Changes in risk over time in patients with MDSs. Shown are smoothened hazard plots (left) and the Kaplan-Meier survival curve (right). Patients with an IPSS-R score of <3.5 at the time of MDS diagnosis are likely to have a continuously low risk of disease and may be thought of as having “constantly lower risk.” In contrast, patients with an IPSS of ≥3.5 have an initial high risk, but their risk of death due to leukemic transformation or progression of MDS declines over time. Thus, these patients may be considered as “initially higher risk.” Based on current recommendations, disease-modifying therapy should be offered to all patients with “initially higher-risk” disease at diagnosis if possible. If treatment is not possible at diagnosis, the patient’s clinical condition should be reassessed before offering treatment, however, as prognosis determined at the time of diagnosis may not be accurate at the time of follow-up. The figure has been adapted from Figure 5 in the article by Pfeilstöcker et al that begins on page 902.