Despite the rapidly changing landscape of treatments available for multiple myeloma, autologous stem cell transplant (ASCT) remains a standard of care among eligible patients, with median overall survival as long as 10 years among standard-risk patients.1
Although myeloma is largely considered a disease of the elderly — the median age of diagnosis of 69 years2 — transplant is not always an option for, or offered to, patients 70 years or older.
“There shouldn’t be an age ceiling for transplant for myeloma, but sometimes there is,” Pashna N. Munshi, MD, of MedStar Georgetown University Hospital’s Lombardi Comprehensive Cancer Center, Washington, D.C. “There is some fear about the toxicities of transplant and that patients older than 70 may not benefit from or tolerate transplant.”
Dr Munshi presented data at the 61st American Society of Hematology (ASH) Annual Meeting & Exposition that confirmed that more and more patients 70 years and older with myeloma are being transplanted, and that outcomes among these patients are similar to those seen in patients aged 60 to 69 years.3
The study looked at 15,999 patients with myeloma reported to the Center for International Blood and Marrow Transplant Research (CIBMTR) database and included the largest number of elderly patients ever studied across the country; 2092 patients were 70 years and older.
Compared with 2013, when 15% of patients 70 years or older received transplant, by 2017, the number had almost doubled to 28%. Using patients aged 60 to 69 years as a reference, patients 70 years and older had a similar nonrelapse mortality (hazard ratio [HR], 1.3; 95% CI, 1.0-1.7; P =.06) and overall survival (HR, 1.2; 95% CI, 1.0-1.4; P =.02).
“This manuscript reflects a meaningful advances in the field, showing that across the board many of us at academic centers that specialize in multiple myeloma are increasingly transplanting older adults based on performance status and other objective measures of health and not age alone,” said Ashley Rosko, MD, of The Ohio State University Comprehensive Cancer Center, Columbus. “It is important to offer transplant as standard of care for all patients because it is associated with progression-free survival advantages.”
Dr Munshi also noted that more than half (58%) of patients 70 years and older received reduced-dose melphalan at 140 mg/m2. This lower dose was associated with worse outcomes among this age group, including nonrelapse mortality at 100 days and overall survival at 2 years.
According to Dr Rosko, reduced-dose melphalan is sometimes given to older patients, but not as a rule. There are other characteristics that better identify which patients may need a reduced dose, such as frailty scores.
“It is not surprising that people who got the 140 mg/m2 dose had a higher nonrelapse mortality because, most likely, the reason to get the dose reduction was that they were less fit than the average person undergoing transplant,” Dr Rosko said.