New Myelofibrosis Guidelines Back Wider Gene Testing at Diagnosis

People with myelofibrosis, a rare blood cancer, and their care teams have new guidance for some of the most common treatment decisions. On Oct. 14, 2026, the American Society of Hematology (ASH) published its 2026 guidelines for managing myelofibrosis in adults in the journal Blood Advances. The guidelines include 10 recommendations on genetic testing, when to use JAK inhibitor drugs, how to manage anemia, when to talk about a stem cell transplant and who may benefit from low-dose aspirin.

Myelofibrosis is a type of myeloproliferative neoplasm, a group of blood cancers in which the bone marrow makes too many of certain blood cells. Over time, scar tissue builds up in the bone marrow. This can lead to anemia (low red blood cell counts), an enlarged spleen and symptoms such as tiredness, night sweats and weight loss. ASH estimates that up to 6 in every 100,000 people are living with the disease.

"These recommendations address questions that routinely come up for clinicians and patients managing myelofibrosis," panel chair Dr. Brady Stein, a professor of medicine at Northwestern University Feinberg School of Medicine, said in a news release from ASH.

Who Wrote the Myelofibrosis Guidelines

The panel included myelofibrosis specialists, transplant specialists and experts in research methods, along with a patient and a caregiver with lived experience of the disease.

All 10 recommendations are "conditional." In ASH guidelines, that means the panel believes the suggested approach is right for most people, but the best choice depends on each person's situation and preferences. For many of the questions, the panel rated the certainty of the evidence as low or very low, which signals that more research is needed.

What the Guidelines Recommend

• Broader genetic testing at diagnosis. The panel suggests extended molecular testing, such as next-generation sequencing, for all patients rather than limited testing of only the three main driver genes (JAK2, CALR and MPL). Broader testing can find high-risk mutations that help guide care.
• JAK inhibitors based on symptoms, not risk alone. JAK inhibitors are pills that can shrink an enlarged spleen and ease symptoms. Approved options include Jakafi (ruxolitinib), Inrebic (fedratinib), Vonjo (pacritinib) and Ojjaara (momelotinib). The panel suggests a JAK inhibitor for people with lower-risk disease who have a symptomatic enlarged spleen or disease-related symptoms. It suggests against starting one in people with higher-risk disease only because of their risk category if they do not have spleen-related symptoms or other symptoms.
• Treatment choices when anemia is the main problem. When anemia is the main reason to start treatment, the panel suggests Ojjaara or Vonjo, or an anemia treatment that is not a JAK inhibitor. If anemia keeps someone from taking a full enough dose of their first JAK inhibitor, the panel suggests switching to Ojjaara or Vonjo. If the current JAK inhibitor still controls the spleen and symptoms, the guidelines favor staying on it and treating the anemia with supportive care.
• Early transplant referral. For people with higher-risk disease who are responding to a JAK inhibitor, the panel suggests an early referral for allogeneic stem cell transplant (a transplant using cells from a donor), rather than waiting until the drug stops working.
• JAK inhibitors right before transplant. The panel suggests against routinely starting a JAK inhibitor before transplant in people who have never taken one, unless they have a markedly enlarged spleen or symptoms.
• Aspirin and iron. The panel suggests low-dose aspirin to help prevent blood clots in people whose disease has the JAK2 V617F mutation and who have no reason to avoid aspirin. It suggests against routine iron chelation (medicine that removes extra iron from the body) for iron overload caused by blood transfusions in people with overt myelofibrosis.
• Early-stage disease. For prefibrotic myelofibrosis, an early form of the disease, the panel suggests against routine use of pegylated interferon when there is no other reason to lower blood counts.

What's Still Unknown

The panel pointed to important gaps in the research. Doctors still need better ways to predict which patients will benefit from specific treatments, better approaches to anemia and clearer evidence on the best timing for a transplant.

"Important gaps in evidence remain, and we hope the questions we asked can help set a future research agenda," Stein said.

What It Means for You

These guidelines do not replace a conversation with your hematologist, and every recommendation leaves room for personal choice. They can help you and your care team talk through decisions such as whether broader genetic testing is right for you, whether a JAK inhibitor makes sense for your symptoms, how to address anemia and when to meet with a transplant team. For more background, read these key takeaways for patients with myelofibrosis.

Questions to Ask Your Care Team

• Has my myelofibrosis been tested with an extended gene panel, and what did it show?
• What is my risk category, and would a JAK inhibitor help my symptoms or spleen?
• If I have anemia, which treatment options fit my situation?
• Should I meet with a stem cell transplant team now, even if I am doing well on treatment?

References

1. "ASH Issues New Recommendations to Improve Myelofibrosis Care." American Society of Hematology. Oct. 14, 2026.
2. Stein B, et al. "American Society of Hematology 2026 Guidelines for the Management of Myelofibrosis in Adults." Blood Advances. Oct. 14, 2026. doi:10.1182/bloodadvances.2026021650

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