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Haematological Cancer
Management of Multiple Myeloma
a report by
Patrizia Falco,
1
Alessandra Larocca,
2
Mario Boccadoro
3
and Antonio Palumbo
4
1. Resident; 2. Research Fellow; 3. Chief; 4. Chief, Myeloma Unit,
Department of Oncology, Division of Haematology, University of Turin
Multiple myeloma (MM) is an incurable malignancy of terminally impact of advanced age in myeloma is predominantly related to a
differentiated B cells that accounts for approximately 10% of combination of factors, including co-morbidity, performance status,
haematological malignancies, and its frequency is constantly increasing decreased physiological reserve, social support, referral bias and,
due to the ageing of the general population.
1,2
Currently, about 35% of especially, under-treatment of the tumour.
12
The outcome for elderly MM
myeloma patients are under 65 years of age, 28% are 65–74 years of patients after conventional chemotherapy has not changed dramatically
age and 37% are over 75 years of age.
3
The aetiology is unknown; since the introduction of the melphalan–prednisone (MP) combination. A
however, a genetic predisposition and exposure to radiation, chemicals, more intensive approach can be safely offered to selected elderly patients,
tobacco use, obesity, diet and alcohol have been hypothesised as always taking into account that anagraphic age may considerably differ
possible causes, but not yet demonstrated.
4
from biological age. Some patients still remain unsuitable for ASCT. The
data available from the most recent studies suggest that the combination
Patients with symptomatic MM, which is defined by the presence of of conventional chemotherapy with the new drugs has the potential to
organ damage (calcium [hypercalcaemia], renal insufficiency, anaemia improve the outcome of the elderly MM patients.
or bone lesions, the so-called CRAB criteria) should be treated
immediately. Treatment choice should be based on the patient’s Front-line Therapy in Elderly Patients or Young Patients
characteristics (age and presence of co-morbidities) and on scientific Inelegible for Autologous Stem-cell Transplantation
evidence. Patients treated with conventional chemotherapy have a Patients who are not transplant candidates have been treated for years with
median survival of three to four years.
5
The use of high-dose standard alkylating agent therapy. In the age group between 65 and 70
chemotherapy followed by autologous or allogeneic stem-cell years, intermediate-dose melphalan appears a suitable option. In a
transplantation (ASCT) has improved the outcome and survival and is
now considered the standard of care for symptomatic MM patients
Patrizia Falco is a Resident in the Division of Haematology
under 65 years of age with good performance status.
6,7
Agents
at San Giovanni Battista Hospital, University of Turin. She is
targeting both the MM cells and the bone marrow microenviroment,
undertaking a PhD programme focusing on haematological
such as thalidomide, lenalidomide and bortezomib, have shown
diseases, particularly plasma cell dyscrasia, and her current
research focuses on new drug combinations for the
significant activity in MM. Combinations of these agents with steroids, treatment of elderly multiple myeloma patients. She has
alkylating agents or anthracyclines have significantly improved
co-authored numerous papers. Dr Falco received her
medical degree from the University of Torino.
response rate (RR) and progression-free survival (PFS). No difference in
overall survival (OS) was reported during a 24-year period from 1971
Alessandra Larocca is a Research Fellow in the Division of Haematology at the University of
to 1994 in a large group of newly diagnosed myeloma patients; there
Turin. Her current research focuses on the treatment of multiple myeloma, especially in the
was a trend towards improvement between 1995 and 2000 and a
field of new drug combinations, and she has clinical and research interestw in plasma cell
statistically significant benefit in OS was shown between 2001 and
dyscrasia. She has co-authored numerous papers. Prior to receiving her medical degree from
the University of Milan, Dr Larocca was a Haematology Resident at the San Gerardo Hospital,
2006.
8
These data suggest that ASCT was responsible for the trends University of Milan.
seen during 1994–2000, while novel agents contributed to the
improvement observed since 2001. Mario Boccadoro is Chief of the Division of Haematology at the University of Turin. He
specialises in malignant haematology and medical oncology and has clinical and research
interest in plasma cell dyscrasia. His research focuses on the pathogenesis and treatment of
Multiple Myeloma and Age
multiple myeloma. In addition to membership of numerous professional organisations, he has
Almost two-thirds of patients with MM are observed with increasing age.
3
authored more than 200 publications in peer-reviewed journals.
The optimal treatment for elderly patients has not yet been established,
partly because these patients tend to be under-represented in clinical
Antonio Palumbo is Chief of the Myeloma Unit of the
trials, which often report a median age for newly diagnosed patients of Department of Oncology in the Division of Haematology at the
around 60 years. Commonly, 65 years of age is the lower limit used to
University of Turin. Previously, he was a Research Associate at
the Wistar Institute, University of Pennsylvania. He specialises
define old patients. There is a significant difference in outcome according
in malignant haematology and medical oncology and has
to age. In a study conducted in the UK on 855 patients, the median
clinical and research interests in plasma cell dyscrasia. Dr
Palumbo’s current research focuses on the pathogenesis and
survival for patients over 65 years of age was 18 months compared with
treatment of multiple myeloma. He has authored more than
42 months in younger patients, regardless of the type of therapy 150 publications in peer-reviewed journals, as well numerous
received.
9
Other studies have confirmed this finding.
10,11
No significant
abstracts and several textbook chapters.
differences in tumour biology have been elucidated to explain the survival E: appalumbo@yahoo.com
difference between older and younger patients. The adverse prognostic
© TOUCH BRIEFINGS 2008 69
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