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

5 – What to aim for?

The goals of therapy are important to keep in mind when deciding on treatment for elderly patients, such as prolonging survival, delaying disease progression and improving quality of life. Until relatively recently, complete response was not achievable in the elderly population of patients. There is varying evidence as to whether the depth of response is an accurate predictor of outcome in elderly patients, with some trials showing that complete response correlates with long-term PFS and OS [24,25] however others found CR was associated with time to progression but not OS [26]. An optimal balance between treatment efficacy and toxicity is of utmost importance in elderly patients therefore quality of response could help better predict outcomes. The prognostic impact of minimal residual disease (MRD) negativity has been observed in transplant-eligible and transplant-ineligible elderly patients with it surpassing CR achievement in terms of PFS and OS. Furthermore, MRD-negativity has shown significantly longer PFS and OS among patients with high-risk cytogenetics which is an effect not shown with CR achievement [27]. Nonetheless, in older patients, settling for a lower degree of response may be reasonable on a case by case basis as treatment-related toxicity may exceed any benefit seen by the achievement of CR or MRD negativity. Therefore, if there is no significant difference in treatment efficacy, treatment choice should be based on quality of life indicators as well as frailty score.