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Abstract
Multiple myeloma (MM) is a plasma cell neoplasm with a chronic disease course that primarily affects elderly individuals. The introduction of novel agents such as thalidomide, lenalidomide and bortezomib has significantly improved the outcome for MM patients, including the elderly. Quality of life in MM is influenced by disease-related symptoms, treatment-related toxicity and treatment response. In addition to conventional endpoints as response, quality of life should be carefully evaluated during each therapeutic phase. Caring for older adults with MM is particularly challenging because of the heterogeneity of aging and the presence of comorbidities and frailty, with a potential risk of over- or under-treatment. Moreover, elderly patients may sometimes prioritize maintaining quality of life above prolonging survival. A careful evaluation of comorbidities and a geriatric assessment can facilitate risk-stratification of elderly patients to identify the older population fit enough to tolerate standard drug dosing, and to detect the frail patients who need age-adapted treatment.
Financial & competing interests disclosure
M Delforge has received speaker’s honoraria from Celgene, Janssen and Amgen. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.
The prevalence of elderly patients with multiple myeloma (MM) is expected to rise in near future due to the aging population and the improved overall survival since the introduction of novel antimyeloma agents such as thalidomide, lenalidomide and bortezomib.
An optimal care for non-transplant-eligible MM patients should focus on improving outcome while preserving quality of life (QoL).
Individualized treatment decision-making is needed to obtain a balance between treatment efficacy and toxicity and requires an appropriate estimation of an older patient’s biological age, vulnerability and comorbidities.
A careful geriatric assessment may help to define fit versus unfit patients and select therapy accordingly.
Current recommendations for tailoring MM therapy claim that frail and unfit patients benefit from a reduced-dose doublet or triplet schema combined with dose escalations in subsequent cycles according to tolerability. By contrast, very fit elderly patients could receive full-dose therapy and even stem cell transplantation, reflecting the heterogeneous process of aging.
The novel agents are generally well-tolerated and ensure QoL, but further studies, including dose-intensity subanalyses and elderly-specific trials, are needed to evaluate the effect of the long-term toxicity on QoL.
Validated dosing strategies combined with standardized and easily applicable assessment tools to perform a geriatric assessment could guide the clinician to select the most appropriate treatment combinations for non-transplant ineligible MM patients with consequently improvement of both outcome and QoL.