PV Guidelines Question 4
Transcript
The correct answer is a patient with persistent leukocytosis, progressive splenomegaly, and frequent phlebotomy requirement. The reason is that although a patient may be classified as low risk based on age and thrombosis history, current guidance recognizes that some low-risk patients still have clinical features that warrant consideration of cytoreductive therapy in addition to aspirin and therapeutic phlebotomy. Cytoreductive therapy can be considered in low-risk PV for persistent symptoms such as headaches, dizziness, difficulty concentrating, uncontrolled itching, or splenomegaly despite standard therapy. The NCCN and European Leukemia Net, or ELN, guidelines recommend considering cytoreduction in low-risk patients with persistent leukocytosis and/or thrombocytosis, although exact blood count thresholds are not fully established. Taken together, a low-risk patient with persistent leukocytosis, progressive splenomegaly, and frequent ongoing symptom burden would be the strongest candidate for escalation beyond phlebotomy and aspirin.
References
- Tremblay D, Kremyanskaya M, Mascarenhas J, Hoffman R. Diagnosis and treatment of polycythemia vera: a review. JAMA. 2025;333(2):153-160. doi:10.1001/jama.2024.20377
- Benevolo G, Vassallo F, Urbino I, Giai V. Polycythemia vera (PV): update on emerging treatment options. Ther Clin Risk Manag. 2021;17:209-221. doi:10.2147/TCRM.S213020
- Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Myeloproliferative Neoplasms V.1.2026. © National Comprehensive Cancer Network, Inc. 2026. All rights reserved. Accessed March 10, 2026. To view the most recent and complete version of the guideline, go online to NCCN.org. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way.
- Barbui T, Vannucchi AM, De Stefano V, et al. Ropeginterferon versus standard therapy for low-risk patients with polycythemia vera. NEJM Evid. 2023;2(6):EVIDoa2200335. doi:10.1056/EVIDoa2200335
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Dr Michael Grunwald is board-certified in internal medicine, hematology, and medical oncology, specializing in the treatment of hematologic malignancies. His clinical focus includes acute and chronic leukemias, myelodysplastic syndromes, and myeloproliferative neoplasms, as well as transplantation and cellular therapy. Dr Grunwald is actively involved in clinical trials focused on leukemia and allogeneic stem cell transplantation. He serves as chief of the Leukemia Section at Atrium Health Levine Cancer, Charlotte, NC, where he is also director of the Transplantation and Cellular Therapy Program. He is a professor of cancer medicine at Wake Forest University School of Medicine.
