Supportive care

In elderly patients who have low-risk or intermediate-1-risk CMML at the time of diagnosis, as assessed with the MD Anderson Prognostic Score (MDAPS),4 the median survival times from presentation are 24 and 18 months, respectively.4 For such patients, supportive care similar to that given for patients with low-risk MDS and participation in clinical trials using low-toxicity agents are recommended. Severe anemia (hemoglobin concentration <10 g/dL) or transfusion-dependent anemia may be treated with weekly doses of erythropoietin of 40,000-60,000 units for a trial period of 6-8 weeks, with pretreatment assessment of endogenous erythro-poietin levels and monitoring of treatment by weekly evaluation of reticulocyte count and hemoglobin concentration. Unlike in MDS,9 the benefit of such treatment in CMML is not well documented. Growth factors such as granulocyte-colony-stimulating factor and granulo-cyte-macrophage colony-stimulating factor should be used cautiously because of their propensity to induce an unwanted monocytic response. Their use should be limited to febrile patients, particularly those with documented infection and severe neutropenia, not responding to antibiotics. To avoid allosensitization, platelet transfusions should be administered on the basis of symptoms of clinically significant hemorrhage rather than on platelet counts; an exception to this rule is the use of prophylactic transfusions in patients enrolled in clinical trials. Routine use of prophylactic platelet transfusions is not recommended. Whether associated with leukocytosis or not, severe thrombocy-topenia usually signals advanced disease and indicates a need for reassessment of the patient's risk status and change in therapeutic strategy.

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