[Neil Cuadra]

David,

The doctors give advice about all of these issues, because there are so many tradeoffs to consider. It's also specific to each patient's circumstances.

Paradoxically, patients can avoid or delay transplants if they are doing well, but if a patient is to go to translate they should be as healthy as possible, with counts as good as they can get, and being younger is an advantage.

It's both a blessing and a curse to have two different treatment approaches, because you have more options but you have to keeping weighing the choice.

It's also a blessing and a curse that the decision is ultimately up to you. You can put your trust in your physicians and listen to their recommendations, but you have the final say.

The "trigger," if there is one, is the point when the balance between transplant risks and the potential for a cure tips toward the transplant. It's less likely to be a doctor's recommendation when you're doing OK (your disease is "livable"), when you don't have a suitable donor lined up, or when you have other health issues that would make a transplant too risky.

Your quality of life and your personal opinion about living with the potential for AA to get worse are also factors to consider. Unless you speak up about these factors, doctors are likely to base their recommendations more on keeping you alive as long as possible than on quality of life or the emotional toll of living with a potentially deadly disease.

You mentioned improved technology. It's true that transplants are safer than in the past, and will presumably become safer still in the future. The most obvious improvements are that transplants can be done for patients at older ages, with less preconditioning, and for patients with less-matched donors.