MDS/MPN Pre-HCT Disease Evaluation

*The timeline requirements for this form are as follows:
Assessment Time Frame: Within 45 days prior to the anticipated start of the conditioning regimen.
Submission Time Frame: Within 5 business days of collection.

*This form will only appear in the EDC if the “Specify the disease indication at diagnosis” field on Recipient Disease form is answered MDS/MPN.

Disease Classification

Specify the MDS/MPN classification at diagnosis:
Report recipient disease classification for MDS/MPN from the available options in the dropdown list.
• CMML-1
• CMML-2
• MDS/MPN with neutrophilia
• MDS/MPN with SF3B1 mutation and thrombocytosis
• MDS/MPN, not otherwise specified

Specify the maximum CPSS score the subject ever achieved:
Subjects with CMML will be scored according to the CMML-specific prognostic scoring system (CPSS), a risk stratification tool, which results in a numeric CPSS-Mol Score and prognosis. Points are assigned to various risk factors. Report the maximum CPSS-Mol score ever achieved in a format of “X.X”.

CPSS Risk Group	Score
Low	0
Intermediate-1	1
Intermediate-2	2-3
High	≥ 4

This field will only appear in the EDC if “Specify the MDS/MPN classification at diagnosis” is answered CMML-1 or CMML-2.

Specify when the maximum CPSS score was documented:
This field will only appear in the EDC if “Specify the MDS/MPN classification at diagnosis” is answered CMML-1 or CMML-2. Report the when the maximum CPSS score was documented as “Diagnosis” or “Between diagnosis and conditioning”.

Specify the maximum CPSS-Mol score the subject ever achieved:
This field will only appear in the EDC if “Specify the MDS/MPN classification at diagnosis” is answered CMML-1 or CMML-2. Report the maximum CPSS-Mol score ever achieved in a format of “X.X”.

Variables and prognostic score values of the CMML genetic score

Variables and prognostic score values of the CPSS-Mol

Specify when the maximum CPSS-Mol score was documented:
This field will only appear in the EDC if “Specify the MDS/MPN classification at diagnosis” is answered CMML-1 or CMML-2. Report the when the maximum CPSS-Mol score was documented as “Diagnosis” or “Between diagnosis and conditioning”.

Specify the pre-transplant disease status:
Report the subject’s pre-transplant disease status from the options available in the EDC.
• CR1
• CR2
• CR3 or subsequent remission
• Hematologic Improvement (HI)
• No response (NR) / Stable disease (SD)
• Progression from HI

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