patient care perspectives

Clinical Recommendations for the Treatment of Elderly or Frail Patients With Multiple Myeloma

by Carol Ann Huff, MD

Overview

Optimizing the care of older patients with multiple myeloma involves striking a balance between efficacy and toxicity. It also involves a deep understanding of each individual patient when formulating a treatment plan.

Expert Commentary

Carol Ann Huff, MD

Associate Professor
Departments of Oncology and Medicine
Medical Director
The Sidney Kimmel Comprehensive Cancer Center
Johns Hopkins University School of Medicine
Baltimore, MD

“It is very satisfying and predictable that, when you treat patients who are symptomatic from their multiple myeloma, as long as the regimen is working, they feel better in a matter of weeks—generally within 4 to 8 weeks after starting treatment.”

Carol Ann Huff, MD

Treating an older patient with multiple myeloma first requires an understanding of who they are, where they are coming from, their physiologic age, and their capabilities and comorbidities, as well as their goals, hopes, and desires. One of my objectives is to distinguish those patients who can tolerate a triplet combination from those patients who are truly frail. I try to strike a balance between the higher response rates—but higher toxicities—of the triplet regimens and the potentially not as active doublet regimen that has better tolerability and quality of life. During both the initial consultation and ongoing discussions, I strive to understand each individual patient as fully as possible when formulating a treatment plan. I ask my patients to tell me if they think that we need to make adjustments. Medication dose and schedule modifications can be made that enable these regimens to be safely delivered, even in patients with symptoms and compromised functional status related to multiple myeloma. A Dana-Farber Cancer Institute trial in transplant-ineligible individuals shows that this patient population can receive lower doses of lenalidomide-bortezomib-dexamethasone triplet therapy (ie, RVD lite) and still achieve good response rates, with robust progression-free and overall survival and with lower toxicity than would be likely at full dosage levels. Often, the corticosteroid component is the first dose to be reduced, and it is also one of the less active agents in the regimen. Similarly, daratumumab, which is now available in combinations, is a well-tolerated agent. It is very satisfying and predictable that, when you treat patients who are symptomatic from their multiple myeloma, as long as the regimen is working, they feel better in a matter of weeks—generally within 4 to 8 weeks after starting treatment. They do not feel perfect, but they feel better, and that helps spur them on to move forward. In fact, some of my patients have told me that they have not felt so well in years with regard to their multiple myeloma. While the published data do show lower survival rates in the older, frail population, it is difficult to attribute those findings to therapeutic differences vs underlying physiologic differences, and, so, I tend not to focus on that, but rather on fully understanding my patients and on achieving the best response, quality of life, and longevity.

References

O’Donnell EK, Laubach JP, Yee AJ, et al. A phase 2 study of modified lenalidomide, bortezomib and dexamethasone in transplant-ineligible multiple myeloma. Br J Haematol. 2018;182(2):222-230.

Palumbo A, Bringhen S, Mateos MV, et al. Geriatric assessment predicts survival and toxicities in elderly myeloma patients: an International Myeloma Working Group report [published correction appears in Blood. 2016;127(9):1213]. Blood. 2015;125(13):2068-2074.

Wildes TM, Campagnaro E. Management of multiple myeloma in older adults: gaining ground with geriatric assessment. J Geriatr Oncol. 2017;8(1):1-7.

Zander T, Aebi S, Pabst T, Renner C, Driessen C. Spotlight on pomalidomide: could less be more? Leukemia. 2017;31(9):1987-1989.

Zweegman S, Engelhardt M, Larocca A; EHA SWG on ‘Aging and Hematology.' Elderly patients with multiple myeloma: towards a frailty approach? Curr Opin Oncol. 2017;29(5):315-321.

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