Chapter 4 – Treatment of elderly patients with myeloma

Contributors: Eileen M Boyle, Charline Legrand, Hélène Demarquette, Stéphanie Guidez, Charles Herbaux, Xavier Leleu, and Thierry Facon

4 – Defining aims

When to treat?

As with younger, fitter patients, the diagnosis of symptomatic myeloma is based on the CRAB criteria (symptoms of hypocalcemia, renal failure, anemia, and bone lesions) and the biomarkers of malignancy (clonal bone marrow plasma cell percentage, serum free light chain ratio, and focal lesions), and usually requires treatment [12,17].

The diagnosis of symptomatic myeloma is often less obvious in the elderly and may be mistaken for other coexisting conditions. For instance, osteoporosis should not be mistaken for myeloma bone disease and myeloma treatment should therefore not be initiated in the absence of any other end-organ damage. These patients should nevertheless still be under active surveillance and their paraprotein monitored closely. Mild kidney impairment is also common in elderly patients, often resulting from hypertension or diabetes, and should not be mistaken for myeloma kidney disease [18]. Finally, regarding anemia, if the degree of anemia seems out of proportion to the disease burden, concurrent causes should be sought. Community-based studies found that 10% and 20% of patients aged ≥65 and ≥85 years, respectively, were anemic [19] and the most common causes of anemia were iron deficiency, vitamin deficiency (chiefly B9 and B12), chronic inflammation, chronic kidney disease, and myelodysplastic syndrome. Often more than one cause was identified per patient [20–23] suggesting that they should all be assessed in the initial work-up of an elderly myeloma patient presenting with anemia. Conversely, elderly patients with chronic heart disease or respiratory failure may not be able to tolerate modest decreases in hemoglobin level and may require disease-specific therapy even in the absence of CRAB criteria.