About one-third of patients with multiple myeloma are older than 75 years at diagnosis, and at least 30% are frail. This is “both due to disease-related symptoms and (age-related) decline in physical capacity, presence of comorbidities, frailty, polypharmacy, nutritional status, and cognitive impairment,” wrote Sonja Zweegman, MD, PhD, professor of hematology and head of the department of hematology at VU University Medical Center in Amsterdam, The Netherlands, in a recent issue of Current Opinion in Oncology.1

The treatment challenge is that regimens “investigated in clinical trials for transplant-ineligible patients have largely been investigated in fit, rather than frail patients, the latter being typically excluded or highly underrepresented therein,” the authors wrote.

Dr Zweegman and colleagues described how to identify frail patients with multiple myeloma and how to tailor treatment thereafter. They noted that over the past decade, the proteasome inhibitors bortezomib, carfilzomib, and ixazomib, as well as the immunomodulatory agents (iMiDs) thalidomide, lenalidomide, and pomalidomide “have significantly improved” patient outcomes.

“However, both in clinical trials and in daily clinical practice, elderly multiple myeloma patients have shown lesser benefit. This is mainly due to less stringent use of proteasome inhibitors and IMiDs, increased toxicity, and subsequent early discontinuation of therapy in elderly,” the authors noted.

When asked whether physicians in general practice either do not treat the elderly, do not add proteasome inhibitors/ImiDs, or whether they use a lower dose of novel agents because older patients included in clinical trials may be fitter than “real-world” patients, Dr Zweegman told Cancer Therapy Advisor, “yes, I do…although with less intensity treatment might well be feasible and should be offered.”