CE lesson worth 1.0 contact hours that are intended for advanced practice nurses, registered nurses, and other healthcare professionals who care for cancer patients.
The overall goal is to update the healthcare professional’s knowledge of cancer detection and prevention and to understand current and new research regarding state-of-the-art care for those with or at risk for cancer.
Intended for advanced practice nurses, registered nurses, and other healthcare professionals who care for cancer patients.
Upon completion, participants should be able to:
Dannemiller is approved by the California Board of Registered Nursing, Provider Number 4229, for 1.0 contact hour. CBRN credit is not accepted by the Michigan and Utah State licensing boards.
The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.
This activity is provided free of charge to participants.
Lauren M. Green
Complementary and alternative (CAM) therapieslike yoga and acupuncture are becoming more popular among cancer patients and survivors to help ease symptoms like pain,fatigue, and distress, but what drives—and deters—the use of these integrative therapies is not well understood.
To help answer this question, researchers at the University of Pennsylvania’s Abramson Cancer Center (ACC) surveyed nearly 1000 patients receiving treatment at the cancer center and found that patients’ expectation of therapeutic benefits from CAM, the opinions of their physician and family members, as well as perceived barriers to obtaining the services, were more likely to affect patients’use of CAM than their clinical and demographic characteristics.
“By aligning with patients’ expectations, removing unnecessary barriers, such as cost and access, and engaging patients’ social and support networks, we can develop patient-centered clinical programs that better serve diverse groups of cancer patients regardless of sex, race, and educationlevels,” noted first author Joshua M. Baumi, MD, an assistant professor in the division of Hematology/Oncology at the Perelman School of Medicine.
Researchers used a Penn-developed survey instrument, the Theory of Planned Behavior, to measure attitudes and beliefs about CAM (ABCAM) among 969 patients receiving care in the thoracic,breast, and GI medical oncology clinics at ACC between June 2010 and September 2011. Demographic and clinical characteristics were captured through self-report and chart abstraction.
They found that patients who were 65 years of age or younger, women, and those who had a college education tended to expect greater benefits from CAM. Nonwhite patients reported more perceived barriers to the use of CAM compared with their white counterparts, but their expectations concerning CAM’s benefits were similar.
The researchers reported that all domains of the ABCAM were significantly associated with CAM use (P <.01), across all patient groups, and these attitudes and beliefs explained more variance in use of integrative approaches than demographic and clinical variables on their own.
With more than 60% of cancer patients using CAM, the researchers hope that the findings may help providers to design more patient-centered programs to remove barriers to CAM.
Baumi JM, Chokshi S, Schapira M, et al. Do attitudes and beliefs regarding complementary and alternative medicine impact its use among patients with cancer? A cross-sectional survey [published online ahead of print May 26, 2015]. Cancer.
Kristin Barber, RN, MSN,APRN
Utah Cancer Specialists Salt Lake City, UT
We are very fortunate to be practicing in a time when more people are accepting to CAM therapies. This study does a great job of identifying the demographics of the most common users of CAM therapies. It also discovered the three factors most likely to affect decisions regarding these therapies. It is two of these factors that I believe we can address to improve patient care.
Patients' expectations are already built into their decision making, but our opinions as their providers can weigh heavily in the decision to use additional modalities like meditation and acupuncture. At our center and at most urban centers, we can offer these services in house. Unfortunately, those in rural settings still struggle with access issues.
Another actionable intervention is to reassure patients that their perceived barriers are not an issue when suggesting CAM therapies. Cancer is expensive, and weekly yoga classes, if not covered by insurance or a nonprofit foundation, are too expensive for many patients. Now that we know and can agree on the benefits of adding CAM therapies to our practices, it is our joint responsibility to suggest and increase the access to them that our patients need. According to the study, 60% are using these interventions. Our goals should also be to focus on those less likely to be aware of these services: the elderly, nonwhite patients, and those without a college education.
A recent study joins a body of evidence suggesting that long-term, regular aspirinuse is associated with a reduced risk for cancer, with the most dramatic reduction being seen in colorectal cancer incidence.
“Our research provides critical information regarding the full constellation of potential benefits of aspirin use, at a range of doses, timing,and duration of use, within a large population of individuals,” noted study author Yin Cao, MPH, ScD, a research fellow in the Department of Nutrition at the Harvard School of Public Health.
For the study, data were collected on aspirin use, cancer diagnoses, and other risk factors from 82,600 women participating in the Nurses’Health Study and 47,651 men from the Health Professionals Follow-up Study. After 32 years of follow-up, 27,985 incident cancers were recorded. Study participants who had two or more aspirin tablets per week had a 5% lower risk for cancer, compared with non-regular aspirin users. In gastrointestinal (GI) cancers, the risk was lowered by 20%,including a 25% reduction in colorectal cancers and a 14% reduction in gastroesophageal cancers. No association was foundbetween regular aspirin use and a lower risk forbreast, lung, or advanced prostate cancers.
Significant risk reduction was seen only after 16 years of aspirin use and was no longer evident within 4 years of discontinuing use.
Senior study author Andrew T. Chan, MD, MPH, director of the Gastroenterology TrainingProgram at Massachusetts General Hospital, who presented the study at the American Association for Cancer Research (AACR) 2015 Annual Meeting, said that based on these data, “there is the possibility that aspirin could have a significant clinical benefit for many individuals… the next step is to confirm these findings in additional populations and conduct further studies examining the potential impact of novel biomarkers which can be used to better personalize who should be treated.”
In that vein, Chan also presented research at AACR on molecular risk stratification for aspirin chemoprevention. He is an investigator on a recently published international study which found that the preventive benefit of aspirin and NSAIDS may be linked to variations in an individual’s DNA (JAMA. 2015;313(11):1133-1142).
Analyzing data from 10 large population-based studies, researchers found that although regular use of aspirin and NSAIDs was associated with an overall reduction in the risk of colorectal cancer, no protective effect was seen among about 9% of the participants who had genetic variations on chromosome 15.
Cao cautioned against general aspirin use for cancer prevention, primarily because there are risks with aspirin, such as GI bleeding. A more tailored approach, including using biomarker research Chan mentioned, may be best.
Cao Y, Nishihara R, Wu K, et al. Long-term aspirin use of aspirin and risk of cancer. Presented at: 2015 AACR Annual Meeting; April 18-22; Philadelphia, PA. Abstract 3197.
Laura Metcalfe, MSN, RN, APN-C, AOCNS
John Theurer Cancer Center
For those of us in oncology for any length of time (27 years for me), this idea has been debated as far back as I can remember. Beginning in the1980s and 1990s several case-control studies, followed by prospective cohort studies, consistentlyassociated aspirin use with a lower risk of colorectal cancer (CRC) and adenoma.
Many people are aware of the benefit of aspirin use in the prevention of cardiovascular disease but may not be aware of its benefit in the preventionof colorectal cancer. It actually makes sense when you realize that many of the risk factors for CRC and cardiovascular disease are the same: older age, overweight/obesity, and physical inactivity. Unfortunately, despite these facts, in 2007 the US Preventive Service Task Force recommended against the routine use of aspirin or NSAIDs to prevent CRC in average-risk individuals,maintaining that the harms outweigh the benefit for the prevention of CRC.
Even the investigator in this study concludes with a caution against aspirin use for CRC prevention, citing the risks which include GI bleeding. While Ican understand the concern for the potential risks, as an oncology nurse Isee these risks paling in comparison to the potential benefit. As a point ofinterest, I recently attended a large GI Cancer conference, attended by manywell-known, well-respected physicians in GI oncology as well as other oncology professionals, including nurses, surgeons, and radiation oncologists. A presentation was given on this very topic, and the presenter asked for a show of hands of who in the audience was taking aspirin for CRC prevention. Almostwithout exception every hand went up, including the presenter!
Colorectal cancer is the third leading cause of cancer death in the United States for both men and women. While screening and other strategies (diet, exercise, maintaining a BMI within the normal range) can also reduce CRCrisk, for many reasons these strategies are not always employed. To my mind,something as simple as an aspirin a day as a preventive strategy would likely be more readily embraced by the general population. Unless a patient has ahigher risk for bleeding or ulcers, for example, a baby aspirin a day taken after eating so as not to take on an empty stomach, should not present any great risk for the average person. Of course, the dose—325 versus 81 mg—has not been definitively defined yet, but the “unscientific” show-of-hands poll at the conference confirmed almost 100% of oncology professionals in attendance took at least a baby aspirin daily.
In our practice, we only meet patients after a CRC diagnosis. For years, however, we have recommended either 325 mg or 81 mg aspirin daily for its known reduction in overall mortality and reduction in colorectal cancerrecurrence (CALGB 89803). The dose is determined based on individual risk factors and comorbidities.
As stated in this study, research into this topic will continue, with attempts to define genetic mutations which may or may not benefit from aspirin as CRC prevention, and this is a good thing. As healthcare professionals, we always want to practice evidence-based medicine. However, based on the information to date, I would say that for a strategy which may help reduce the risk of CRC cancer, “An aspirin a day keeps the cancer away.”
Lauren M. Green
Weight training was shown to help stave off deterioration of physical function in breast cancer survivors, conferring a benefit twice that of women in a control group who did not participate in the weight-lifting intervention, according to a post hoc analysis of results from a randomized trial.
Studies have shown that physical function in the nation’s more than 3 million breast cancersurvivors can decline more rapidly than it does in women who have not been diagnosed with cancer. Poor physical function is not only associated with premature mortality, but also increases the risk of falls, fractures, disability, and frailty at a younger age.
For this study, Kathryn H. Schmitz, PhD, MPH, and colleagues at the University of Pennsylvania’s Perelman School of Medicine examined data from the Physical Activity and Lymphedema (PAL) trial conducted between October 2005 and August 2008 comparing a twice-weekly, slowly progressive, weight-lifting intervention with standard care in a group of 295 breast cancer survivors, all of whom had at least one lymph node removed and were cancer-free at the start of the study.
Schmitz, a professor of epidemiology at Perelman, also was an investigator on the original PAL trial which evaluated lymphedema onset in participants after 1 year of weight training versus standard care controls, but that trial did not specifically examine the effect of the intervention on physical function, the purpose of the post hoc analysis reported online May 11, 2015, in the Journal of Clinical Oncology.
In the PAL study, participants were evenly divided to receive the intervention—involving a 12-month fitness center membership that included 13 weeks of twice-weekly sessions with an exercise professional—or usual care.
The exercise sessions included stretching andstrengthening of major muscle groups, aerobic warmup, and weight lifting. At the conclusion of the supervised weight-lifting, participants were told to continue the same exercise prescription for an additional 39 weeks. Weight-lifting adherence was determined by attendance logs; those in the experimental arm were contacted by exercise professionals when they missed sessions.
Incident physical deterioration, defined as deterioration of ≥10 points on the physical function subscale of the 36-item Medical Outcomes Short-Form questionnaire (SF-36) after 12 months, was the primary outcome for this analysis. Study participants were asked to perform 10 tasks involving such activities as lifting groceries, climbing stairs, and walking distancesranging from one block to one mile.
Prior studies have linked a 10-point or more deterioration in physical function to premature mortality among breast cancer survivors, with the risk increasing by 6% for each 10-point decrease in physical function.
After 12 months, 24 of 147 participants in the control arm (16.3%) experienced incident physical deterioration, compared with 12 of 148 (8.1%) in the weight-lifting group (relative risk, 0.49; 95% CI, 0.25-0.96; P = .04). Participants in the weight-lifting group also had increased upper and lower body strength compared with controls as measured by 1-RM bench press strength (5.0 + 0.8 vs 0.1 + 0.7 kg, respectively; P < .001) and 1-RM leg press strength (21.0 + 3.2 vs 3.1 + 3.1 kg; P < .001). No serious adverse events were found to be connected to the weight-lifting intervention.
The authors noted that their post hoc analysis marks the first to demonstrate “that weight lifting prevents the deterioration of physical function compared with standard care using a ≥10-point decrease on the physical function subscale of the SF-36 questionnaire.”
They said the findings suggest a need for further study, looking specifically at the role of aerobic exercise (eg, walking), in reducing the likelihood of developing a major mobility disability in breast cancer survivors, as well as research identifying which survivors may be at greatest risk for physical deterioration.
“These data are hypothesis-generating,” the authors wrote, “… [and] will be useful to inform the development of a confirmatory study to provide conclusive evidence to shape clinical practice and maximize the health and longevity of survivors of breast cancer.”
Brown JC, Schmitz KH. Weight lifting and physical function among survivors of breast cancer: a post hoc analysis of a randomized controlled trial [published online ahead of print May 11, 2015]. J Clin Oncol..
Janice Famorca Tran, RN,MS, AOCNP, CBCN, ANP-C
Texas Oncology Houston, TX
The study performed by Brown and Schmidt revealed promising results for breast cancer survivors who participated in a slowly progressive weight training program compared with those who did not participate in the weight-lifting program. The results showed that twice as many women (16.3%) who did not exercise lost physical function over a period of 1 year compared with the women who exercised (8.1%), proving the benefit of a regular exercise regimen on physical health for this population of individuals. In general, regular weight training helps develop and increase muscle strength and mass, burn calories, increase energy, and can improve one’s quality of life.
Lack of exercise can often lead to fatigue, sleep and mood disorders, and weight gain, especially when individuals are undergoing cancer treatment. The American Cancer Society recommends that cancer survivors participate in regular physical activity, avoid being inactive, return to normal daily activities as soon as possible after diagnosis, try to exercise at least 150 minutes per week, and to include strength training at least 2 days per week.
At diagnosis and regularly thereafter, it is essentialthat breast cancer survivors be educated about the recommendations of exercise for cancerpatients based on professionally recognized oncologyorganizations (such as the American Cancer Society and the National Cancer Institute), as well as the benefits of maintaining a regular exercise regimen. Nurses can assist these individuals to attain and develop an exercise regimen that is suitable for them and at the same time, enjoyable.
Tony Berberabe, MPH
Although use of robotic surgery for prostate cancer has surpassed open surgical procedures, the impact of this approach on patient quality of life has not been well-studied.
To address this knowledge gap, a group of researchers compared quality of life (QOL) indicators from two prior studies of patients who had either robotic or open surgery and found that scores on sexual function were better for those who had the robotic procedure, yet comparative results for urinary function were not as conclusive. The findings were presented at the 2015 American Urological Association (AUA) Annual Meeting. (Abstract PII-LBA5)
Currently most available QOL data on robotassisted, laparoscopic radical prostatectomy (RALP) and open radical prostatectomy (RRP),are from single surgeon/center reports, lack adequate risk-adjustment, or use limited information on patient-reported outcomes, explained Brock O’Neil, MD, of the department of Urologic Surgery at the Vanderbilt University Medical Center.
To gain a better understanding of post-prostatectomy QOL, researchers looked at data from two large cohort studies: the earlier Prostate Cancer Outcomes Study (PCOS) and the more recent Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study (2011-2012). All PCOS patients had open surgery, and QOL was assessed using the UCLA Prostate CancerIndex. The majority of men (78%) in CEASAR had the robotic procedure, and QOL was assessed using the Expanded Prostate Cancer Index Composite-26. In order to account for differences in these tools, researchers identified four common measures of urinary incontinence, three of sexual function, and set modified domain summary scores on a scale of 0-100, with 100 indicating ideal function.
Data were analyzed for 2438 men across the two study cohorts, 1505 of whom had RRP, and 933 had RALP. Among the men who underwent RRP, 1243 were from the PCOS study and 262 were from the CEASAR study. For the 74% of men with excellent urinary function scores (= 100) at baseline, those who underwent RALP had a mean QOL score of 74.1 at 6 months versus 70.4 in the RRP group; however, urinary continence scores were not significantly better at 12 months (78.7 vs 77.5, respectively).
Among the upper quartile of men with excellentbaseline sexual function, the mean score after 6 months was 55.1 in the RALP group versus44.9 in the RRP cohort. Notably, and unlike the urinary continence scores, at 12 months, the sexual function score differential was sustained, with better scores in the robotic surgery group (61.4 vs 51.1, respectively).
In the lower quartile of men with reduced sexual function at baseline (score = 65) the mean score for those undergoing robotic surgery still had a statistically significant better score (45.9 vs 40.7, respectively, which continued at 12 months; mean scores were 3.3 points higher in the RALP group (49.0 vs 45.7, respectively).
“Sensitivity analysis, which compared robotic CEASAR vs open CEASAR, robotic CEASAR vsopen PCOS, and open CEASAR vs open PCOS, provided consistent support for the sexual functionoutcomes and mixed support for urinary incontinence outcomes,” O’Neil concluded. Longerfollow-up is required to establish whetherbenefits persist beyond 1 year and to assess for differences in oncologic outcomes.
Tony Berberabe, MPH
When the United States Preventive Services Task Force (USPSTF) recommended against routine PSA screening for early detection of prostate cancer in May 2012, it caused a sea change in practice patterns among primary care physicians.
Data presented at the 2015 American Urological Association Annual Meeting by Ryan Werntz, MD, showed that after the guideline was issued, the overall rate of PSA testing decreased by 50% among primary care physicians at Oregon Health & Science University (OHSU). In particular, the most significant decrease in PSA use was seen in men aged 50 to 70 years—a cohort most likely to benefit from screening. (Abstract PD44-02)
“If you look back before PSA was a big part of prostate cancer screening, 20% to 25% of menwould often first see a physician with back pain and be subsequently diagnosed with metastaticdisease,” said Werntz, a urologic resident at OHSU. “It’s a little bit unnerving, because if the guidelines for primary care physicians are recommending not to screen for prostate cancer, we could go back to those days when 1 in 5 men are presenting with metastatic disease. Now, only 4% of men are presenting with metastatic disease, and that has to be due to PSA screening.”
The goals of the study were to identify trends in PSA testing by OHSU primary care physicians before and after the recommendation was issued,to determine which age groups were impacted the most, and to identify the rate of PSA testing in men with lower urinary tract symptoms (LUTS).
Men aged >40 years who were new patients at the family or internal medicine clinic at OHSU between January 2008 and December 2013 were identified for inclusion in the study using the OHSU electronic database. Those with a history of prostate cancer or who had previously been treated by a urologist were excluded.
Researchers compared PSA testing before and after the USPSTF recommendation, with results stratified by age. They found that PSA testing for men aged 50-59 years fell from 19.2% over the 4 years 2008-2012 before the USPSTF recommendation, to 8.5% after May 2012 when the guideline was issued—a reduction in screening of 56%. Similarly, for men aged 60-69 years, the rate fell by 60%, from 19.3% to 7.2%, respectively.
The researchers observed no significant difference in the frequency of PSA testing for men aged 40 to 49 years after the recommendation was issued (4.2% vs 4.4%, respectively) and for men 70 years or older (10.2% vs 9.3%, respectively). LUTS was a noted diagnosis in 3.6% of new patients examined, yet only 36% of men with this diagnosis were given a PSA test, suggesting underutilization of PSA in this symptomatic group of men.
Treatment strategies for patients with myelodysplastic syndromes (MDS) are built upon a foundation of supportive care, which consists of transfusions, iron chelation, and growth factor therapy, according to a presentation by Thomas Prebet MD, PhD, at the 2015 InternationalMDS Symposium.1
A majority of patients with MDS worldwide are treated solely with best supportive care(70%-80%), as novel therapies are generally reservedfor high-risk or cytogenetically defined individuals. Traditionally, supportive care has been administered solely to ameliorate symptoms; however, contemporary research suggeststhat “best supportive care” could prolong survivalfor patients with MDS, noted Prebet, assistant director of myeloid malignancy research at the Smilow Cancer Hospital at Yale-New Haven.
For patients with low- or intermediate-risk disease, best supportive care is the standard of care. Red blood cell (RBC) transfusions are generally the first step in a supportive care treatment strategy for many patients with MDS, since up to 80% of patients will experience anemia over the course of the disease.
“Most patients with MDS are diagnosed after the age of 70, and there is strong evidence that the anemia in patients over 70 is associated with a worse outcome and morbidity, such as fatigue, poor quality of life, increased risk of hospitalization, increased risk of cardiovascular events, and eventually, an increased risk of death,” Prebet explained.
Erythropoiesis Stimulating Agents Beneficial
Both short- and long-term follow-up are needed to optimize transfusion. Early detection of volume overload could help predict and prevent iron overload, Prebet explained. Additionally, frequent monitoring allows for the rapid discovery of RBC alloimmunization, which can occur in 15% to 20% of patients with MDS who receive chronic transfusions.
While transfusion optimization has utility, the administration of erythropoiesis stimulating agents (ESAs) could prevent or delay transfusion dependency, which is associated with chronic iron overload and significant economic costs:
“Treatment with an ESA has been associated with improvements in quality of life in most of the studies published to date. We also know that early introduction of ESAs improves response rate and duration.”
In a study of 112 patients with de novo low or intermediate-1 IPSS risk MDS who had not undergone transfusion, outcomes were significantly improved when an ESA was administered less than 6 months from diagnosis. In patients who received an ESA within 6 months, the median interval from diagnosis to transfusion dependency was 80 months compared with 35 months when an ESA was delayed.2
A number of factors have been identified that could be predictive of response to ESAs in patients with MDS, Prebet noted. Serum erythropoietin (EPO) levels below 200 UI/l were associated with a response rate of 69% compared with 42% in patients with higher EPO levels. Patients with low or intermediate-1 risk MDS also were more likely to respond to ESAs.
Additionally, studies have demonstrated superior response rates with high-dose ESAs compared with traditional doses. Responses with a high-dose ESA were 20% to 50% higher.
“Based on what we know, patients with lowest risk disease, lowest EPO, and a low transfusion burden need to be treated as soon as possible,based on what we know about the 6-monththreshold from diagnosis,” he summarized. “Oran ESA can be used later, but we need to usehigh-dose treatment to maximize the chances of response for these patients.”
Chelation Therapy to Address Iron Overload
Patients who do not respond to standard ESA treatment could be eligible for a combination strategy. Studies have shown promise with the combination of an ESA and G-CSF, with benefits shown in response and potentially overall survival. However, the administration of this combination is controversial, Prebet added.
“Early ESA treatment failure is associated with a bad outcome for these patients, with an overall survival around 2 years, which is really low compared with the standard for low-risk disease,” he said. “In these patients after a few years, they will be transfusion dependent again, and we will have to face the consequences of this dependence. One of these consequences is iron overload.”
High ferritin levels from chronic iron overload are associated with liver and cardiac toxicity. Iron chelation therapy (ICT) is recommended for patients with low-risk MDS who have received ≥20 RBC transfusions with a serum ferritin above 1000, Prebet suggested.
ICT is primarily administered to prevent organ damage, which can be caused by increased ferritin levels. Improvements with chelation can be observed using MRI or liver function tests. During the first 12 months of ICT, ferritin levels decline by 500 to 700 ng/mL. However, withinthis same timeframe, approximately 50% of patients will discontinue treatment due to progressionor adverse events (~25%).
“Compliance is a key issue for the effectiveness of these treatments,” Prebet said. “Shorter durations of ICT, less than 3 months or less than 6 months, does not bring any real benefits. Wereally need to coach these patients to ensure compliance with this treatment is correct.”
The ICT deferasirox is commonly administered for chronic iron overload. Recently, the FDA approved an oral formulation of the medication. The ease of this administration route could improve compliance rates, believes Prebet.
“This new pill limits the gastrointestinal toxicity seen with other formulations of deferasirox, and this is maybe something that will help the patients stay compliant allowing for enough exposure to the drug for a clear benefit,” he said. “Close follow up with this therapy is needed in the first months of this therapy, since this is the time when you have trouble with toxicity andcompliance.”
In addition to declines in ferritin, ICT is associated with hematologic improvement (HI) in patients with MDS. In a 247-patient study, the HI erythroid, platelet, and neutrophil rates were 21.5%, 13%, and 22%, respectively. The median time to response was approximately 169 days.3 In addition to HI, other analyses have suggested that ICT could improve survival.
“Based on a large Medicare database analysis, there’s a survival benefit with ICT,” Prebet said. “Clearly, we’re talking about selected patients. We really need to be cautious about these dataand our communication of this data with patients. This should not be labeled an effectivetreatment for survival until we have prospective results.” As larger prospective studies continueto illuminate the long-term benefits of supportivecare in MDS, it remains clear that optimizing this intervention significantly improves quality of life. Best supportive care is highly dependent on each individual, and represents the most personalized therapy you can provide, Prebet concluded.
1. T Prebet. Supportive care including chelation. Leukemia Research. 2015;39:1s (suppl; abstr 5).
2. Park S, Kelaidi C, Sapena R, et al. Early introduction of ESA in low risk MDS patients may delay the need for RBC transfusion: a retrospective analysis on 112 patients. Leukemia Research. 2010;34(11):1430-1436.
3. Gattermann N, Finelli C, Della Porta M, et al. Hematologic responses to deferasirox therapy in transfusion-dependent patients with myelodysplastic syndromes. Haematologica. 2012;97(9):1364-1371.