MDS treatment algorithm. Not all patients with MDS require therapy; some can be safely observed with intermittent blood count monitoring for a period of time. Once therapy is justified by the presence of symptoms, severe cytopenias, or increasing blast proportion, prognostic risk assessment can aid in selection of lower-intensity therapies vs disease-modifying treatments, including allogeneic stem cell transplantation, which is the only potentially curative approach. Clinical trial enrollment is encouraged at all phases of disease. The level of evidence supporting the recommendations in this algorithm varies, with some approaches supported by a randomized prospective trial (eg, azacitidine in higher-risk MDS, lenalidomide in del5q MDS) and others supported only by phase 2 data (eg, iron chelation) or case series (eg, androgens). G-CSF, granulocyte colony stimulating factor; sEPO, serum EPO level; TSA, thrombopoietin receptor agonist (thrombopoiesis stimulating agent). Modified from Steensma and Stone.¹²⁹