Recently Diagnosed or Relapsed? Stop Looking For a Miracle Cure, and Use Evidence-Based Therapies To Enhance Your Treatment and Prolong Your Remission
Multiple Myeloma an incurable disease, but I have spent the last 25 years in remission using a blend of conventional oncology and evidence-based nutrition, supplementation, and lifestyle therapies from peer-reviewed studies that your oncologist probably hasn't told you about.
Click the orange button to the right to learn more about what you can start doing today.
- You are here:
- Home »
- Blog »
- Multiple Myeloma »
- Newly Diagnosed Elderly Myeloma
Newly Diagnosed Elderly Myeloma
You are a newly diagnosed elderly myeloma patient. Or you are a caregiver for an elderly NDMM. Your oncologist is talking about several different chemo cocktails. All which sound overwhelming.
- The average age of NDMM patients is 70 according to research.
- Thirty-five percent of NDMM patients are elderly aka 75 or older.
- Unfortunately for elderly MM patients, the vast majority of clinical trials exclude elderly patients simply because toxicity is difficult to handle.
Consider Dr. Rajkumar’s controlling of MM therapy plan (see below) rather than the aggressive, standard-of-care FDA “potentially curative” approach (though MM is incurable…)
The study linked and excerpted below talks about the benefits of a low dose approach to therapy. Controlling multiple myeloma rather than aggressive therapies considered “potentially curative,” even though oncology has never cured a myeloma patient.
What are the challenges of treating the newly diagnosed elderly myeloma patient?
- Treatment Tolerance: Elderly patients may have reduced tolerance to aggressive treatment regimens due to age-related decline in organ function and overall health. Chemotherapy, radiation, and stem cell transplantation may be more challenging for them.
- Comorbidities: Elderly patients often have multiple comorbidities such as heart disease, diabetes, and kidney dysfunction. Managing these alongside myeloma treatment can be complex, as some treatments may exacerbate existing conditions.
- Frailty: Frailty is common in the elderly and can affect treatment decisions and outcomes. Frail patients may have reduced functional status and resilience to stressors, making them more vulnerable to treatment side effects and complications.
- Risk of Infection: Elderly patients with myeloma are at increased risk of infections due to immunosuppression from both the disease itself and treatment. Preventing and managing infections is crucial in this population.
- Polypharmacy: Elderly patients often take multiple medications for various chronic conditions. Managing polypharmacy is important to prevent drug interactions and adverse effects, which can complicate myeloma treatment.
- Cognitive Impairment: Some elderly patients may have cognitive impairment or dementia, which can affect their ability to understand and adhere to treatment plans. Caregiver involvement may be necessary to ensure treatment compliance.
- Financial Constraints: Elderly patients may face financial challenges related to healthcare costs, especially if they are retired or on a fixed income. Access to expensive medications or treatments may be limited, impacting treatment decisions.
- Psychosocial Support: Elderly patients with myeloma may experience increased psychological distress, loneliness, and depression. Providing adequate psychosocial support and addressing emotional needs is essential for their overall well-being.
I am a long-term MM survivor. I have first-hand experience with the short, long-term and late stage side effects caused by chemotherapy and radiation.
To put this another way, conventional oncology rarely talks about quality-of-life as a goal of your therapy plan- when talking about newly diagnosed elderly myeloma. In my experience, your therapy plan should be half quantity-of-life, half quality-of-life.
Are you a NDMM patient? What are your symptoms? What are your therapy goals? If you’d like to learn more about both conventional and non-conventional MM therapies send an email to David.PeopleBeatingCancer@gmail.com
Thanks,
David Emerson
- MM Survivor
- MM Cancer Coach
- Director PeopleBeatingCancer
Dose/schedule-adjusted Rd-R vs continuous Rd for elderly, intermediate-fit patients with newly diagnosed multiple myeloma
“Lenalidomide-dexamethasone (Rd) is standard treatment for elderly patients with multiple myeloma (MM). In this randomized phase 3 study, we investigated efficacy and feasibility of dose/schedule-adjusted Rd followed by maintenance at 10 mg per day without dexamethasone (Rd-R) vs continuous Rd in elderly, intermediate-fit newly diagnosed patients with MM.
Primary end point was event-free survival (EFS), defined as progression/death from any cause, lenalidomide discontinuation, or hematologic grade 4 or nonhematologic grade 3 to 4 adverse event (AE).
Of 199 evaluable patients, 101 received Rd-R and 98 continuous Rd. Median follow-up was 37 months. EFS was 10.4 vs 6.9 months (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.51-0.95; P = .02); median progression-free survival, 20.2 vs 18.3 months (HR, 0.78; 95% CI, 0.55-1.10; P = .16); and 3-year overall survival, 74% vs 63% (HR, 0.62; 95% CI, 0.37-1.03; P = .06) with Rd-R vs Rd, respectively.
Rate of ≥1 nonhematologic grade ≥3 AE was 33% vs 43% (P = .14) in Rd-R vs Rd groups, with
- neutropenia (21% vs 18%),
- infections (10% vs 12%), and
- skin disorders (7% vs 3%)
the most frequent; constitutional and central nervous system AEs mainly related to dexamethasone were more frequent with Rd.
Lenalidomide was discontinued for AEs in 24% vs 30% and reduced in 45% vs 62% of patients receiving Rd-R vs Rd, respectively.
In intermediate-fit patients, switching to reduced-dose lenalidomide maintenance without dexamethasone after 9 Rd cycles was feasible, with similar outcomes to standard continuous Rd. This trial was registered at www.clinicaltrials.gov as #NCT02215980…
The International Myeloma Working Group (IMWG) frailty score identifies
- fit,
- intermediate-fit, and
- frail patients with multiple myeloma (MM)
that have different survival predictions and risks of toxicity from treatment in newly diagnosed MM (NDMM). According to the score, intermediate-fit patients are those age 76 to 80 years or younger with impairments in functional abilities…
Combination therapies, including
- lenalidomide-dexamethasone (Rd),
- bortezomib-melphalan-prednisone (VMP), and
- bortezomib-Rd,2-4
are considered standard treatment options for elderly patients not eligible for autologous stem cell transplantation (ASCT).2-4 Monoclonal antibody–based treatments, including daratumumab plus either Rd or VMP,5,6 have been approved by the European Medicines Agency and US Food and Drug Administration and have recently become new standards of care in this setting…
Although life expectancy should be considered, there is large variability within the same age groups (eg, from 4.9 to 14.2 years in the population of those age 75 years), reflecting health status variability.9 …
Furthermore, older patients are more susceptible to adverse events (AEs) that may negatively affect the duration of treatment or outcome because of increased comorbidities, altered pharmacodynamics, or functional impairments.10 Standard treatments may induce a high rate of grade 3 to 4 AEs (75% to 91%), leading to discontinuation because of AEs in 30% of patients.2,3,11-13 …
In the FIRST trial, among patients age >75 years treated with continuous Rd, one-third discontinued lenalidomide and 44% required dose reduction. Moreover, at 18 months, only 30% of patients age ≥75 years were receiving the full planned dose of lenalidomide.7 In the EMN01 study, in which the lenalidomide dose was reduced to 10 mg during maintenance after full-dose induction, median PFS in intermediate-fit patients was 16.6 months, 16% of patients discontinued treatment because of AEs, and 16% reduced lenalidomide.15,16
Therefore, reducing the dose of lenalidomide after induction seems a valuable strategy to improve the feasibility of treatment in elderly intermediate-fit patients…
Assessments of end points
The primary end point of the study was EFS, which was defined as
- the occurrence of grade 4 hematologic AEs,
- grade 3 to 4 nonhematologic AEs (including second primary malignancy [SPM]),
- discontinuation of lenalidomide, PD, or death…
In summary, we confirmed the efficacy and feasibility of continuous lenalidomide therapy. An optimization of this combination, sparing steroids and reducing lenalidomide dose after induction (Rd-R), can allow patients to remain on treatment longer, maintaining disease control over time.
Our results suggest that, at least in intermediate-fit elderly NDMM patients, treatment intensity during continuous treatment can be deescalated without a negative impact on outcome. Ongoing and future trials including frailty-adjusted strategies to optimize treatment in the era of personalized therapy will evaluate this steroid-free approach, with newer drugs and combinations…”
Treatment of Myeloma: Cure vs Control
“Although not often openly acknowledged, “cure vs control” is the dominant philosophical difference behind many of the strategies, trials, and debates related to the management of myeloma. Should we treat patients with myeloma with multidrug, multitransplant combinations with the goal of potentially curing a subset of patients, recognizing that the risk of adverse events and effect on quality of life will be substantial? Or should we address myeloma as a chronic incurable condition with the goal of disease control, using the least toxic regimens, emphasizing a balance between efficacy and quality of life, and reserving more aggressive therapy for later…?
Cure vs control is debated because the strategies currently being tested are not truly curative but rather are intended to maximize response rates in the hope that they will translate into an operational cure for a subset of patients…”
Outside of a clinical trial setting, I prefer disease control as the treatment goal, except in selected high-risk patients in whom an aggressive approach to achieving CR may be the only route to long-term survival…”