Summary
An educational session titled “Geriatric Assessment in the Management of Multiple Myeloma” at 2019 ASCO Annual Meeting focused on insights into caring for this growing population of patients.
Managing elderly patients with multiple myeloma comes with a host of challenges, and insights into caring for this growing population of patients was the focus of an educational session titled “Geriatric Assessment in the Management of Multiple Myeloma” at 2019 ASCO Annual Meeting.
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Original Article
Insights Into Managing Elderly Patients With Multiple Myeloma
Oncology Times
By Christina Bennett, MS
An educational session titled “Geriatric Assessment in the Management of Multiple Myeloma” at 2019 ASCO Annual Meeting focused on insights into caring for this growing population of patients.
Managing elderly patients with multiple myeloma comes with a host of challenges, and insights into caring for this growing population of patients was the focus of an educational session titled “Geriatric Assessment in the Management of Multiple Myeloma” at 2019 ASCO Annual Meeting.
To Treat of Not to Treat Octogenarians
The decision to treat multiple myeloma patients aged 80 years or older can be difficult and is expected to only become more frequent as the population grows. In 2015, the number of octogenarians globally was approximately 125 million, with an estimated 30,000 new cases each year of multiple myeloma in patients 80 years or older. The number of octogenarians is expected to reach 434 million by 2050, and the number of new cases each year is expected to grow to 150,000.
“For octogenarians, the paradigm holds that the older you get, the older you will become,” said the presenter Sonja Zweegman, MD, PhD, from the VU University Medical Center, Amsterdam Netherlands. “At first, the life expectancy of women is 81 years; however, when you reach 80 years of age, your life expectancy moves to 89, but the life expectancy is not only dependent on age—also on comorbidities and functional measures.”
For example, the Lee prognostic index considers age, sex, comorbidities, and functional measures and was shown to successfully stratify older patients and predict mortality risk (JAMA 2006;295(16):1900). “It’s important to determine life expectancy in order to decide whether to treat or not,” emphasized Zweegman.
Currently, there is a lack of data about treatment benefit in octogenarians from pivotal, randomized clinical trials because the age limit for subgroup analyses is 75 years. There are, however, post-hoc subgroup analyses of trials that have shown similar progression-free survival outcomes among octogenarians and younger patients.
For example, a post-hoc subgroup analysis of the HOVAN 87 trial showed that the median progression-free survival among octogenarians with multiple myeloma (22 months) was similar to that of patients aged 76-79 (22 months) and 75 or younger (21 months).
However, that trend may not hold true for overall survival. Post-hoc subgroup analyses of several trials showed inferior overall survival for octogenarians with multiple myeloma. Specifically, the HOVAN 87 trial showed a worse median overall survival for octogenarians (41 months) compared with patients aged 76-79 (55 months) and 75 or younger (56 months). “So comparable progression-free survival, but inferior overall survival,” summed up Zweegman.
As for toxicity from treatment, higher rates have been seen among octogenarians compared with younger patients. For instance, a single-center study of Greek patients reported a 4-fold higher rate of death due to treatment-related toxicity among multiple myeloma patients who were 80 years or older compared with younger patients (12% vs. 3%) (Leuk Lymphoma 2019;60(3):619-628). The study also showed a higher early toxic death rate, almost 5 percent within 2 months after the diagnosis.
Zweegman concluded that the outcome of octogenarians is inferior, with more toxicity, but progression-free survival is comparable. “Therefore, treatment can be beneficial,” she said.
Managing High-Risk Myeloma in Older Patients
When treating older patients with high-risk melanoma, Tanya Wildes, MD, Associate Professor at the Washington University School of Medicine in St. Louis, emphasized the importance of considering the patient perspective. Traditionally, she explained, the treatment approach has been to examine disease-focused outcomes, such are response rates, progression-free survival, and overall survival, but it is also important to consider other outcomes, particularly toxicity, maintenance of functional independence, and quality of life.
“This perspective is supported by a body of literature that has examined the treatment preferences of older adults,” Wildes said. For instance, when a cohort of 121 older adults with cancer were asked their preferences before starting chemotherapy, several insights were revealed (J Clin Oncol 2018;36(15S): abstract 10009). Specifically, when asked whether the most important thing to them was to live as long as they could, 60 percent of patients disagreed with that statement, and when asked whether they would rather live a short life than lose their ability to take care of themselves, again nearly 60 percent of patients said that they would not want a therapy that would make them lose their ability to take care of themselves. In response to another question, over 80 percent of patients said they would not want to lose their thinking ability at the expense of living longer.
Similarly, in a study of patients with relapsed or refractory multiple myeloma, researchers identified subgroup of patients who prioritized side effects of therapy over longer disease control (Blood 2018; 132(S1): abstract 614). For example, they preferred to decrease the chances of developing peripheral neuropathy over longer control of their myeloma. “This is particularly important in older adults because peripheral neuropathy can specifically interfere with daily activities,” Wildes explained.
Christina Bennett is a contributing writer.