Multiple myeloma in the very elderly patient: challenges and solutions

Abstract

Diagnosis and management of myeloma in the very elderly patient is challenging. Treatment options have vastly improved for elderly myeloma patients but still require the clinician to personalize therapy. In this paper, we offer evidence-based, pragmatic advice on how to overcome six of the main challenges likely to arise: 1) diagnosis of myeloma in this age group, 2) assessment of the need for treatment, and the fitness for combination chemotherapy, 3) provision of the best quality of supportive care, 4) choice of combination chemotherapy in those fit enough for it, 5) treatment of relapsed myeloma, and 6) provision of end of life care. With an increased burden of comorbidities and a reduced resilience to treatment and its associated toxicities, the management of myeloma in this age group requires a different approach to that in younger patients to maximize both quality and length of life.

Keywords: diagnosis; elderly; myeloma; treatment.

Figure 1

The challenges of diagnosis and treating the very elderly patient with multiple myeloma. Abbreviation: VTE, thromboembolism.

Figure 2

Clinical features of myeloma and other diagnoses which may mimic myeloma. Notes: The incidences of calcium ≥2.75 mmol/L (11 mg/dL), hemoglobin #100 g/L, creatinine ≥177 μmol/L (2 mg/dL), and bone pain at initial diagnosis of myeloma are shown. Abbreviations: BPH, benign prostatic hypertrophy; CKD, chronic kidney disease; NSAIDs, nonsteroidal anti-inflammatory drugs; eGFR, estimated glomerular filtration rate.