The Latest Myeloma News from the American Society of Hematology Meeting

Andrew Schorr:

How important now, and I know they do this in Europe a lot, a lot of the studies I saw showed they were studying people 65 or older and then others were related to people under 65. How important is that cutoff? What if you're 64-and-a-half or you're 70, but you play tennis every day, or you used to before your myeloma diagnosis, and you're trying to get back to that? Where does age come into it, at least the way we practice medicine in the U.S., Dr. Lonial?

Dr. Lonial:

Well, I think that the Europeans have created this arbitrary demarcation between transplant-eligible, and non-transplant-eligible, and I think most would argue that that 65 age limit probably doesn't make a whole lot of sense. Even the Europeans would say that doesn't make a lot of sense, but those are the rules they created, and they try and play by those rules. I think that in this country we probably base it more on performance status and comorbid illnesses rather than on a certain age, so I don't think of age as being a qualification for treatment one way or another. I think about how well a patient is and whether or not I think they could tolerate the kind of therapy that may or may not involve high-dose therapy. If they are, then I would consider whether or not dexamethasone would be an option for them. If they're not, then I consider prednisone or melphalan and prednisone based regimens. So, I think it's a little bit different in terms of the spectrum as we don't use an absolute age cutoff.

Andrew Schorr:

Okay, and what about you in Los Angeles, gentlemen? What about age? That's so important. How about you, Dr. Berenson, first, just related to age, what's your view of that?

Dr. Berenson:

I think age is one of the many factors that comes into play in terms of what decision I make to initial treat a patient with. So, basically I draw a Venn diagram, which is three circles. The extent of disease; that is, how much is it affecting bone marrow, is the patient significantly anemic, how much is it affecting the kidney, how much is it affecting the bone, what are the cytogenetics, and what's the patient's current quality of life as the disease is affecting them? Secondly I look at the patient's work and lifestyle. are they, for example, a surgeon or a pianist like my wife so that neuropathy is going to be an issue? Are they very active in terms of their lifestyle. Then, third, what are the comorbid conditions? Do they have diabetes? For example, a patient I saw an hour ago has diabetic neuropathy, nerve problems, and so issues of using drugs like thalidomide are certainly important to recognize. Does the patient have heart failure?

So, all three of these come into my decision making in terms of how I'm going to treat a patient. We really try to individualize therapy here and not just "one size fits all." So, I don't use age as much of a criteria. I think it's a minimal criterion for me in terms of what I'm going to give a patient.

Andrew Schorr:

Any comment from you, Brian? I know people hear all this, and they say, well how does this apply to me, and some of these studies, again, use age as a demarcation point.

Dr. Durie:

I think age is actually very important, and I've been impressed with the data from the IFM group and also from the Italian group where they have shown that actually the 65 cutoff does influence both the benefit and the side effects from the therapy, and one important trial was to compare thalidomide and dexamethasone, which we use widely for both younger and older patients versus the melphalan/prednisone/thalidomide and melphalan/prednisone/Revlimid combinations, and what the French group showed was that actually melphalan and prednisone, and certainly melphalan/prednisone/thalidomide, is it's better than thalidomide and dex for the older patient in terms of not just lesser side effects but actually efficacy. The inclusion of the melphalan, which is a very important synergistic agent gives a better outcome, and so I actually find it helpful to look at the 65. It is an arbitrary cutoff, but positioning in that over-65 group we can look at combinations, which are particularly well-tolerated for that group, which goes up to 75-85, but also which works well. One of the strangest things is that we actually have some fantastic synergistic combinations, which have been evaluated in this older group, which are looking pretty good for our younger patients too. So, things are moving in the opposite direction. What's working well for older patients can work well for younger patients, and that includes the Velcade/melphalan/prednisone that we were talking about but also melphalan/prednisone/thalidomide. So, I think that it is helpful, and I think that increasingly I can see that the therapy will be divided in some way like that.

Andrew Schorr:

Brian, and you and I march towards that cutoff age, we think about it. Okay, we're going to take a break. I know people out there have questions, and we've kind of set the stage here.

We're visiting with Dr. Sagar Lonial from the Winship Comprehensive Cancer Center at Emory University in Atlanta, and Dr. James Berenson from the Institute for Myeloma and Bone Cancer Research, and Dr. Brian Durie from the International Myeloma Foundation and Cedars-Sinai Comprehensive Cancer Center in Los Angeles. We'll be right back with more of Patient Power.

Andrew Schorr:

Here we are, we're back live with our web cast, world wide special edition of Patient Power discussing multiple myeloma with three noted myeloma experts, Dr. Lonial from the Winship Comprehensive Cancer Center at Emory University, Dr. Berenson who's with us from Los Angeles with the Institute for Myeloma and Bone Cancer Research, and then Dr. Brian Durie from the International Myeloma Foundation.

Okay, so we're starting to get questions, and we got some, a lot of them. I should mention, by the way, folks listen to the replays of our previous programs. Among them there's one with Dr. Durie after the big meeting of only the myeloma specialists at Kos, Greece. Another program on side effect management with one of the nurse practitioners who's an expert in myeloma and dealing with the side effects, and then also with Dr. Berenson earlier just several weeks ago.

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Page last updated on November 22, 2013