Jason Gotlib, MD, MS
	Associate Professor of Medicine (Hematology) Stanford University School of Medicine/Stanford Cancer Institute Stanford, California

The role of iron chelation in MF has not been studied well, and oncologists will borrow information from the MDS literature. I would say that if you have a patient with lower-risk MF who has many years potentially ahead of him or her, who is already requiring transfusions and whose ferritin level is headed above 2,000, then it would not be unreasonable to start thinking about iron chelation. If you have a patient with MF who’s at high risk and who may have a prognosis of 1.3 years, even if their ferritin is above 2,000, in the absence of organ damage, I’m not sure lowering high levels of iron would be high on my priority list for items to tackle. This is how I approach it. I borrow basic ideas and guidelines from other diseases such as MDS, where the NCCN guidelines recommend iron chelation when there are 20 to 30 units of blood. At about 2,500 I start thinking about its use.

	Elias Jabbour, MD
	Associate Professor Leukemia Department The University of Texas MD Anderson Cancer Center Houston, Texas

I have been asked this question before and the answer is — we don’t know. Even in MDS we don’t know the right answer. We don’t have data from any prospective trials. All the data we have are retrospective. We don’t have any prospective trials. The FDA has requested the pharmaceutical company to run a prospective trial with survival as an endpoint, but the trial has had difficulty accruing. I think an oncologist’s common sense comes into play. If I have a young patient who is faring well and whose disease is responding, then yes, I will consider iron chelation. However, in the real world, this may not be a realistic scenario because increases in creatinine levels are also observed in patients undergoing iron chelation and this is a limiting factor. I do not give iron chelation high priority on my agenda when I have patients with MF.

	Ruben A Mesa, MD
	Chair, Division of Hematology and Medical Oncology Deputy Director, Mayo Clinic Cancer Center Professor of Medicine Mayo Clinic in Arizona Scottsdale, Arizona

This is a good question, and one we do not have a lot of information on at this point. We have effective iron chelation drugs available, but I have seen in patients to whom I have been administering these drugs, or in patients who have come to me already on these drugs, that these agents can definitely increase creatinine and affect organ function. They definitely can result in abnormal liver function test results, and I have found it challenging to initiate or continue treatment with these drugs when I try to place patients on clinical studies. I would say the issue in MF remains the same as it does with MDS. We know that patients have an increase in iron, but does an individual with MF that is transfusion dependent have an estimated survival that is long enough that they will benefit from iron chelation?

I rarely use iron chelation. I tend to think about it in the same group of patients that I do with MDS. These would be patients that primarily have anemia alone, or a younger patient who I think is likely to have a long survival and transfusion dependence is the only risk factor. For such patients I fear that they have a long time to live with the disease and that the iron has a much longer period to potentially become an issue.

	David P Steensma, MD
	Attending Physician Dana-Farber Cancer Institute Associate Professor of Medicine Harvard Medical School Boston, Massachusetts

This is an area of huge controversy in MDS, and I think some of that controversy spills over to MF. It is less clear that ferritin or heavy transfusion dependence is an independent prognostic marker in MF. Transfusion dependence is in the DIPSS, but that probably is a prognostic marker because it’s a marker of people with worse marrow failure, rather than iron overload. I rarely use iron chelators in this group. However, some patients are going to live 10 years or more, and they may be transfusion dependent for some of those years, and they start having ferritin levels in the 3,000 and 4,000 range. If you order an MRI of their liver you see a very high iron burden in the liver, and that’s a group in which perhaps we should consider using iron chelation.

I can count on my fingers the number of my patients with MF currently receiving chelation. It’s a small amount, but there is probably a niche for iron chelation.