How would you manage an elderly patient with mild pancytopenia who refuses bone marrow biopsy and whose flow cytometry is suggestive of CMML/MDS?   

It depends on the actual age of the patient - 70s, 80s versus 90s. If 80s or 90s and not transfusion dependent - suggest observation as likely low-risk disease. Alternatively, if there is a need to start hypomethylating agents then would send peripheral blood for NGS and cytogenetics especially if...

My management would be tailored depending on the age of the patient, and more importantly, their goals of care. For geriatric patients who are not transplant eligible, the goals of therapy are focused on improving quality of life. Depending on the counts, you may still be able to obtain valuable NGS...