Doublet Regimen for Elderly Patients With MM

Ravi Vij, MD:We have a 72-year-old gentleman here who has been treated with a 2-drug regimen of lenalidomide (Revlimid) and dexamethasone. Certainly, based on randomized clinical data from the FIRST trial, this is appropriate management for a patient who is not transplant-eligible. However, I think even in the older patients, one needs to make an assessment whether a patient can be treated with a 3-drug regimen or with a 2-drug regimen. Even patients who are not transplant-eligible, between the ages of 70 and 80, often can tolerate dose-reduced bortezomib (Velcade), lenalidomide, and dexamethasone. Barring any serious comorbidities that prevent one from using the 3 drugs, my own inclination is to treat the patients with a 3-drug regimen.

In the case that we have here, we are provided with somewhat limited information about the patient’s actual performance status. We certainly don’t have any geriatric assessment done here. We are provided with information regarding his past medical history of hypertension and his inability to climb stairs.

I think that, given the data that we have here, I see actually no contraindication to have treated this patient with a 3-drug regimen. If the patient had had other comorbidities—often the patients have diabetes and neuropathy—that is one thing that, in an elderly patient especially, may drive me away from the use of bortezomib. However, I should think that, as far as this patient goes, he did have a good response. So, with a very good partial response, I think that is an acceptable level of response in an elderly population.

In younger patients these days, especially those who are transplant-ineligible, we try to strive for deeper depths of response, because deeper depths of response have been correlated with better long-term outcomes in terms of survival. However, in this elderly population, we do often balance the benefits in terms of depth and durability, with durability and quality of life. In the elderly, there is data that depth of response does correlate with survival though. But I think medicine is as much art as it is science, and we do want to individualize treatment for our patients.

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