Multiple Myeloma: A Case Review

Ravi Vij, MD:We have a 72-year-old gentleman who in 2016 had a new diagnosis of multiple myeloma. He had revised ISS stage I disease, and at the time of diagnosis, he had a history of hypertension. He had some limitation in his ability to function; climbing upstairs was difficult for him. He received initial treatment with lenalidomide (Revlimid) and dexamethasone. He took that for about 9 months and then stopped after attaining a very good partial remission. Thereafter he has been off treatment for about 12 months.

Multiple myeloma is a disease that, on an average, occurs in patients over 70 years of age; that’s the median age. So, this patient is very typical of patients we would see in our clinic every day. As we all age, we do develop a limitation in our function abilities. We have somewhat limited information on this case in terms of his true performance status these days. It is also being advocated that we do more detailed geriatric assessments on our patients, and I think that this is a little difficult to do in the real world, but certainly, performance status is a surrogate that we all use. We look at comorbidities; we look at the physiological age of the patient, rather than the chronological age in making our determination on treatment options.

There are a variety of goals that we can have, depending on a patient’s demographics and performance status. Originally this patient was not felt to be a candidate for stem cell transplantation. That’s the first thing that we look for in a patient—whether he’s a candidate for transplant or not. For those who are not transplant candidates, I personally would think patients fall into 2 broad categories: those who are between 70 and 80 and then those who are over 80, who have usually much more in the way of frailty issues and comorbidities.

For those who are between 70 and 80, the choice often boils down to whether we give the patient a regimen like RVD-lite; which is dose-reduced lenalidomide, bortezomib, dexamethasone; or whether the patient should just be treated with a 2-drug regimen of lenalidomide and dexamethasone. In this case, the determination was made that it was appropriate to treat the patient with a 2-drug regimen. The patient, having achieved a very good partial response, decided with his physician to stop treatment.

That is something that can be opened to a variety of interpretations whether that was the right thing to do for this patient or not. We can discuss some of that in this course, but the fact is that patients these days with multiple myeloma, we do tend to want to be on continuous therapy for prolonged periods of time if possible. Continuous therapy has been shown to improve in at least meta-analysis, both progression-free and overall survival. However, we know that the older patients often are not able to get prolonged periods of treatment without side effects, and we often have to stop. In the elderly, quality of life often carries equal importance in our decision making, as does efficacy in terms of longevity and depth of response.

Transcript edited for clarity.

CASE: A 72-year-old Caucasian Man With Relapsed Multiple Myeloma

September 2016

• Patient history: At the age of 72, a Caucasian man was diagnosed with multiple myeloma; R-ISS stage I
• Other relevant history includes hypertension and difficulty walking up stairs
• He was treated with lenalidomide/dexamethasone and achieved a VGPR
• Treatment duration was 9 months; patient subsequently discontinued therapy 12 months ago

June 2018

• On routine follow-up, patient complains of increasing problems with fatigue, and has rising levels of M protein
• Laboratory results:
  • Hb, 9.6 g/dL
  • Ca²⁺9.2 mg/dL
  • Creatinine, 0.8 mg/dL
  • M-protein, 3.0 g/dL
  • 30% plasma cells in bone marrow
• Cytogenetics/FISH: del(17p)
• ECOG PS: 2