Approaches and Challenges in the Management of Multiple Myeloma in the Very Old: Future Treatment Prospects

Abstract

The increasing incidence of geriatric patients with multiple myeloma has elevated concerns in clinical practice. While the introduction of novel therapeutic agents has substantially improved outcomes in younger patients with myeloma, poorer outcomes remain in older patients. Managing older patients requires a multidisciplinary team approach to consider factors that may influence both treatment selection and outcomes. Aging is associated with remodeling of vital organs, physiological downregulations of basal metabolism, susceptibility to multiple comorbidities with ultimate frailty, thereby contributing to the underrepresentation and exclusion of very old patients from clinical trials. Therefore, timely confirmation of a precise diagnosis is crucial for prompt initiation of treatment if the desired outcome is to be achieved. Adequate and judicious assessment using comprehensive geriatric assessment tools minimizes toxicities and treatment discontinuation. Initiating treatment with combinational therapy requires knowledge of indications and anticipated outcomes, as well as individualized therapy with appropriate dose-adjustment. Individualized therapy based on good clinical acumen and best practices obverts unwanted polypharmacy, preventing iatrogenic harm. This review will therefore address the approaches and challenges faced in managing myeloma in geriatric patients aged 80 years and older, highlighting recommended therapeutic strategies and future prospective regimens.

Autologous cellular therapy for myeloma: Giving ex vivo expanded NK cells their due

“… 2 However, with a median age of diagnosis of 65–70, intensive therapies that attain remission and maintain long-term control of disease may be challenging to administer. 3 Furthermore, the long-term use of maintenance therapy has a number of important side effects, including a higher risk of cytopenia, thrombotic events, secondary malignancy with lenalidomide, and neuropathy with proteasome inhibitors 4 . The use of an alternative cellular therapy as consolidation following ASCT is an interesting and promising approach without these potential side effects.…”

Role of Anti-B-Cell Maturation Antigen (BCMA) in the Management of Multiple Myeloma

“…In southeast Asia, which comprises generally developing countries, its incidence and mortality rates are lower, at 0.96/100,000 and 0.82/100,000, respectively [ 2 ]. Predictions indicate that the frequency of cases regarding the disease is set to increase by 80% per year, with the number of cases doubling in the next 20 years because of the aging population and the prevalence of MM in elderly patients [ 3 , 9 ]. Multiple myeloma is more debilitating in high-risk populations, including frail elderly patients, who have a median age of 70 years at diagnosis, and patients with high-risk cytogenetics and RRMM [ 3 , 4 , 9 ].…”

Management of Multiple Myeloma in the Middle East: Unmet Needs, Challenges and Perspective

“…Current real-world evidence shows that triplet therapy followed by autologous hematopoietic stem cell transplantation, consolidation and maintenance for fit responder patients remains the backbone of MM treatment in Lebanon, while novel regimens are being explored whenever possible [ 9 ]. Fit patients might even receive quadruplet regimens, while adjusted intensity regimens are optimal for frail elderly patients [ 10 ]. The inevitability of aging and its associated comorbidities and biological changes complicate the treatment of very elderly MM patients.…”