Page 23 - Haematologica May 2020

Structured assessment of frailty in multiple myeloma as a paradigm of individualized treatment algorithms in cancer patients at advanced age
Ferrata Storti Foundation
Haematologica 2020 Volume 105(5):1183-1188
The results were presented in part at the 'American Society of Hematology' (ASH) meet- ings and the 'German, Austrian and Swiss annual Hematology & Oncology meetings' (DGHO)
Monika Engelhardt,1 Gabriele Ihorst,2 Jesus Duque-Afonso,1 Ulrich Wedding,3 Ernst Spät-Schwalbe,4 Valentin Goede,5 Gerald Kolb,6 Reinhard Stauder7 and Ralph Wäsch1
1Department of Medicine I, Hematology, Oncology and Stem Cell Transplantation, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; 2Clinical Trials Center Freiburg, Faculty of Medicine, University of Freiburg, Germany; 3Palliativmedizin Universitätsklinik Jena, Jena, Germany; 4Vivantes Klinikum Spandau, Innere Medizin, Hämatologie, Onkologie, Palliativmedizin, Berlin, Germany; 5Geriatrie Köln, St. Marien-Hospital, Köln, Germany; 6Bonifatius Hospital Lingen, Medizinische Klinik, Fachbereich Geriatrie, Akademisches Lehrkrankenhaus der Westfälischen Wilhelms-Universität Münster, Münster, Germany and 7Universitätsklinik für Innere Medizin V (Hämatologie und Onkologie), Medizinische Universität Innsbruck, Innsbruck, Austria
Introduction
Life expectancy and incidence of cancer have substantially increased, the latter being closely interlinked to our longevity. Today, 617 million people are ≥65 years; by 2050, this number will have reached 1.6 billion, nearly 20% of the world’s pop- ulation, and the number of "very old" (>80 years) will have more than tripled.1 This aging of the population involves enormous changes to patient care. For the moment, the most profound changes are to be seen in Japan, Europe and North America. Major risk factors associated with aging include cancer (also multiple cancers in a single patient),2 and cardiovascular and neurodegenerative diseases, all requiring long-term care. Therefore, especially high-income countries are obliged to meet the challenges.1
Multiple myeloma (MM), as one example of cancer, and the 2nd most frequent hematologic malignancy, affects adults of all ages, but is primarily a disease of the elderly. The highest burden of MM-related deaths occurs among persons between 65 and 84 years of age.3-7 Similarly to the situation in several other types of cancers, management of older MM patients is more demanding due to their often impaired organ function, underlying comorbidities, and co-existing frailty, which may increase therapy-related toxicity, and lead to dose reduction and shorter treatment endurance.3,4,6-9 The high prevalence of geriatric impairments is increasingly being recognized, but is not always easily detectable without an objective assessment.3,6,7 Our goal today involves reducing the risk of under-treating fit patients and over- treating those who are frail.5,10-12 Although eligibility criteria for studies of anti-can- cer/-MM agents have traditionally relied on age cut-offs and performance status, geriatric and MM-specific frailty assessments are just beginning to be incorporated into more accurate stratification plans of treatment algorithms.6,7,11,12 Similarly to MM patients, geriatric assessments (GA) have been defined for patients with chronic lymphocytic leukemia (CLL)8,13,14 and myelodysplastic syndrome (MDS),15,16 where determination of frailty versus fitness has moved into clinical practice. However, solutions as to how they might be more uniformly used and valued in their daily pratice have not been fully determined.
Recommendations of the geriatric oncology working groups (i.e. German Society of Geriatrics/German Society of Hematoloogy&Oncology) have suggested GA-tools to check comorbidity in patients aged ≥70 years via the Charlson Comorbidity Index (CCI), cognition via the Mini Mental test (MMST), activity/instrumental activity of daily living (ADL/IADL), mobility via the Timed Up and Go test, depression via the geriatric depression scale (GDS), and nutrition via body mass index (BMI) and Mini Nutritional Status.6,7,11,12,17 While these GA- tools have been established and validated, their execution is time-consuming, an additional workforce is needed, and the involvement of a geriatric team is advis- able.6,7,9,11,12,17 Whether shorter frailty scores in cancer patients may substitute and/or add to GA-tools is being pursued in single- and multi-center trials (Table 1).
Correspondence:
MONIKA ENGELHARDT
monika.engelhardt@uniklinik-freiburg.de
Received: November 14, 2019. Accepted: January 30, 2020. Pre-published: April 2, 2020.
doi:10.3324/haematol.2019.242958
Check the online version for the most updated information on this article, online supplements, and information on authorship & disclosures: www.haematologica.org/content/105/5/1183
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