening cytopenia or additional cytopenias, and onset of transfusion dependency,” the authors concluded.

Reference

Mukherjee S, Dong W, Schiltz NK, et al. Patterns of diagnostic evaluation and determinants of treatment in older patients with non-transfusion dependent myelodysplastic syndromes. Oncologist. Published online April 29, 2023. doi:10.1093/oncolo/oyad114