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Treatment patterns and outcomes in elderly patients with multiple myeloma

Leukemia volume 27, pages 971–974 (2013)Cite this article

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Age at diagnosis is an important determinant of outcome among patients with multiple myeloma (MM). The median age at diagnosis is 70 years in the United States, which is similar to that in the United Kingdom (73 years) and Sweden (70 years).1, 2, 3 The subgroup over the age of 75 years represents a population in which the natural history of the disease and outcomes are not well studied.4, 5, 6, 7 In one report, the median survival was less than 6 months in patients greater than 75 years of age, and hemoglobin and age were significant predictors of survival.4 Rodon et al.6 reported a median survival of 22 months in patients >75 years of age. Poor performance and elevated creatinine were adverse prognostic factors in this study. However, the majority of patients received melphalan or cyclophosphamide with prednisone and represent the era before introduction of the novel agents. The IFM01/01 trial8 enrolled patients over 75 years and showed a prolongation of survival with modest toxicity with melphalan, prednisone and thalidomide. We performed the current study to better define the outcome among patients over 75 years, who were seen at the Mayo Clinic between 1 January 1999 and 31 December 2008. The treatment responses were estimated according to the Uniform Response Criteria of the International Myeloma Working Group.9 The survival of MM patients aged ⩽75 years in the same period was also reviewed for comparison. The study was approved by the Institutional Review Board.

We focused on the comparison of survival before and after the introduction of novel agents in elderly myeloma patients. Thirty-five patients who received novel agents as first-line therapy as well as 69 patients who received one or more novel agents anytime during the treatment period showed superior survival compared with patients treated with conventional therapy in univariate analysis, but failed to show a survival benefit in multivariate analysis. Salvage therapy with novel agents might explain this result. Patients over 75 years of age who received MP or MP plus thalidomide had a median survival of 44 months compared with 29 months in an IFM (Intergroupe Francophone du Myelome) randomized trial.8 Our retrospective analysis included elderly patients exposed to various novel agents, and the IFM study also included use of novel agents as rescue treatment in patients with progressive disease. We presume that adequate choice of novel agent according to patients’ organ function and modification of dose intensity will prolong the survival of elderly MM patients. The second point is the relation between response to first therapy and survival. Achievement of stabilization or response increased the median survival to 50 months compared with 6 months in patients with progressive or inevaluable disease in our study. The IFM01/01study8 reported higher rates of PR, VGPR and CR in the MP plus thalidomide group, but not an increased survival. They also reported the same overall survival after progression in both the groups. This suggests that appropriate choice of rescue therapy is important in elderly myeloma patients after disease progression. The last comparison is with younger patients in the same period. The significant difference of median survival was observed in our analysis (62 versus 27 months). Elderly patients have more co-morbidities such as cardiovascular disease, depression or arthritis. In one report patients aged 65 years or more usually had an average of three different concurrent diseases.10 Our study contained the 17 untreated patients because of concurrent diseases. They had a short median survival (2 months versus 30 months for treated patients). Elderly MM patients also have limited social and financial support, and reduced functional status, which may interrupt active treatment. Both elderly patients and their physicians are more likely to choose less intensive or supportive therapy, which may be appropriate in patients with significant co-morbidities.11 The reduction of dose and early termination after toxicity are frequent decisions by physician, patient or family during treatment.

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Acknowledgements

This work was supported in part by CA-62242 from the National Cancer Institute and the JABBS and Predolin Foundations.

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  1. Division of Hematology, Mayo Clinic, Rochester, MN, USA

    S-M Bang, R A Kyle, S V Rajkumar & S Kumar

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Correspondence to S Kumar.

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Bang, SM., Kyle, R., Rajkumar, S. et al. Treatment patterns and outcomes in elderly patients with multiple myeloma. Leukemia 27, 971–974 (2013). https://doi.org/10.1038/leu.2012.259

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