Cancer Therapy Advisor: How important are social support networks for treatment adherence among older patients with multiple myeloma?
Dr Wildes: Many of the current treatment options for patients with myeloma are orally administered. While oral therapy is convenient and often preferred by patients, adherence to complex regimens can be challenging. This includes not only the cancer therapy, but required supportive care medications, such as VTE prophylaxis, varicella zoster prophylaxis, and vitamin D supplements.
Depression, multi-morbidity, polypharmacy, and cognitive impairment are among the factors associated with poorer adherence to medications. Patients who are unmarried/unpartnered are at greater risk for nonadherence,19 underscoring the importance of social support in optimizing adherence. Simple interventions, such as using a weekly medication pill box, can improve patient satisfaction and were preferred for administration of oral anticancer treatment.20 In a patient who lives alone, home nursing can be employed to support adherence through assisting with medication setup.21
CTA: What should clinicians know about the timing of supportive/palliative care for older patients with myeloma?
Dr Wildes: The American Society of Clinical Oncology (ASCO) has called for earlier integration of palliative care into the overall care of patients with cancer.22 Yet unfortunately clinicians who treat hematologic malignancies perceive palliative care as being equivalent with end-of-life care.23
Oncologists who treat hematologic malignancies are more likely to recommend chemotherapy for patients with poor performance status and limited life expectancy than their colleagues focusing on solid tumors.24 Patients with hematologic malignancies referred for hospice have a significantly shorter length of stay on hospice and are more likely to die within 24 hours of hospice referral than patients with solid tumors.25
We also know that patients with multiple myeloma have among the worst quality of life of patients with cancer.26 Patient preferences are also an important component of decision-making; older patients, for example, are more likely to forego treatments that would render them more dependent or cognitively impaired and prioritize their independence over length of life.27,28
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Together, this suggests that there is a significant opportunity to improve the care of older adults with myeloma, both from the standpoint of attention to symptom management throughout the disease course, prioritization of treatment preferences, and addressing end-of-life needs earlier.
- Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009;27:2758-65.
- Rosenberg PS, Barker KA, Anderson WF. Future distribution of multiple myeloma in the United States by sex, age, and race/ethnicity. Blood. 2015;125:410-2.
- Kumar SK, Rajkumar SV, Dispenzieri A, et al. Improved survival in multiple myeloma and the impact of novel therapies. Blood. 2008;111:2516-20.
- Pulte D, Gondos A, Brenner H. Improvement in survival of older adults with multiple myeloma: results of an updated period analysis of SEER data. Oncologist. 2011;16:1600-3.
- Pulte D, Jansen L, Castro FA, et al. Trends in survival of multiple myeloma patients in Germany and the United States in the first decade of the 21st century. Br J Hematol. 2015;171:189-96.
- Costa LJ, Brill IK, Omel J, Godby K, Kumar SK, Brown EA. Recent trends in multiple myeloma incidence and survival by age, race, and ethnicity in the United States. Blood Adv. 2017;1:282-7.
- Palumbo A, Rajkumar SV, San Miguel JF, et al. International Myeloma Working Group consensus statement for the management, treatment, and supportive care of patients with myeloma not eligible for standard autologous stem-cell transplantation. J Clin Oncol. 2014;32:587-600.
- Palumbo A, Bringhen S, Mateos MV, et al. Geriatric assessment predicts survival and toxicities in elderly myeloma patients: an International Myeloma Working Group report. Blood. 2015;125:2068-74.
- Kumar SK, Dispenzieri A, Lacy MQ, et al. Continued improvement in survival in multiple myeloma: changes in early mortality and outcomes in older patients. Leukemia. 2014;28:1122-8
- Bringhen S, Mateos MV, Zweegman S, et al. Age and organ damage correlate with poor survival in myeloma patients: meta-analysis of 1435 individual patient data from 4 randomized trials. Haematologica. 2013;98:980-7.
- Williams GR, Deal AM, Jolly TA, et al. Feasibility of geriatric assessment in community oncology clinics. J Geriatr Oncol. 2014;5(3):245-51.
- Hamaker ME, Schiphorst AH, ten Bokkel Huinink D, Schaar C, van Munster BC. The effect of a geriatric evaluation on treatment decisions for older cancer patients–a systematic review. Acta Oncol. 2014;53:289-96.
- Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol. 2011;29:3457-65.
- Hurria A, Mohile S, Gajra A, et al. Validation of a prediction tool for chemotherapy toxicity in older adults with cancer. J Clin Oncol. 2016;34:2366-71.
- Extermann M, Boler I, Reich RR, et al. Predicting the risk of chemotherapy toxicity in older patients: The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer. 2012;118:3377-86.
- Engelhardt M, Domm AS, Dold SM, et al. A concise revised myeloma comorbidity Index as a valid prognostic instrument in a large cohort of 801 multiple myeloma patients. Haematologica. 2017 Feb 2. doi: 10.3324/haematol.2016.162693 [Epub ahead of print]
- Wildes TM, Tuchman SA, Trinkaus K, Colditz G. Geriatric assessment in older adults with multiple myeloma. Paper presented at: 2016 American Society of Hematology Annual Meeting; December 3-6, 2016; San Diego, CA.
- Palumbo A, Cavo M, Bringhen S, et al. Aspirin, warfarin, or enoxaparin thromboprophylaxis in patients with multiple myeloma treated with thalidomide: a phase III, open-label, randomized trial. J Clin Oncol. 2011;29:986-93.
- Berry D, Blonquist T, Hong F, Halpenny B, Partridge AH. Self-reported adherence to oral cancer therapy: relationships with symptom distress, depression, and personal characteristics. Patient Prefer Adherence. 2015;9:1587-92.
- MacIntosh PW, Pond GR, Pond BJ, Leung V, Siu LL A comparison of patient adherence and preference of packaging method for oral anticancer agents using conventional pill bottles versus daily pill boxes. Eur J Cancer Care. 2007;16:380-6.
- Mohile SG, Velarde C, Hurria A, et al. Geriatric assessment-guided care processes for older adults: a Delphi consensus of geriatric oncology experts. J Natl Compr Canc Netw. 2015;13:1120-30.
- Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017;35:96–112.
- LeBlanc TW, O’Donnell JD, Crowley-Matoka M, et al. Perceptions of palliative care among hematologic malignancy specialists: a mixed-methods study. J Oncol Pract. 2015;11(2):e230–8. doi: 10.1200/JOP.2014.001859
- Hui D, Bansal S, Park M, et al. Differences in attitudes and beliefs toward end-of-life care between hematologic and solid tumor oncology specialists. Ann Oncol. 2015;26:1440-6.
- LeBlanc TW, Abernethy AP, Casarett DJ. What is different about patients with hematologic malignancies? A retrospective cohort study of cancer patients referred to a hospice research network. J Pain Symptom Manage. 2015;49(3):505-12.
- Kent EE, Ambs A, Mitchell SA, Clauser SB, Smith AW, Hays RD. Health-related quality of life in older adult survivors of selected cancers: data from the SEER-MHOS linkage. Cancer. 2015;121:758-65.
- Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002;346(14):1061-6.
- Fried TR, Tinetti ME, Iannone L, O’Leary JR, Towle V, Van Ness PH. Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Arch Intern Med. 2011;171(20):1854-6.