Supportive care strategies in myelodysplastic syndromes and acute myeloid leukemia in older adults: a national survey of Canadian hematologists

Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) are severe myeloid disorders associated with significant morbidity and mortality. Because of patient and disease factors, many older adults are treated as outpatients with less-intensive therapy. Optimal supportive care strategies to minimize bleeding and infectious complications in this patient population have not been systematically evaluated. We conducted a survey of Canadian hematologists to explore current practice in the use of tranexamic acid (TXA) and prophylactic antimicrobials in patients with MDS/AML treated with less-intensive therapy, and to evaluate equipoise for future trials. Survey items were generated through a combination of literature review and discussion with content experts. The survey was disseminated to 304 potential respondents with a response rate of 52%. Prophylactic platelet transfusions were used by 95%, while prophylactic TXA was used by 57%; the most frequent reason for not using TXA was uncertainty about benefit or harm. Use of prophylactic antimicrobials varied by chemotherapy regimen. If antimicrobial prophylaxis was used, the most frequently prescribed antibacterials were fluroquinolones (90%) and trimethoprim/sulfamethoxazole (21%); the most commonly used antifungals were fluconazole (66%) and voriconazole (36%). The most common reason for not using prophylactic antimicrobials was insufficient evidence of benefit. Most respondents agreed that clinical trials are needed to define the use of TXA and prophylactic antimicrobials in this patient population. Among survey respondents, there was variation in the use of supportive care strategies to address bleeding and infection risk in older adults with MDS/AML. The results of this survey will help to inform clinical trials to assess the benefits and risks of these prophylactic strategies.