Treatment stores

Geriatric assessment may help treatment decisions for hard-to-treat multiple myeloma

Alessandra Larocca, MD, PhD, discusses the use of patient- and disease-related factors that affect treatment decisions for frail elderly patients with relapsed/refractory multiple myeloma.

When it comes to treating patients with multiple myeloma, it’s important to consider more than chronological age alone, especially for patients with difficult-to-treat disease, explained Alessandra Larocca, MD, PhD. , who added that performing a geriatric assessment can help guide optimal treatment decisions in this population.

“[Treatment decisions] are multidimensional and [require] complex assessment to choose the most appropriate plan [for this patient population]”, said Larocca. “Now that we have different treatments available, we are lucky because we can identify the most appropriate treatment regimen for each patient, depending on some of the characteristics of the patients and the disease.

In an interview with Live®Larocca, Hematologist, Division of Hematology, University of Turin, Azienda Ospedaliero‐Universitaria Città della Salute e della Scienza di Torino, Italy, discussed the use of patient- and disease-related factors that affect treatment decisions for elderly and frail patients in relapse. / refractory multiple myeloma.

Live®: In your experience with relapsed/refractory multiple myeloma, what makes the disease more difficult to manage?

Larocca: We have to consider different factors that can define the prognosis of the patient. Difficult-to-treat patients [have] certain disease-related factors [that contribute to poor prognosis]including the presence of high-risk characteristics, such as the presence of high-risk chromosomal abnormalities or aggressive disease, [which we see in patients with] plasma cell leukemia, extramedullary disease or early relapse.

[Additionally, we have to consider] patient-related factors, such as age, state of frailty, presence of comorbidities, functional disorders and organ function.

How do you define and assess frail elderly patients with relapsed/refractory multiple myeloma? What else makes their disease difficult to treat?

There is no standard frailty assessment for [patients with] relapsed/refractory multiple myeloma. Frailty scores were primarily defined for patients at the time of diagnosis. However, geriatric assessment, including assessment of comorbidities, functional status, independence, and social support, can help define patient characteristics and the feasibility of treatments for each patient. The patients [who are] difficult to deal with [include those] with early relapse, aggressive presentation and features of frailty.

What could help meet the current unmet needs of frail elderly patients with relapsed or refractory multiple myeloma?

It might be useful to define the frailty status of patients with a geriatric assessment or the use of a frailty score other than chronological age assessment [alone].

This could be useful during a relapse because we could have a more objective measure of the patient’s frailty, in order to be able to choose the most appropriate treatment.

How do you view the progress made in recent years in the treatment of patients with relapsed/refractory multiple myeloma? How could these advances benefit elderly or frail patients?

[Advancements have been made in] immunotherapy. For elderly patients, monoclonal antibodies, anti-CD38 monoclonal antibodies and other monoclonal antibodies that are coming [down the pipeline] have been a great innovation for relapsed/refractory multiple myeloma. [These agents are] associated with better outcomes, even in elderly patients, and they are tolerable for frail patients.

Could you tell us about your experience in caring for relapsed/refractory patients with renal failure? What challenge does kidney failure present?

The challenge for patients with renal failure is the use of drugs that do not require adjustment of renal function or [those that] can be used with kidney function adjustment. For example, with monoclonal antibodies you do not need to adjust the dose and they are safe for patients with kidney failure.

When choosing a treatment for patients with relapsed/refractory disease, do you take into account that the diet has been studied in difficult-to-treat patients?

Data presented in subgroup analyzes of studies can help guide treatment decisions. However, difficult-to-treat population subgroups are [often] limited and may not be sufficient to guide the decision-making process. You may use any data presented in the essay, [as well as information gathered in] clinical practice, to guide the decision-making process.