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Letters to the Editor
time-restricted assessment in each of the external EMN/DSMM centers (Würzburg, Ulm, Jena and Leipzig). Our results do, therefore, warrant even larger confirma- tory analyses.
In conclusion, based on existing recommendations, the R-MCI can be applied in routine clinical care, multicenter analyses and future clinical trials. It may also be used in research to compare risk profiles of MM cohorts, to adjust for imbalanced risk profiles and to provide a basis to establish new clinical or biological prognostic factors.6 We use the R-MCI for both clinical trial and non-trial patients and in our MM-tumor assessment, in which the R-MCI is immediately scored by those who see and treat the patient. In the future, the R-MCI may help to support treatment decisions, improve treatment tolerability and avoid toxicity.21 Since any prospective comorbidity, frailty and disability evaluation in MM can be time-consuming, we have implemented the R-MCI within a web-based technology application (www.myelomacomorbidityindex. org).6
Moreover, with the present study we have verified that comorbidity score analyses can be similarly and swiftly performed at other centers, that these scores add to the description of a population of patients, compared to that provided by the patients’ characteristics alone (Table 1), and that the scores may show substantial differences between centers (Table 2). The comparative analysis of different comorbidity scores (R-MCI, CCI, IMWG-frailty score) in the entire cohort is best illustrated in Figure 1A- C, in which the application of different scores resulted in substantial differences in proportions of fit versus frail MM patients. This was of interest because one might have postulated, contrarily, that the entire prospective MM cohort with 284 patients would have consisted of very similar proportions of fit, intermediate-fit and frail patients with each score. This difference between pro- portions, namely between fit versus frail patients, was most striking when the Freiburg and multicenter cohorts were compared (Figure 1D-F). We therefore demonstrate that the R-MCI is a useful tool to assess the fitness status of MM patients and can be implemented into MM care at different centers. It was prospectively compared to two other comorbidity scores often used in MM; i.e., the IMWG frailty score, which has the CCI implemented therein. With five multivariate risk factors (vs. age, ADL, IADL and CCI [this last with 18 factors that need to be assessed]), the R-MCI is convenient to use.
Sandra Maria Dold,1,2,3* Mandy-Deborah Möller,1,3 Gabriele Ihorst,4 Christian Langer,5 Wolfram Pönisch,6 Lars-Olof Mügge,7,8 Stefan Knop,9 Johannes Jung,1,3 Christine Greil,1,3 Ralph Wäsch1,3 and Monika Engelhardt1,3*
*SMD and ME contributed equally to this work.
1Department of Medicine I Hematology and Oncology, University of
2 FreiburgMedicalCenter,FacultyofMedicine,Freiburg; Facultyof
Biology, University of Freiburg, Freiburg; 3Comprehensive Cancer Center Freiburg (CCCF), University of Freiburg Medical Center, Faculty of Medicine, Freiburg; 4Clinical Trials Unit, University of Freiburg Medical Center, Freiburg; 5Hematology, Oncology & Rheumatology, University of Ulm Medical Center, Ulm;
6Hematology & Oncology, University of Leipzig Medical Center, Leipzig; 7Hematology & Oncology, University of Jena Medical Center, Jena; 8Hematology & Oncology, Heinrich-Braun-Klinikum Zwickau, Zwickau; and 9Hematology & Oncology, University of Würzburg Medical Center, Würzburg, Germany
Correspondence: MONIKA ENGELHARDT monika.engelhardt@uniklinik-freiburg.de
Disclosures: SMD, MM, GI, CL, WP, LOM, SK, JJ, CG and RW have no financial or other relationships that might lead to a conflict of interest. ME has received educational and trial support and honorar- ia and consultancy fees from Amgen, BMS, Janssen, Takeda, entirely unrelated to this study.
Contributions: MM and SMD acquired the data. SMD analyzed the data. SMD and ME wrote the manuscript. SMD, RW and ME designed the project. CL, LOM, WP and SK provided access to patients’ data and assessment. GI controlled the statistics. MM, JJ, CG, CL, LOM, WP, SK, GI, RW and ME revised the manuscript. RW and ME supported the project.
Acknowledgments: the authors thank distinguished IMWG, EMN, DSMM and GMMG myeloma experts for their advice, recommen- dations and insightful, inspiring comments. ME and all authors also thank all German, Austrian, Swiss, European and international elderly MM task forces, especially Valentin Goede (Köln) Ulrich Wedding (Jena), Friedemann Honecker (Hamburg, St. Gallen), Carsten Bokemeyer (UKE Hamburg), Gerald Kolb (Bonefatius KH Lingen), Drs. Francesca Gay, Alessandra Larocca, Sara Bringhen (University of Turin), Gordon Cook (University of Leeds), Sonja Zweegmann (University of Amsterdam) and Torben Plesner (University of Southern Denmark) for their support and both AG Engelhardt & Wäsch group members, especially Drs. Heike Reinhardt and Christine Greil for their eager enthusiasm. We also thank Dr. Karin Potthoff (Iomedico) for urg- ing us to share the data of this multicenter assessment, which was part of the master thesis of Sandra Maria Dold. Finally, we thank the three anonymous reviewers for their input and recommendations that led us to further improve the paper.
Funding: this work was supported by the Deutsche Krebshilfe (grants 1095969 and 111424, to ME and RW).
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