Geriatric Assessment May Aid Treatment Decisions for Difficult-to-Treat Multiple Myeloma

Alessandra Larocca, MD, PhD

When it comes to treatment for patients with multiple myeloma, it is 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 steer optimal treatment decisions in this population.

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

In an interview with OncLive^®, Larocca, hematologist, Division of Hematology, University of Torino, 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 with relapsed/refractory multiple myeloma.

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

Larocca: We have to consider different factors that may define the patient’s prognosis. Difficult-to-treat patients [have] some 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, frailty status, the presence of comorbidities, functional impairments, and organ function.

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

There is not a standard assessment of frailty for [patients with] relapsed/refractory multiple myeloma. Frailty scores were mostly defined for patients at diagnosis. However, the geriatric evaluation, including the assessment of comorbidities, functional status, independence, and social support, may help in defining patient characteristics and the feasibility of treatments for each patient. Patients [who are] difficult to treat [include those] with an early relapse, aggressive presentation, and characteristics of frailty.

What could help address the current unmet need for elderly and frail patients with relapsed/refractory multiple myeloma?

It could be helpful to define the frailty status of patients with a geriatric evaluation or the use of a frailty score other than the evaluation of chronological age [alone].

This could be helpful at relapse because we could have a more objective measure of the frailty of the patient, so we can choose the most appropriate treatment.

How do you view advancements in the treatment of patients with relapsed/refractory multiple myeloma in recent years? How might these advancements 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 improved outcomes, even in older patients, and they are tolerable for frail patients.

Could you elaborate on your experience managing relapsed/refractory patients with renal impairment? What challenge does renal impairment present?

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

When choosing a treatment for patients with relapsed/refractory disease, do you consider whether the regimen has been studied in difficult-to-treat patients?

The data presented in subgroup analyses of studies may be of help in orienting treatment decisions. However, the subgroups of difficult-to-treat populations are [often] limited and may not be enough to guide the decision process. You can use all the data presented in the trial, [as well as information gathered in] clinical practice, to orient the decision process.