Patients With MM Living Longer, but Elderly Still Face Worse Survival

Though therapeutic advances are improving outcomes for patients with multiple myeloma (MM), new data suggest elderly patients aren’t benefiting to the same degree as other populations.

The study, published in the European Journal of Haematology, suggests that factors other than comorbidity might be at play in the poorer survival rates of older patients.

Investigators from the London School of Hygiene and Tropical Medicine and King’s College Hospital NHS Foundation Trust, both in the United Kingdom, wanted to gain a better understanding of survival trends among patients with MM in different age cohorts. They pulled health records for 56,010 people in the United Kingdom who were diagnosed with MM between 1998 and 2014, a period of time during which a number of important anti-myeloma therapies were approved.

About 4 in 10 (41%) of patients in the study were between the ages of 75 and 90 at the time of their diagnosis. Thirty percent were between the ages of 65 and 74. The remaining 29% were aged 64 or younger.

All age groups saw increases in survival over the period covered by the study. For instance, the youngest age group (15-64) had a 5-year survival rate of 46.3% between 1998 and 2004, compared to a 64.7% survival rate between 2010 and 2014. Over the same time period, those aged 75 and up saw 5-year survival nearly double, from 15.7% to 30.6%.

Yet, those advances did not close the gap in terms of the additional risk of death associated with older age. For those ages 65-74, the 5-year excess hazard ratio (EHR) during the first time frame (1998-2004) was 1.65 (95% confidence interval); by 2010-2014, the EHR for death at 5 years was still 1.46. The EHR for death at 1 year was 2.15 for patients 75 and older who were diagnosed between 1998-2004. Those 75 and older who were diagnosed between 2010 and 2014 had an even higher EHR of 2.98. Those gaps persisted even when the authors adjusted for comorbidities.

“Undoubtedly the greatest improvements in myeloma survival have been due to the use of novel drugs such as thalidomide derivatives and proteasome inhibitors, but it is unclearwhether older patients have benefited as fully or in as timely a manner as in younger patients,” wrote corresponding author Adam Jones, MSc, and colleagues.

The investigators noted that trials for new therapies tend to exclude older patients and those with comorbidities, so it may be that such therapies, once approved, likewise are administered first to younger patients and only given to older patients once physicians are comfortable with the toxicity profile in younger patients.

It’s also possible, Jones and colleagues said, that patients’ own beliefs and values, or cultural and structural ageism lead the older patients getting the best-available treatments.

And while their data showed comorbidities did not account for the increased risk of death in older patients, the authors said it could be that some comorbidities have a bigger impact on treatment possibilities than others, which could partially explain the gap.

The investigators said one solution might be the use of better “frailty” metrics, which could help identify patients who are strong enough to undergo intensive therapies even though they are older.

“The use of validated frailty scores to guide treatment may reduce both over-treatment and under-treatment in elderly patients with myeloma,” they said.

Reference

Jones, A., Bowcock, S. and Rachet, B. Survival trends in elderly myeloma patients. Eur J Haematol. Published online October 9, 2020. doi: 10.1111/ejh.13530